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BACKGROUND The efficacy of preoperative oral antibiotics alone compared to mechanical bowel preparation and oral antibiotics in minimally invasive surgery is still a matter of ongoing debate. OBJECTIVE This study aimed to assess the trend of surgical site infection rates in parallel to the utilization of bowel preparation modality over time for minimally invasive surgery colorectal surgeries in the United States. DESIGN Retrospective analysis. SETTINGS The American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS Adult patients who underwent elective colorectal surgery and reported bowel preparation modality. MAIN OUTCOME MEASURES The trends and compare surgical site infection rates for mutually exclusive groups according to the underlying disease (colorectal cancer, inflammatory bowel disease, and diverticular disease) who underwent bowel preparation using oral antibiotics or combined mechanical bowel preparation and oral antibiotics. Patients who had rectal surgery were analyzed separately. RESULTS A total of 30,939 patients were included. Of them, 12,417 (40%) had rectal resections. Over the seven-year study period, mechanical bowel preparation and oral antibiotics utilization has increased from 29.3% in 2012 to 64.0% in 2018; p

Background: Renal resistive index (RRI) was suggested as an indicator of renal atherosclerotic changes in hypertensive patients with possible prognostic role in treatment. Objectives: This study aimed to assess RRI in hypertensive subjects, its relation to other predictors of target organ damage and prognostic usefulness in management, specifically, with different antihypertensive drugs. Patients and methods: The study included 100 newly diagnosed hypertensive adult subjects, who underwent abdominal ultrasound with Doppler to assess RRI, which was correlated with their clinical parameters including estimated glomerular filtration rate (eGFR) and other subclinical atherosclerosis markers as carotid intima-media thickness (IMT) and aortic knob width (AKW) calculated from chest radiograph. Another 50 non hypertensive subjects were assessed for their RRI as a control group. In addition, some of hypertensive patients were followed up one year after starting treatment was done and effects of different antihypertensive agents on their RRI were compared. Results: The mean baseline RRI in hypertensive patients (0.71 ± 0.04) was significantly higher compared to control group (0.60 ± 0.02) and was positively significantly correlated with their clinical parameters (age, systolic, diastolic, pulse pressure and eGFR) and with their atherosclerotic parameters (IMT and AKW). In addition, ACE/ARBs treatment was associated with significant decrease of RRI compared to other drugs [beta blocker (BB) and calcium channel blocker (CCB)], indicating their more renal protective effect. Conclusion: Assessment of RRI in patients with primary hypertension not only reflecting intrarenal perfusion changes, but it indicates systemic atherosclerotic changes, so it can be useful as prognostic parameter in addition to its possible therapeutic implications.

There is limited data about the safety of colorectal surgery after immune checkpoint inhibitors (ICI). We aimed to share our experience about postoperative outcomes of colorectal surgery for patients treated with ICI. Overall, 31 patients were identified, 22 (71%) underwent elective and nine (29%) underwent emergent/urgent surgery. The 30-day Clavien Dindo class ≥ III complication rates were 27.3% (n = 6) for elective and 55.5% (n = 5) for emergent/urgent cases. Four patients underwent emergency surgery for immune-related colonic perforation and developed postoperative septic shock; two died. Considering patients’ comorbidities, cancer stage, and surgical complexity, elective colorectal surgery after ICI seems relatively safe. However, emergent/urgent colorectal surgery was associated with high postoperative morbidity. Indeed, colonic perforation in the setting of ICI treatment has a significant risk of postoperative mortality. Therefore, for patients on ICI with any acute abdominal symptoms, surgical consult should be involved, and colon perforation should be ruled out.

To date, there is no cohort in the literature focusing on the impact of the type of anastomosis in robotic ileocolonic resections for Crohn’s Disease (CD). We aimed to compare short-term postoperative outcomes of robotic ileocolic resection for CD between patients who had intracorporeal (ICA) or extracorporeal anastomosis (ECA). We retrospectively included all consecutive robotic ileocolonic resections for CD at our institution between 2014 and 2020. We compared baseline, perioperative characteristics, and postoperative outcomes between ICA and ECA. The analysis included 89 patients: 71% underwent ICA and 29% ECA. Groups were similar in age, sex, body mass index, smoking, CD duration, Montreal classification, surgical history, and previous CD medical treatments. Return to bowel function was achieved sooner in the ICA group (ICA 1.6 ± 0.7 day, ECA 2.1 ± 0.8 days; p = 0.026) despite longer operative time (ICA 235 ± 79 min, ECA 172 ± 51 min; p

There is limited literature on the impact of the extent of resection on short-term outcomes in patients with ulcerative colitis (UC) in an elective setting. The aim of this study was to better understand the impact of approach and extent of resection on short-term outcomes for patients undergoing total proctocolectomy (TPC) and subtotal colectomy (STC) for UC. Patients with UC who underwent elective TPC or STC were captured from the ACS-NSQIP® 2011-2018 database and divided into four cohorts: Open TPC (O-TPC), Laparoscopic TPC (L-STC), Open STC (O-STC), and Laparoscopic STC (L-STC). Baseline and perioperative variables were compared between the four groups alongside 30-day mortality and 30-day complication rates. Of 3387 patients, 368 (10.9%) underwent O-STC, 406 (12%) underwent O-TPC, 1958 (58%) underwent L-STC, and 655 (19%) underwent L-TPC. Overall rate of prolonged length of stay (LOS) was 27% and 9% needed a blood transfusion. There was no difference in the risk of complications between open TPC and open STC. Those who had open surgery had a higher risk of complications and prolonged LOS. Patients who had L-TPC had prolonged LOS compared to patients who had L-STC, but less compared to those who had O-STC. Elective surgery for UC is associated with high rates of prolonged LOS and blood transfusion despite MIS approaches. Short-term outcomes and LOS are more impacted by the operative approach than the extent of resection. Despite this laparoscopic TPC has higher rates of prolonged LOS when compared to laparoscopic STC.

As robotic surgery continues to disseminate into the field of colon and rectal surgery, there is a growing interest in the utilization of intracorporeal anastomosis to potentially improve surgical outcomes. The purpoe of this study was to compare feasibility, safety, and short-term outcomes of robotic sigmoid and low anterior resections performed with completely intracorporeal anastomosis (CICA) technique to the traditional extracorporeal assisted anastomosis (ECAA) technique. Consecutive series of patients who underwent elective robotic sigmoid or low anterior resections for benign or malignant disease utilizes either CICA or ECAA between August 2017 and November 2019. Surgical complications were assessed until 30 postoperative days and compared between the two groups. A total of 160 patients were identified; 73 (45.6%) in the CICA group and 87 (54.4%) in the ECAA group. Most of the procedures were performed for malignancy (76%). Estimated blood loss was lower in the CICA group (80.7 mL vs. 110.2 mL; p = 0.048), while operative times were longer (5.9 ± SD hours vs. 4.9 ± SD hours; p = < 0.001). Overall conversion rate was 1.9%, with no conversions in the CICA group. Overall complications occurred in 54 patients (33.8%) with 13 (8.3%) representing major complications. There were no significant differences in 30 day outcomes between the two groups. This study demonstrates the feasibility and safety of robotic sigmoid and low anterior resections with CICA. Outcomes for robotic sigmoid and low anterior resections are encouraging regardless of anastomotic technique (CICA vs ECAA).

