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Aspergillosis is a fungal infection cause reduction or suppression of innate immune system. Occasionally silver nanoparticles showed antibacterial activity rather than anti-fungal activity. In the current paper three different shapes and concentrations of silver nanoparticles (AgNPs) were synthesized using dextrin and starch, then applied to cotton for acquiring antifungal properties. TEM illustrates the size, shape and homogeneity of the AgNPs. Atomic absorption spectroscopy (AAS) quantified the AgNPs in the colloidal solution. Attenuated total reflection ATR/FT-IR spectroscopy and scanning electron microscope (SEM) coupled with Energy Dispersive X-Ray Analysis (EDX) to screen the homogeneity and dispersion of the AgNPs. Different shapes (rode and triangular) of AgNPs (10-17nm) were produced using 10~5 ppm of the AgNPs. Antifungal activity towards Aspergillus Niger fungus was documented using the disc diffusion method. Cotton treated with AgNPs showed significant effective antifungal properties at lower concentrations (~10 ppm) preserving its white color compared to the higher concentrations (>100 ppm)of the AgNPs. Manufactured cotton fabrics treated with low concentrations of AgNPs were examined towards the recognition of the antifungal properties with minimal industrial footprint which may expose a novelpossibility for antifungal applications.

Elements accumulation in crayfish is proportional to the increase in bioavailability (direct contact) with the surrounding water, sediment, and feeding. Five heavy metals (Cu, Cr, Mn, Ni, and Ag) and lithium (Li) were analyzed in the sediment, water, and crayfish tissues. Elements (heavy metals and lithium) concentrations in sediment, water, and crayfish tissues showed significant differences between the two sampling stations (El-Qanatir and El-Rahawi drain). However, the levels of elements in crayfish tissues were arranged in declining order as hepatopancreas > gills > exoskeleton > muscles for Cu and Cr; hepatopancreas > exoskeleton > gills > muscles for Ni and Ag; and exoskeleton > gills > hepatopancreas > muscles for Li and Mn. The human health hazard evaluation of heavy metals and lithium exposure via edible tissue consumption was assessed for both children and adult consumers. The target hazard quotient THQ values of crayfish edible tissues (less than 1) will not impose any health implications for consumers who ingest edible tissues in sufficient quantities. Furthermore, the hazard index (HI) values reported for children and adult consumers were lower than one, indicating non-carcinogenic and carcinogenic hazards, suggesting that crayfish edible tissues are safe for human ingestion. This evidence also found that Procambarus clarkii could be a good bio-indicator organism for monitoring potentially metals in aquatic systems.

Minimally invasive ileocolic resection for complicated Crohn disease, defined as penetrating Crohn disease associated with intra-abdominal fistula, abscess, or phlegmon, is challenging. In addition, the impact of the minimally invasive approach on postoperative outcomes is still debated. This study aimed to compare the intraoperative and postoperative outcomes of minimally invasive ileocolic resection for complicated versus uncomplicated Crohn disease.A retrospective analysis of all consecutive adult patients with Crohn disease undergoing minimally invasive ileocolic resection from 2014 to 2021 was performed. Perioperative outcomes were compared between patients with complicated Crohn disease (complicated group) and patients without these lesions (uncomplicated group).Among the 274 patients undergoing minimally invasive ileocolic resection for Crohn disease, 101 (36.9%) had a robotic approach, and 84 (30.7%) had complicated Crohn disease. Complicated patients were more frequently malnourished (32.1% vs 16.1%, P = .004) and had more frequent previous bowel resections for Crohn disease (22.1% vs 9.5%, P = .002). There were no differences between both groups regarding intraoperative complications (1.1% uncomplicated group vs 2.4% complicated group, P = .463), conversion rate (2.6% uncomplicated group vs 4.8% complicated group, P = .463), postoperative morbidity (27.4% uncomplicated group vs 34.5% complicated group, P = .231), intra-abdominal septic complications (4.2% uncomplicated group vs 7.1% complicated group, P = .309), and length of stay (3.8 ± 2.0 days uncomplicated group vs 4.2 ± 3.0 complicated group, P = .188).Minimally invasive ileocolic resection for complicated Crohn disease is safe and feasible. Future prospective studies are needed to confirm these results.