Aim: The aim of this study was to assess the implementation of an intraoperative standardized surgical site infection (SSI) prevention bundle. Methods: The multimodal, evidence-based care bundle included nine intraoperative items (antibiotic type, timing, and re-dosing, disinfection, induction temperature control &gt, 36.5°, glove change, intra-cavity lavage, wound protection, and closure strategy). The bundle was applied to all consecutive patients undergoing colonic resections. The primary outcome, SSI, was independently assessed by the National Infection Surveillance Committee for up to 30 postoperative days. A historical, institutional pre-implementation control group (2012–2017) with an identical methodology was used for comparison. Findings: In total, 1516 patients were included, of which 1256 (82.8%) were in the control group and 260 (17.2%) were in the post-implementation group. After 2:1 propensity score matching, the groups were similar for all items (p &gt, 0.05). Overall compliance with the care bundle was 77% (IQR 77–88). The lowest compliance rates were observed for temperature control (53% overall), intra-cavity lavage (64% overall), and wound protection and closure (68% and 63% in the SSI group, respectively). Surgical site infections were reported in 58 patients (22.2%) vs. 21.4% in the control group (p = 0.79). Infection rates were comparable throughout the Centers for Disease Control and Prevention (CDC) categories: superficial, 12 patients (4.5%) vs. 4.2%, p = 0.82, deep incisional, 10 patients (3.7%) vs. 5.1%, p = 0.34, organ space, 36 (14%) vs. 12.4%, p = 0.48. After propensity score matching, rates remained comparable throughout all comparisons (all p &gt, 0.05). Conclusions: The implementation of an intraoperative standardized care bundle had no impact on SSI rates. This may be explained by insufficient compliance with the individual measures.

Background Diffuse large B‐cell lymphoma (DLBCL) is an aggressive cancer of the lymphatic system. About 30% to 40% of people with DLBCL experience relapse and 10% are refractory to first‐line treatment usually consisting of R‐CHOP chemotherapy. Of those eligible for second‐line treatment, commonly consisting of salvage chemotherapy followed by autologous stem‐cell transplantation (ASCT), around 50% experience relapse. With a median overall survival of less than six to 12 months, the prognosis of individuals who relapse or are refractory (r/r) to advanced lines of treatment or of those who are ineligible for ASCT, is very poor. With the introduction of chimeric antigen receptor (CAR) T‐cell therapy, a novel treatment option for these people is available. Objectives To assess the benefits and harms of chimeric antigen receptor (CAR) T‐cell therapy for people with relapsed or refractory (r/r) DLBCL. Search methods An experienced information specialist performed a systematic database search for relevant articles on CENTRAL, MEDLINE and Embase until September 11th, 2020. We also searched trial registries and reference lists of identified studies up to this date. All search results were screened by two authors independently and a third author was involved in case of discrepancies. Selection criteria We included prospectively planned trials evaluating CAR T‐cell therapy for people with r/r DLBCL. We had planned to include randomised controlled trials (RCTs) and we flexibly adapted eligibility criteria to the most reliable study designs available. We excluded studies involving fewer than 10 participants with r/r DLBCL and studies with a proportion of participants with r/r DLBCL below 70%, unless data were reported separately for this subgroup. Data collection and analysis Two review authors extracted data and performed risk of bias ratings independently. A third author was involved in case of disagreements. As our search did not yield any completed RCTs, prospective controlled non‐randomised studies of interventions (NRSIs) or prospective observational studies with a control group, we did not meta‐analyse data and reported all results narratively. We adopted the GRADE approach to assess the certainty of the evidence for prioritised outcomes. Main results We identified 13 eligible uncontrolled studies evaluating a single or multiple arms of CAR T‐cell therapies. We also identified 38 ongoing studies, including three RCTs. Ten studies are awaiting classification due to completion with no retrievable results data or insufficient data to justify inclusion. The mean number of participants enrolled, treated with CAR T‐cell therapy and evaluated in the included studies were 79 (range 12 to 344; data unavailable for two studies), 61 (range 12 to 294; data unavailable for one study) and 52 (range 11 to 256), respectively. Most studies included people with r/r DLBCL among people with other haematological B‐cell malignancies. Participants had received at least a median of three prior treatment lines (data unavailable for four studies), 5% to 50% had undergone ASCT (data unavailable for five studies) and, except for two studies, 3% to 18% had undergone allogenic stem‐cell transplantation (data unavailable for eight studies). The overall risk of bias was high for all studies, in particular, due to incomplete follow‐up and the absence of blinding. None of the included studies had a control group so that no adequate comparative effect measures could be calculated. The duration of follow‐up varied substantially between studies, in particular, for harms. Our certainty in the evidence is very low for all outcomes. Overall survival was reported by eight studies (567 participants). Four studies reported survival rates at 12 months which ranged between 48% and 59%, and one study reported an overall survival rate of 50.5% at 24 months. The evidence is very uncertain about the effect of CAR T‐cell therapy on overall survival. Two studies including 294 participants at baseline and 59 participants at the longest follow‐up (12 months or 18 months) described improvements of quality of life measured with the EuroQol 5‐Dimension 5‐Level visual analogue scale (EQ‐5D‐5L VAS) or Function Assessment of Cancer Therapy‐Lymphoma (FACT‐Lym). The evidence is very uncertain about the effect of CAR T‐cell therapy on quality of life. None of the studies reported treatment‐related mortality. Five studies (550 participants) reported the occurrence of adverse events among participants, ranging between 99% and 100% for any grade adverse events and 68% to 98% for adverse events grade ≥ 3. In three studies (253 participants), 56% to 68% of participants experienced serious adverse events, while in one study (28 participants), no serious adverse events occurred. CAR T‐cell therapy may increase the risk of adverse events and serious adverse events but the evidence is very uncertain about the exact risk. The occurrence of cytokine release syndrome (CRS) was reported in 11 studies (675 participants) under use of various grading criteria. Five studies reported between 42% and 100% of participants experiencing CRS according to criteria described in Lee 2014. CAR T‐cell therapy may increase the risk of CRS but the evidence is very uncertain about the exact risk. Nine studies (575 participants) reported results on progression‐free survival, disease‐free survival or relapse‐free survival. Twelve‐month progression‐free survival rates were reported by four studies and ranged between 44% and 75%. In one study, relapse‐free survival remained at a rate of 64% at both 12 and 18 months. The evidence is very uncertain about the effect of CAR T‐cell therapy on progression‐free survival. Thirteen studies (620 participants) provided data on complete response rates. At six months, three studies reported complete response rates between 40% and 45%. The evidence is very uncertain about the effect of CAR T‐cell therapy on complete response rates. Authors' conclusions The available evidence on the benefits and harms of CAR T‐cell therapy for people with r/r DLBCL is limited, mainly because of the absence of comparative clinical trials. The results we present should be regarded in light of this limitation and conclusions should be drawn very carefully. Due to the uncertainty in the current evidence, a large number of ongoing investigations and a risk of substantial and potentially life‐threatening complications requiring supplementary treatment, it is critical to continue evaluating the evidence on this new therapy.

Background The aim of the study is to compare the effectiveness and safety of ultrasound-guided pudendal nerve block versus caudal epidural block as a part of multimodal analgesia in children undergoing hypospadias surgery. In this prospective, single-blinded study, 50 patients were randomized into 2 groups (25 each group) either receiving ultrasound-guided pudendal nerve block group A or caudal epidural block group B. In the pudendal nerve block group, patients were injected with 0.3 mL/kg 0.25% bupivacaine and 1 ug/kg fentanyl. In the caudal epidural group, patients were injected with 1 mL/kg 0.25% bupivacaine and 1 ug/kg fentanyl. Consumption of paracetamol was assessed during the first 24 h postoperatively. The “objective pain scale” done by Hannalah and Broadman was used to assess postoperative pain. Results This prospective randomized controlled single-blind clinical study was performed on total (50) ASA status I or II patients, of age 3 to 6 years scheduled for hypospadias surgery. For the primary outcome, there was no statistically significant difference found between the two studied groups regarding objective pain score at arrival to PACU with p value = 1.000 while there was a statistically significant increase in pain score in group B than group A at 6 h and 12 h with p value = 0.017 and 0.003, respectively. Also, no statistically significant difference found between the two groups after 18 h with p value = 0.238 may be due to receiving acetaminophen dose in group B. Finally there was a statistically significant increase found in objective pain score in group B at 24 h than group A with p value = 0.015. And there was a statistically significant increase in time to first analgesia in group A than group B with p value < 0.001 while there was a statistically significant increase in total dose of acetaminophen in group B than group A with p value < 0.001. Conclusion Both ultrasound-guided pudendal block and caudal epidural block are effective and safe methods for postoperative analgesia for children undergoing hypospadias surgery but ultrasound-guided pudendal block gives more postoperative pain control.

Background This systematic review aimed to investigate the reliability of ultrasound method compared with digital vaginal examinations in detecting cervical dilation. Methods We searched Cochrane (CENTRAL), MEDLINE, EMBASE, CINAHL, ISI Web of Science Core Collection, Trip Database, PubMed, DARE and NHS EED, HTA, and PROSPERO. Ten observational studies with a total sample size of 856 were included in the meta-analysis. Results The intraclass correlation coefficient (ICC) values ranged between 0.21 and 0.69. The fixed-effect models for the ultrasound test showed an average of ICC (r = 0.32 (95% CI 0.26–0.38). Correlation between two methods was poor (r = 0.359, 95% CI 0.26–0.44). In nulliparous and multigravida participants the correlation between ultrasound measurements and digital examinations was (r = 0.349, 95% CI 0.25–0.43) and ICC (r = 0.676, 95% CI 0.419–0.833), respectively. Conclusion Trans-perineal ultrasonography seems to be a reliable method for assessing labor progression in multigravida women, but its usage in nulliparous women needs further studies.

Background: Multiple sclerosis (MS) is a chronic autoimmune disease which is the main cause of non-traumatic disability among young and middle-aged adults. The diagnosis of MS is not often feasible, whereas many disorders are mimicking MS. Objective: retrieving the difference in demographics, clinical, and paraclinical characteristics of MS mimics in order to ensure early diagnosis and adequate treatment of such patients. Patients and Methods: All patients with clinically suspected MS and aged 18-60 years old were included in the current study from the MS unit of Neurology Department, Al-Azhar University Hospitals, during the period from May, 2017 to April, 2019. Those patients were furtherly assorted based on Mcdonald's Criteria 2017 and paraclinical assessment into two groups; patients who had confirmed MS and those with MS mimics. Results: In the present study, 515 patients with a suspected diagnosis of multiple sclerosis were enrolled. There were 400 (77.6 %) patients diagnosed as MS, while 115 (22.4%) patients were not fulfilling such criteria and considered MS mimics. After reaching a final diagnosis, our cases distributed as follows: Thirty cases (26.1) migraine, twelve cases (10.4%) radiological isolated syndrome, eleven cases (9.6%) small vessel disease, ten cases (8.7%) psychogenic, eight cases (7%) neuromyelitis optica, five cases (4.3%) systemic lupus erythematosus, five cases (4.3%) Behcet’s disease, five cases (4.3%) anterior ischemic optic neuropathy, four cases (3.5%) antiphospholipid syndrome, and four cases (3.5%) transverse myelitis. Conclusion: Patients with a suspected diagnosis of MS should be subjected to meticulous neurological assessment coupled with MRI and the appropriate laboratory investigations to reach the definite diagnosis.

Background Characteristics and indications for discharging patients to home or a specific facility type have been studied; however, critical evaluation of these facilities through analysis of post-discharge complications and readmission rates is mandatory. The aim of this study was to compare complications occurring after discharge to home, skilled, and unskilled care facilities to identify potential pitfalls. Methods All adult (≥18 years) patients who underwent surgery for colon or rectal cancer from 2012 to 2017 as reported in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database were included. Patients were categorized according to the discharge destination into: home, skilled care (rehabilitation center, separate acute care, skilled facility), and unskilled care (multilevel senior community, facility which is home, unskilled facility). Demographics, surgical risk factors and predischarge complications were compared between the three groups. Primary endpoints were overall, major, surgical, and medical complications occurring post-discharge, within 30 days of surgery. Further assessed were specific complications, readmission, length of stay, and 30-day mortality. Results A total of 108,617 patients were identified. Of them, 100,478 (92%) discharged to home, 7313 (7%) to skilled, and 826 (1%) to unskilled care. Of patients discharged to skilled care, 1928 (26%) discharged to rehabilitation centers, 368 (5%) to separate acute care, and 5017 (69%) to skilled facilities. Adjusted overall, major, surgical, and medical post-discharge complications were highest among patients discharged to skilled care destinations. Subgroup analysis revealed separate acute care (inter-hospital transfer) to be associated with the highest morbidity. Main reasons for readmission were primarily related to surgical site infection and intestinal obstruction among the three main destinations, whereas readmissions for systemic sepsis and medical complications were more frequent in patients admitted to skilled care. Conclusion This study identified higher rates of post-discharge complications associated with skilled care destinations, despite risk adjustment. This over-morbidity is potentially related to prevailing medical complications and inter-hospital transfers. Further studies are needed to better understand those findings and to improve quality of post-acute care and related outcomes.