Fractionation of the stem bark of Enantia chlorantha Oliv yields three alkaloids Palmatine (1), Jatrorrhizine (2), Columbamine (3), and β-Sitosterol (4). In this investigation, density functional theory (DFT) calculations were carried out to evaluate the electronic structure and properties of 1-4 by DFT-B3LYP/6-31G level of theory using Gaussian 09 software. Quantum molecular descriptors of the title compounds: ionization potential (IP) and Electron Affinities (EA), Hardness (η), Softness (S), Electronegativity (μ), Electrophilic Index (ω), Electron Donating Power (ω-), Electron Accepting Power (ω+) and Energy Gap (Eg) have been calculated. The in vitro cytotoxicity of the compounds was investigated against MCF-7, HCT116 cancer cell lines using Wi-38 cells as control. The compounds inhibited the proliferation of the MCF-7 and HCT116 cell lines and induced apoptosis via up-regulation of caspase-3, Bax, PARP cleavage, and downregulation of Bcl-2. DFT analyses revealed that compounds 1 and 3 have smaller energy gaps, 0.072 and 0.071eV, respectively, with the highest dipole moments, hence, more chemically reactive and exhibited better modulation of caspase-3 enzyme and inhibitory activities of the MCF-3 and HCT116 cell lines. The antimicrobial and antiparasitic evaluation of 1 - 4 showed moderate efficacy against the bacterial strains and moderate antiparasitic activity against Cichlidogyrus tilapia.

This study aimed to compare the survival of patients with isolated inguinal lymph node metastases from rectal cancer to patients with inguinal and additional synchronous distant metastases from rectal cancer who treated with curative intent. A retrospective review of all consecutive adult patients with rectal adenocarcinoma and inguinal lymph node involvement who underwent curative therapy at our institution from 2002 to 2020 was conducted. Patients were classified as having synchronous inguinal lymph node metastasis (SILNM), or synchronous inguinal lymph node and distant organ metastasis (SILNDOM). Patients in the SILNM group had a median overall survival of 75 months compared to 17.6 months in the SILNDOM group;p-value = 0.09. The recurrence-free survival for patients with SILNM was 19.6 months compared to 2.4 months in the SILNDOM group;p-value = 0.053. In conclusion, SILNM appears to represent a distinct subgroup of patients with metastatic rectal cancer. These patients warrant consideration of treatment with curative intent. Further studies are needed.

Purpose: One-third of patients with Crohn’s disease (CD) require multiple surgeries during their lifetime. So, reducing the incisional hernia rate is crucial. We aimed to define incisional hernia rates after minimally invasive ileocolic resection for CD, comparing intracorporeal anastomosis with Pfannenstiel incision (ICA-P) versus extracorporeal anastomosis with midline vertical incision (ECA-M). Methods: This retrospective cohort compares ICA-P versus ECA-M from a prospectively maintained database of consecutive minimally invasive ileocolic resections for CD performed between 2014 and 2021 in a referral center. Results: Of the 249 patients included: 59 were in the ICA-P group, 190 in the ECA-M group. Both groups were similar according to baseline and preoperative characteristics. Overall, 22 (8.8%) patients developed an imaging-proven incisional hernia: seven at the port-site and 15 at the extraction-site. All 15 extraction-site incisional hernias were midline vertical incisions [7.9%; p=0.025], and 8 patients (53%) required surgical repair. Time-to-event analysis showed a 20% rate of extraction-site incisional hernia in the ECA-M group after 48 months (p =0.037). The length of stay was lower in the intracorporeal anastomosis with Pfannenstiel incision group [ICA-P: 3.3±2.5 vs. ECA-M: 4.1±2.4 days; p=0.02] with similar 30-day postoperative complication [11(18.6) vs. 59(31.1); p=0.064] and readmission rates [7(11.9) vs. 18(9.5); p=0.59]. Conclusion: Patients in the ICA-P group did not encounter any incisional hernias while having shorter hospital length of stay and similar 30-day postoperative complications or readmission compared to ECA-M. Therefore, more consideration should be given to performing intracorporeal anastomosis with Pfannenstiel incision during Ileocolic resection in patients with CD to reduce hernia risk.