Although much focus is placed on oncological outcomes for rectal cancer, it is important to assess quality of life after surgery of which sexual function is an important component. This study set about to describe the prevalence of sexual dysfunction by resection type and gender among patients undergoing surgery for rectal cancer, usingretrospective analysis. All English-speaking living patients who underwent surgery for stage I–III rectal cancer with curative intent between 2012 and 2016 were identified from a prospectively maintained database at our institution. Eligible patients were invited to complete either the Female Sexual Function Index (FSFI) or the International Index of Erectile Function (IIEF). Primary outcomes were overall rates of sexual dysfunction, defined as more than one standard deviation below the mean of the normal population for each tool. A total of 147 patients responded, yielding a response rate of 38%. The overall sexual dysfunction rate was 70% at a median time from surgery of 38 months. Sixty-two men (62%) and 41 women (87%) reported overall scores that fell below one standard deviation of the population mean. There was no significant difference in sexual dysfunction for both male and female patients between low anterior resection, coloanal anastomosis, or abdominoperineal resection.. The present study revealed a high rate of sexual dysfunction after rectal cancer surgery, particularly in female patients. This study serves as a reminder to surgeons and their teams to openly discuss the impact of surgery on sexual function and ensure adequate consent and appropriate peri-operative management strategies. The retrospective nature of the analysis is the limitation of this study.

To determine the risk factors for developing primary postoperative pulmonary complications (PPC) in patients undergoing minimally invasive colorectal surgery (MIS) for the treatment of cancer and to identify the potential indicators for more extensive preoperative evaluation. The ACS-NSQIP ® database was interrogated to capture patients who had elective colon or rectal cancer and underwent MIS between 2012 and 2017. Patients who had primary PPC including pneumonia, unplanned intubation and/or failure to wean from mechanical ventilation for > 48 h were compared to patients without PPC. Significant risk factors for PPC were retained to build a predictive risk model through logistic regression analysis. The model was then internally validated using 2018 data. Of 50,150 patients identified, 637 (1.3%) had PPC. The final risk prediction model included six variables: history of chronic obstructive pulmonary disease, age, smoking status, functional health status, pre-operative congestive heart failure, and American Society of Anesthesiology class ≥ 3. The model achieved good calibration (Hosmer-Lemeshow goodness-of-fit test, p = 0.614) and discrimination (c statistics = 0.757). Internal validation achieved similar discrimination (c statistics = 0.798). Primary postoperative pulmonary complications affected 1.3% of patients undergoing MIS for colon or rectal cancer. The novel predictive risk score showed good discrimination and may help to identify patients who may benefit from perioperative optimization.

Utility of adjuvant chemotherapy for stage II cancer remains a matter of debate. Clinical guidelines suggest adjuvant chemotherapy for stage II tumors with high-risk features, in particular T4 tumors. However, limited consensus exists regarding the importance of other high-risk features (lymphovascular or perineural invasion, microsatellite instability). Our study aimed to investigate the impact of adjuvant chemotherapy for stage IIA (T3N0) colon cancer patients. Patients who underwent colectomy for stage IIA colon adenocarcinoma (2010-2015) were identified in the National Cancer Database (NCDB) and divided in two groups based on receipt of adjuvant chemotherapy vs observation. Inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier and Cox proportional hazards regression analyses were performed to compare overall survival between the two groups. Subgroup analysis of patients with specific high-risk features LVI, PNI and MSI was performed. Among 46 688 surgical patients with stage IIA colon adenocarcinoma 5937 (12.7%) received adjuvant chemotherapy, while 40 751 (87.3%) were observed. Five-year IPTW-adjusted survival was higher in the adjuvant chemotherapy group (79.7% [95% CI 79.1, 80.2]) compared to the observation group (70.3% [95% CI 69.7, 70.9]). Patients with high-risk pathological features showed an estimated 5-year survival benefit of 11.3% (78.2% [95% CI 77.4, 79.1] vs 66.9% [95% CI 65.9, 67.8]) when treated with adjuvant chemotherapy. This NCDB analysis revealed a survival benefit for patients with stage IIA colon adenocarcinoma and high-risk features that were treated with adjuvant chemotherapy.

Background While minimally invasive surgery contributed to improved outcomes in bariatric surgery, less is known about current utilization trends and outcomes related to surgical technique for colorectal resections in super-obese patients (body mass index ≥50 kg/m2). Objective The aim of this study was to compare surgical modalities and short-term outcomes of patients with super obesity who underwent elective colectomy in the United States. Setting A retrospective review was performed of patients with super obesity who underwent elective colectomy between 2012 to 2018 using the American College of Surgeons National Quality Improvement Program data pool. Methods Patients were categorized into an open, laparoscopic, or robotic group. Baseline characteristics and perioperative outcomes including 30-day complications and length of stay were compared between the 3 groups. Furthermore, utilization trends of surgical modalities were assessed. Results Of 1199 patients, 338 (28.2%) had open, 735 (61.3%) laparoscopic, and 126 (10.5%) robotic colectomy during the study period, primarily for colon cancer (50.8%). Patients in the open group tended to have more baseline co-morbidities. Laparoscopic approach showed better risk-adjusted outcomes compared with open for postoperative ileus (adjusted odds ratio [aOR]: .6, 95% confidence interval [CI; .383–.965]), overall medical complications (aOR: .4, 95%CI [.3–.8]), and length of stay (OR .6, 95% CI [.394–.968]). Trend utilization showed increasing utilization of the robotic platform over the study period, which was associated with less unplanned conversion to open (aOR .417, 95%CI [.199–.872]). Conclusion Laparoscopic colectomy provides advantageous outcomes over open surgery for colectomy in super-obese patients. The robotic platform has been increasingly used over time, and potential benefits need to be further studied.

Background: BMI ≤18.5 kg/m2 and preoperative weight loss may lead to inaccurate assessment of nutritional status, given the increasing prevalence of obesity. The aim of this study was to assess whether clinical evaluation of malnutrition based on these parameters is sufficient to predict complications after colorectal cancer surgery. Materials and Methods: The American College of Surgeons-National Quality Improvement Program database was queried from 2005 to 2018. Patients undergoing elective colorectal cancer surgery were divided into 4 groups: (1) albumin plus [BMI 2 if age 2 if age ≥70 years]), (3) both aforementioned criteria, and (4) none of aforementioned criteria. Results: Of 82,280 patients, 5,932 (7.2%) had hypoalbuminemia p < 0.05 vs. OR 1.18 in the ESPEN 2 group, p < 0.05), major complications (OR 1.98, p < 0.05 vs. OR 1.20, p < 0.05), surgical complications (OR 1.77, 95% p < 0.05 vs. OR 1.1, p > 0.05), medical complications (OR 1.73, p < 0.05 vs. OR 1.16, p > 0.05), surgical site infection (OR 1.32, p < 0.05 vs. OR 0.86, p > 0.05), and prolonged hospitalization (OR 1.79, p < 0.05 vs. OR 1.22, p < 0.05). Patients who met both criteria were at highest risk. Conclusions: Preoperative measurement of serum albumin appears to be essential to identify patients at risk for complications after colorectal cancer surgery. Clinical evaluation through BMI and weight loss alone may underestimate surgery-associated risks in the USA.

The aim of this study was to identify national utilization trends of robotic surgery for elective colectomy, conversion rates over time, and the specific impact of conversion on postoperative morbidity. Conversion to open represents a hard endpoint for minimally invasive surgery (MIS) and is associated with worse outcomes when compared to MIS or even traditional open procedures. All adult patients who underwent either laparoscopic or robotic elective colectomy from 2013 to 2018 as reported in the American College of Surgeons Quality Improvement Program (ACS-NSQIP) database were included. National trends of both robotic utilization and conversion rates were analyzed, overall and according to underlying disease (benign disease, inflammatory bowel disease (IBD), cancer), or the presence of obesity (body mass index (BMI) ≥ 30 kg/m 2 ). Demographic and surgical risk factors for surgical conversion to open were identified through multivariable regression analysis. Further assessed were overall and specific postoperative 30-day complications, which were risk adjusted and compared between converted patients and the remaining cohort. Of 66,652 included procedures, 5353 (8.0%) were converted to open. Conversion rates were 8.5% for laparoscopic and 4.9% for robotic surgery (p < 0.0001). A decline in conversion rates over the 6-year inclusion period was observed overall and for patients with obesity. This trend paralleled an increased utilization of the robotic platform. Several surrogates for advanced disease stages for cancer, diverticulitis, and IBD and prolonged surgical duration were identified as independent risk factors for unplanned conversion, while robotic approach was an independent protective factor (OR 0.44, p < 0.0001). Patients who had unplanned conversion were more likely to experience postoperative complications (OR 2.36; 95% CI [2.21-2.51]), length of hospital stay ≥ 6 days (OR 2.86; 95% CI [2.67-3.05], and 30-day mortality (OR 2.28; 95% CI [1.72-3.02]). This nationwide study identified a decreasing trend in conversion rates over the 6-year inclusion period, both overall and in patients with obesity, paralleling increased utilization of the robotic platform. Unplanned conversion to open was associated with a higher risk of postoperative complications.

Background and Objectives: The goal of this study was to compare disease-specific risk factors and 30-day outcomes between patients with Crohn’s disease (CD) and colon cancer (CC) undergoing right-sided surgical resection. Methods: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP®) was interrogated to extract all patients ≥18 years undergoing elective right-sided resection for CD versus CC. Independent risk factors for surgical complications were identified through multivariable logistic regression for both groups. In a second step, surgical and medical 30-day morbidity was compared after risk adjustment. Results: The cohort consisted of 17,516 patients, of which 2,899 (16.6%) underwent surgery for CD versus 14,617 (83.4%) for CC. Independent risk factors for surgical complications in patients with CD were male gender, African American race, ASA score (III or IV), active smoking, prolonged surgery, and preoperative anemia. Independent risk factors for surgical complications in the cancer group were age ≥70 years, male gender, ASA score (III or IV), respiratory and cardiovascular comorbidities, and preoperative hypoalbuminemia (p = 0.002), sepsis (OR 1.64, p = 0.012), and unplanned readmissions (OR 1.39, p = 0.004) were more common in patients with CD. Thirty-day mortality was higher in cancer patients (1.1 vs. 0.1%, p < 0.0001). Conclusions: Patients with Crohn’s disease were more prone to surgical complications and postoperative sepsis compared to the cancer group undergoing the same procedure. Careful evaluation and correction of disease-specific modifiable risk factors of patients with CD and CC, respectively, are important.

Despite an increasing trend towards utilization of minimally invasive approaches (MIS), results regarding their safety profile are contradictory. All patients who underwent elective colectomy for any underlying disease with an identifiable operative approach available from the targeted colectomy files of the ACS-NSQIP PUFs 2013 to 2018 were included. The trend of utilization and complication rates of the different operative approaches (open, laparoscopic, robotic) were assessed during the inclusion period. Furthermore, overall, surgical, and medical complications were compared between the three approaches. The study cohort included 78,987 patients. Of them, 12,335 (15.6%) patients underwent open, 57,874 (73.3%) laparoscopic, and 8,778 (11.1%) robotic surgery. There was an increasing trend towards the utilization of robotic surgery (2.5% increase per year) at the expense of the other approaches. With the increasing trend toward the utilization of the robotic approach, a decreasing trend in overall and surgical complications and length of stay was observed. After adjusting for the baseline confounders, robotic surgery was associated with shorter length of stay, lower rate of overall (OR 0.397; p < 0.05 compared to open and OR: 0.763; p < 0.05 compared to laparoscopy) and surgical complications (OR: 0.464; p < 0.05 compared to open and OR: 0.734; p < 0.05 compared to laparoscopy). This study revealed an increasing trend toward the utilization of MIS for elective colectomy in the US. Robotic surgery was associated with a decreasing trend in overall and surgical morbidity and length of stay.

Statins can decrease hepatocellular carcinoma (HCC) occurrence, but the magnitude and the predictors of these effects remain unclear. This meta-analysis provides a pooled estimate of the impact of statin use on HCC occurrence. Pooled effects were calculated using a random-effects model by means of the DerSimonian and Laird test. Primary endpoint was the time-dependent correlation between statin use and HCC incidence expressed as hazard ratio (HR), both crude and adjusted. The crude and adjusted odds ratios (OR) for HCC occurrence between statin users and non-users were analyzed. Twenty-five studies with 1,925,964 patients were included. Crude OR for HCC incidence was 0.59 (95% CI: 0.47&ndash, 0.74), confirmed in adjusted analysis (OR: 0.74, 95% CI: 0.70&ndash, 0.78). Adjusted HR was 0.73 (95% CI: 0.69&ndash, 0.76). This effect was more pronounced in HBV patients (HR: 0.46, 95% CI: 0.36&ndash, 0.60) and with a cumulative daily dose beyond 365 (HR: 0.27, 95% CI: 0.11&ndash, 0.67). Lipophilic statins were associated with reduced HCC incidence (HR: 0.49, 95% CI: 0.39&ndash, 0.62). Atorvastatin determined the greater magnitude of effect (HR: 0.43, 95% CI: 0.28&ndash, 0.65). This meta-analysis demonstrates the beneficial chemopreventive effect of statins against HCC occurrence. This effect is dose-dependent and more pronounced with lipophilic statins.

Background: Acute Heart Failure (AHF) complicates acute Myocardial Infarction (AMI) as a result of complex interaction of structural, hemodynamic, neurohormonal, and genetic maladaptations. This study aims to analyse the role of Left Atrial Volume Index (LAVI) compared to other con-ventional parameters of systolic and diastolic Left Ventricular function (LV) in patients with first time ST Segment Elevation Myocardial Infarction (STEMI), in predicting in-Hospital Heart failure (HF), in-hospital mortality and development of heart failure and subsequent rehospitalisation over a follow-up period of 6 months.Material and Methods: The present study is a prospective observational study conducted in the Cardiology Department of Assiut University Hospitals (AUH) on 70 STEMI patients admitted to Coronary Care Unit (CCU). Left Ventricular Ejection Fraction (LVEF), LV End-Systolic and End-Diatolic Dimensions (LVESD and LVEDD), LAVI, diastolic and systo-lic parameters were measured within 24 hours after admission and then 6 months later. These variables were correlated with the development of heart failure according to Killip classifi-cation on admission and 6 months later by NYHA classifica-tion.Results: There was a statistically significant difference regarding development of in-hospital HF (Killip classification >II) with the following variables LAV, LAVI, LVESD, FS, EF, and the diastolic parameters used to evaluate diastolic function except Isovolumetric Relaxation Time (IVRT) and E/A ratio, whereas in-hospital mortality was related signifi-cantly to the same variables except LAVI, E/A ratio and EF by univariate analysis. (p-value

Background: multiple sclerosis is an inflammatory demyelinating disease with a neurodegenerative component mainly characterized by progressive accumulation of focal white matter (WM) lesions. The degree of cortical damage at baseline was associated with the progression of disability. Cognitive deficits could be better explained by cortical lesions (CLs) than by WM lesions. Fatigue in MS could be due to damage to the cortico striato thalamo cortical circuit. Aim of the Work: to detect (CLs) in MS patients and correlate these lesions with physical disability, cognitive dysfunction and fatigue. Subjects and Methods: a case-control study on 64 subjects including 44 known multiple sclerosis patients diagnosed according to revised McDonald's criteria 2017. Results: we observed a statistically significant difference between MS patients and healthy controls as regard number of (CLs), Symbol Digit Modality Test (SDMT), Fatigue Severity Scale (FSS) and P300 wave latencies and amplitudes. Secondary progressive (SPMS) subgroup was affected more than relapsing remitting (RRMS) subgroup. (CLs) were located mainly in temporal lobes. Conclusion: This study suggested that cortical affection is directly associated with physical and cognitive disability progression.

Background: The transversus abdominis plane (TAP) block provide effective postoperative analgesia in lower abdominal surgery. Subcostal TAP block as a new technique to provide analgesia for the supraumbilical abdomen. Traditionally, pain relief for these patients is provided by epidural analgesia or IV opioid analgesia. Although epidural analgesia is currently the “gold standard” for postoperative pain treatment, associated complications and contraindications may limit its use. IV opioid analgesia may cause opioid-related side effects and be associated with inadequate analgesia. Aim of the Work: This study aimed at clinically evaluating and statistically comparing between lumber epidural versus transversus abdominus plane block as postoperative Analgesia for laparoscopic sleeve gastrectomy. Also, our goal was to figure out the most possible effective technique for this kind of procedure with most benefits and least side effects. Patients and Methods: This single blinded randomized clinical trial was carried out at Ain Shams University hospitals on 60 adult Bariatric patients undergoing elective Laparoscopic sleeve Gastrectomy, aged 20 to 50 years, ASA I-II, BMI equal or less than 45 Kg/m2. Results: Patients in the Lumber Epidural group had significantly less pain score when compared to the other TAP group (p-value < 0.001). And, they had longer time to first request rescue analgesia (nalbuphin) (P = 0.0013). Also, total dose of nalbuphin consumption was less in Lumber Epidural group than TAP group (P < 0.001). Conclusion: This study concluded that TAP block was effective in pain relief after Laparoscopic sleeve gastrectomy, however, Lumber Epidural was superior in pain relief, less narcotic consumption and overall more patient satisfaction.

Background Although magnetic resonance imaging (MRI) is often the “gold standard” for diagnosing knee problems, it has many limitations. Therefore, ultrasonography has been suggested as an effective rapid alternative in many knee abnormalities, especially after injuries of the meniscus and collateral ligaments. Purpose To determine the diagnostic accuracy of point-of-care ultrasound (POCUS) in detecting injuries of the meniscus and collateral ligament compared to MRI. Material and Methods An observational cross-sectional blinded study was conducted of 60 patients with clinically suspicious meniscus and collateral ligament injuries who were planned for an arthroscopy and or operative procedure. These patients underwent both blinded POCUS and MRI of the knees before the intervention procedure and results of both imaging modalities were compared according to the operative and arthroscopic findings. Results The preoperative reliability of POCUS compared to MRI for the assessment of meniscus injuries was sensitivity (92.9% vs. 90.5%), specificity (88.9% vs. 83.3%), positive predictive value (PPV; 95.1% vs. 92.7%), negative predictive value (NPV; 84.2% vs. 79%), and overall accuracy (91.7% vs. 88.3%). However, for diagnosing collateral ligament injures, POCUS versus MRI assessed sensitivity (92.3% vs. 88.5%), specificity (100% vs. 97.1%), PPV (100% vs. 95.8%), NPV (94.4% vs. 91.7%), and overall accuracy (96.7% vs. 93.3%). Conclusion Ultrasonography is a useful screening tool for the initial diagnosis of meniscal and collateral ligament pathology compared to or even with potential advantages over MRI, especially when MRI is unavailable or contraindicated. As newly advanced portable ultrasonography becomes available, it could be considered as a point-of-injury diagnostic modality.

Background The assessment of liver stiffness and the degree of fibrosis are important factors affecting the management strategy. Multiple non-invasive tools are now available to offer an adequate alternative to biopsy. In this study, we tried to compare the performance of 2D shear wave elastography (SWE) to the transient elastography/fibroscan as a non-invasive tool in the prediction of liver stiffness. This is a prospective study of 215 patients confirmed by serology to have positive virus C or B infection. 2D SWE was done followed by vibration-controlled transient elastography (VCTE) known as fibroscan at the same session. Biopsy results were collected. Results The mean age was 51.07 years ± 6.07 SD. Five cases were excluded due to insufficient data. Fibroscan failed in 30 cases out of 210 cases (failure rate of 14.3%) compared with only 12 patients (6.7% failure rate) while using SWE. Only 180 patients completed the study to the result analysis. SWE results showed significant agreement to the fibroscan results with 86.7% agreement with a tendency for overestimation of the degree of fibrosis (11.7%). The efficacy of SWE was the highest during the assessment of patients with F0 (98.9%), F1 (97.8%), and F4 (93.3%) respectively and relatively low in F2 (92.8%) and F3 (90.6%). Conclusion 2D SWE is a relatively recent non-invasive tool in the assessment of liver fibrosis grading which can be used as an alternative to the fibroscan with almost similar diagnostic performance especially when fibroscan is not capable to obtain adequate results such as in obesity and ascites.

Regorafenib showed promising results as a second-line agent after sorafenib failure in hepatocellular carcinoma patients. The aim of this meta-analysis was to evaluate the efficacy and safety of regorafenib in hepatocarcinoma patients. A computerized bibliographic search was performed on the main databases. The primary outcome was overall survival. Secondary outcomes were progression-free survival, tumor response, and the adverse events rate. Outcomes were pooled through a random-effects model and summary estimates were expressed in terms of median and 95% confidence interval or rates, as appropriate. One randomized-controlled trial and seven non-randomized studies with 809 patients were included. The great majority of recruited patients were in Child-Pugh A and ECOG 0 stage. Median overall survival was 11.08 months (9.46–12.71) and sensitivity analyses confirmed this finding, with a median survival ranging from 10.2 to 13.8 months. Duration of regorafenib therapy was 3.58 months, whereas median progression-free survival was 3.24 months (2.68–3.86). The pooled objective response rate was 10.1% (7.8–12.5%) while the disease control rate was 65.5% (61.3–69.7%) with no evidence of heterogeneity (I2 = 0%; Diarrhea, fatigue, and hand-foot skin reaction were the most frequent adverse events. The current meta-analysis shows that regorafenib represents a valuable and relatively safe therapeutic option in intermediate/advanced hepatocellular carcinomapatients who progress on sorafenib.

Most ovarian cancer patients present with disseminated disease at the time of their diagnosis, which is one of the main reasons for their poor prognosis. Metastasis is a multi-step process and a clear understanding of the mechanism of regulation of these steps remains elusive. Productive reciprocal interactions between the metastasizing ovarian cancer cells and the microenvironment of the metastatic site or the tumor microenvironment play an important role in the successful establishment of metastasis. Much progress has been made in the recent past in our understanding of such interactions and the role of the cellular and acellular components of the microenvironment in establishing the metastatic tumors. This review will outline the role of the microenvironmental components of the ovarian cancer metastatic niche and their role in helping establish the metastatic tumors. Special emphasis will be given to the mesothelial cells, which are the first cells encountered by the cancer cells at the site of metastasis.

Aim To characterize the sociodemographic, clinical and radiological findings of patients with depressed skull fractures overlying cranial dural sinuses that we have faced in our institute. In addition, to explore the indications and choices for the surgical and nonsurgical management of such cases, and assess outcomes in these two treatment groups. Material and methods We prospectively followed up a cohort of 34 patients with fractures over dural venous sinuses from January 2013 to December 2017. Twelve (35.1%) were simple depressed fractures (SDFs) and 22 (64.7%) were compound depressed fractures (CDFs). Eighteen patients (52.9%) were treated surgically, and 16 (47.1%) were treated conservatively. Results The mean age was 20.8 years. Thirty-two of the patients were males (94.12%). The mean time from trauma until hospital arrival was 3.8 hours, and the mean admission Glasgow Coma Score (GCS) was 13.7. Direct trauma was the most common mode of injury. Funduscopy was performed in 16 patients (47.1%), and magnetic resonance venography (MRV) in four patients (11.8%). Twenty-four patients (70.59%) had the fracture overlying the superior sagittal sinus (SSS). The mean length of hospital stay was five days, and the mean follow-up duration was 6.8 months. Twenty-eight patients (82.35%) had a good recovery. Conclusion The majority of SDFs and some CDFs overlying dural sinuses can be managed safely without major surgical intervention. Conservation should be favored when the sinus is patent, dura intact, and bone displacement is insignificant in neurologically intact patients with an apparently clean wound. Otherwise, surgery should be considered. We also propose including a funduscopic examination and venogram as parts of the initial trauma work-up for these patients.

Objective Osteoarthritis (OA) is a global public health problem and a leading cause of morbidity and disability. Due to lack of sensitive and specific tools for early OA diagnosis and predicting prognosis, the availability of new reliable and sensitive biomarkers is a widely appreciated need to identify patients at risk for incident disease or disease progression. Accordingly, our study was conducted to validate the usefulness of disintegrin and metalloproteinase with thrombospondin motifs 5 (ADAMTS5) and follistatin-like protein 1 (FSTL1) to achieve this goal. Design Fifty-four male Wistar rats were randomized into 3 groups; 24 rats were subjected to medial meniscal tear (MMT) surgery on the right knee joint (OA group), 24 rats were subjected to sham surgery (sham group), and 6 healthy rats (negative control group). Six animals from each group were sacrificed every 2 weeks. At each time point, the right knee joint of each animal was visualized radiologically, a blood sample was collected, and cartilage tissues were isolated for histopathological and western blot analysis. Results We found that the expression levels of ADAMTS5 and FSTL1 significantly increased with OA progression, especially at weeks 4, 6, and 8 after surgery. Notably, the serum levels of ADAMTS5 and FSTL1 showed significant positive correlations with each other and with the studied inflammatory markers. Conclusions Our findings suggest that ADAMTS5 and FSTL1 can serve as important and informative serological markers of disease activity in OA. However, further research is needed to validate their use for improving the diagnosis and prognosis of OA in humans.

Background Bacterial vaginosis (BV) is one of the common vaginal infections among childbearing women. The usual treatment for BV is metronidazole; hence 30% of women have recurrence within 60 to 90 days after treatment. There are some studies which assessed the effect of secnidazole on BV. The aim of this systematic review was to investigate the effectiveness of secnidazole for treatment of BV. Methods The Cochrane Library, MEDLINE (PubMed), Scopus, and Web of Science (all databases from inception till October 28, 2018) were searched. Primary outcomes were clinical cure rate and microbiologic cure rate and the secondary outcomes were adverse events. Data was extracted from eligible studies by two review authors individually and analyzed by RevMan 5.3. Results Our search found six trials involving 1528 participants. Treatment with 2 g secnidazole could significantly reduce the risk of BV in patients with three or less episodes of BV in the last year by OR: 7.54 (95% CI, 3.89–14.60, p p = 0.0.008). Secnidazole (2 g) could significantly increase the microbiologic cure rate in women with 3 or less episodes of BV in the last year (OR: 7.63, 95% CI: 2.30–25.33, p = 0.0009) but not in the women with 4 or more episodes of BV in the last year (OR: 20.17, 95% CI: 1.06–382.45, p = 0.05). The clinical cure rate, microbiological effect and the therapeutic cure rate of 2 g secnidazole was significantly more than that of 1 g secnidazole. The results showed that the clinical cure rate of 2 g secnidazole was not different from the following medications: metronidazole (500 mg bid for 5 days), secnidazole plus vaginal metronidazole, 2 g single dose of oral metronidazole and 2 g secnidazole plus vaginal ornidazole. Conclusion This review showed that 2 g and 1 g secnidazole were better than placebo, however, 2 g secnidazole was more effective than 1 g. Secnidazole 2 g was not different from metronidazole (500 mg bid for 5 days), or from secnidazole plus vaginal metronidazole, or 2 g single dose of oral metronidazole or from 2 g secnidazole plus vaginal ornidazole.

Despite the advances in screening protocols and treatment options, hepatocellular carcinoma (HCC) is still considered to be the most lethal malignancy in patients with liver cirrhosis. Moreover, the survival outcomes after failure of first-line therapy for unresectable HCC is still poor with limited therapeutic options. One of these options is immune checkpoint inhibitors. The aim of this study is to comprehensively review the efficacy and safety of immune checkpoint inhibitors for patients with HCC.

Hepatitis B virus is mainly considered to cause hepatocellular carcinoma which is the fourth leading cause of cancer-related mortality worldwide. Treatment of Hepatitis B virus with nucleos(t)ide analogues can decrease the progression of the disease and subsequently decreases the incidence of hepatocellular carcinoma. In this review, we have discussed the different classes of nucleos(t)ide analogues used in the treatment of Hepatitis B virus and their relationship with the development of hepatocellular carcinoma. Furthermore, we discussed the effect of treatment of Hepatitis B virus with Nucleoside analogues (NAs) before, during and after surgery, chemoembolization, radiofrequency ablation, and chemotherapy for the treatment of hepatocellular carcinoma.

Background: Carbon tetrachloride (CCl4) causes hepatic injury. Galectin-3 is amember of the lectin family; several studies have suggested that Gal-3 could repairliver damage. Objective: To estimate Gal-3 expressions in different periods after CCl4administration and to explore the mechanism of repair of the injured liver by Gal-3either through modulation of apoptosis or oxidative stress. Materials and methods:Twenty male mice (age 6 weeks; weight 25-30 g) were divided into 4 groups of 5 miceeach in separate cages with free access to food and water. Group (I): Control group.Groups II, III and IV administered orally CCl4 as a single dose 50% (W/W); CCl4 inolive oil at 2 ml/kg of body weight and left for 48, 72 and 96 hours respectively. Theperiod of repair of hepatocytes injured by CCl4 and signaling proteins intrinsic tothese periods were examined. Results: A 30 kDa polypeptide was detected by bothRT-PCR and Western blot analysis using anti-galectin-3 antibody in livers from mice48 to 96 hours after administration of a single dose of CCl4 and was identified asgalectin-3 in hepatocytes. Levels of Gal-3 were significantly higher in liver of mice at48 to 72 hour after CCl4 treatment compared to the control. Its level was reduced at96 hours after CCl4 administration. Bcl-2 levels increased significantly during theexperimental period after administration of CCl4, where presented in low amount inthe control mice. Caspase-3 was detected in trace amount in control mice, increasedafter 48 and 72 hours from administration of CCl4 and then decreased gradually at96 hours. Both tissue homogenate levels of nitric oxide and lipid peroxidation showedmarked increase at 48 hours as compared to controls. Their levels decreasedgradually at 72 and 96 hours after CCl4 administration. The tissue homogenate levelsof antioxidants CAT, GSH and SOD activity of all groups were significantlydecreased at 48 hours and then increased gradually at 72 and 96 hours after CCl4administration but did not reach to normal level. Conclusion: Gal-3 plays animportant role in repairing the hepatocellular damage which occurred by CCl4through its role as anti-apoptotic agent and against free radical generation.

Background Papillary breast lesions comprise a spectrum of histopathologic diagnoses ranging from benign papillomas to papillary carcinomas. There is ongoing controversy regarding the management of papillary lesions diagnosed by core needle biopsy (CNB). Some authors advocate observation of papillary lesions when the CNB is benign, while others recommend surgical excision of all papillary lesions. The current study assessed the adequacy of CNB in evaluating papillary breast lesions. Methods A search of the pathology database at our institution identified 122 papillary lesions diagnosed by CNB. The study population consisted of 71 papillary lesions that were subsequently surgically excised. Results Of the 71 papillary lesions excised, 8 were malignant, 16 were atypical, and 47 were benign at the time of CNB. Of the 47 papillary lesions thought to be benign, 13 (28%) revealed atypia and 4 (9%) revealed malignancy upon surgical excision. Of the 13 atypical papillary lesions on CNB, 7 lesions (54%) were associated with malignancy upon excision. Slightly over half the upgrades were due to finding atypia or malignancy in the tissue surrounding the papillary lesion. The total rate of upgrades from the CNB diagnosis to the excisional diagnosis was 38%. Conclusions When a core biopsy of a papillary lesion is encountered, there is a strong likelihood of discovering atypia or malignancy in the index lesion or in close proximity. Therefore, surgical excision should be performed to avoid missing a malignancy and to allow for accurate breast cancer risk assessment that can impact survival and decisions regarding chemoprevention.

Background In patients with infected nonunion the primary goal is eradication of infection, before achieving union. Release of antibiotics from bone cement at a higher concentration prevents bacterial growth and formation of biofilm by bacteria. Penetration of antibiotics to the surrounding tissue, including cortical and cancellous bone, prompted the use of antibiotic cement in the control of bone infection. Patients and methods This was a prospective study of 12 patients with infected nonunions managed with antibiotic-impregnated bone cement who were followed up for an average period of 1.2 years, with encouraging results. The infected fracture site was exposed and thorough debridement done. The implant was replaced with vancomycin and clindamycin-impregnated cement following adequate debridement. Culture and sensitivity was done for the debrided tissues to identify the pathogen and sensitive antimicrobial agent. Follow-up was performed clinically, radiologically, and using laboratory investigations (by complete blood cell count, erythrocyte sedimentation rate, C-reactive protein). Results Infection was eradicated in all patients except one after an average period of 9 weeks (range: 6–14 weeks). Culture revealed no growth and discharge disappeared at the end of this period. Cement was removed after an interval of 6–12 weeks after control of infection and was replaced with definitive fixation with or without bone grafting. Conclusion Management of infected nonunions using antibiotic-impregnated cement is a simple and very effective method that allows infection control and promotes bone union. This simple procedure is encouraging, cost effective, and less cumbersome.