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

Symptomatic Uncomplicated Diverticular Disease (SUDD) is a syndrome within the diverticular disease spectrum, characterized by local abdominal pain with bowel movement changes but without systemic inflammation. This narrative review reports current knowledge, delivers practical guidance, and reveals challenges for the clinical management of SUDD. A broad and common consensus on the definition of SUDD is still needed. However, it is mainly considered a chronic condition that impairs quality of life (QoL) and is characterized by persistent left lower quadrant abdominal pain with bowel movement changes (eg, diarrhea) and low-grade inflammation (eg, elevated calprotectin) but without systemic inflammation. Age, genetic predisposition, obesity, physical inactivity, low-fiber diet, and smoking are considered risk factors. The pathogenesis of SUDD is not entirely clarified. It seems to result from an interaction between fecal microbiota alterations, neuro-immune enteric interactions, and muscular system dysfunction associated with a low-grade and local inflammatory state. At diagnosis, it is essential to assess baseline clinical and Quality of Life (QoL) scores to evaluate treatment efficacy and, ideally, to enroll patients in cohort studies, clinical trials, or registries. SUDD treatments aim to improve symptoms and QoL, prevent recurrence, and avoid disease progression and complications. An overall healthy lifestyle – physical activity and a high-fiber diet, with a focus on whole grains, fruits, and vegetables – is encouraged. Probiotics could effectively reduce symptoms in patients with SUDD, but their utility is missing adequate evidence. Using Rifaximin plus fiber and Mesalazine offers potential in controlling symptoms in patients with SUDD and might prevent acute diverticulitis. Surgery could be considered in patients with medical treatment failure and persistently impaired QoL. Still, studies with well-defined diagnostic criteria for SUDD that evaluate the safety, QoL, effectiveness, and cost-effectiveness of these interventions using standard scores and comparable outcomes are needed.

While the safety of laparoscopic redo ileocolonic resection for Crohn's disease has been described before, the safety of robotic redo ileocolonic resection is still unelucidated.This study aimed to share our preliminary experience regarding the safety of robotic redo ileocolonic resection for Crohn's disease.Retrospective analysis.Tertiary care center.All consecutive adult patients who underwent robotic ileocolonic resection for Crohn's disease at our institution between 2014 and 2021 were included. Patients were divided into redo ileocolonic resection and primary ileocolonic resection groups.Baseline demographics, preoperative risk factors, and intraoperative details were compared between both groups. The primary outcome was conversion to open, and secondary outcomes were 30-day postoperative complications.A total of 98 patients were included. Of them, 18 (18.4%) had a redo ileocolonic resection. Patients who had a redo ileocolonic resection were more likely to have a longer duration of disease, associated anoperineal disease, a higher number of previous lines of medical treatments, more likely to have received total parental nutrition before the operation for correction of malnutrition, and longer time for adhesiolysis. Patients who had redo ileocolonic resection had a higher risk for conversion to open [3 (16.7%) versus 2 (2.5%); p value 0.04]. There was no statistically significant difference regarding the overall length of stay and the 30-day morbidity between both groups. No 30-day mortality or anastomotic leaks occurred in either group.Retrospective nature of the analysis.Robotic redo ileocolonic resection showed similar short-term postoperative outcomes to robotic primary ileocolonic resection for Crohn's Disease. However, conversion rates are higher in robotic redo ileocolonic resection yet appear lower than previously published results in laparoscopic surgery. See Video Abstract at http://links.lww.com/DCR/C77.

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.

In the present paper, a new algorithm for solving the control problem in electrical power systems, is introduced. This new algorithm is based on the sliding mode property existing in variable structure system (VSS). The resulting control law is discontinuous by its nature. However, it does not require accurate informations about the system parameters or its manner of variation. The only requirements are the maximum and minimum limits of variation for each parameter, An adaptive controller is designed for an electrical power system, on the basis of that new algorithm The main function of the controller is the frequency control of the electrical power system, meanwhile, it can be used for stability improvement, Theoretical and computational results, using that controller insure the frequency control property in the electrical power system model. The adaptive property verifies under rapid and wide range of parameters variation and also, under the effect of a unit step external disturbance.

During COVID-19 pandemic, hospitals changed visitation policy to limit the infection spread. We aimed to evaluate the impact of evolving visitation policy on short-term surgical outcomes.All adult patients who underwent colorectal surgery between January 1A total of 439 patients were included. Of them, 128 (29.2%) patients had surgery during the NVA policy, and 311 (70.8%) patients underwent surgery during VA policy. Patients who had surgery during the NVA policy were more likely to have emergency surgery and a longer operation time. However, the other baseline characteristics, surgical approach, underlying disease, extent of resection, and the need for intraoperative blood transfusion were comparable between the two groups. There was no difference between both groups regarding the 30-day readmission rate (10.3% vs. 7.8% in the NVA group; P0.05) and median LOS (4 days vs. 3 days in the NVA group; P0.05).Restricting inpatient visitors for patients undergoing colorectal surgery was not associated with increased postoperative complications and readmission rates. LOS was similar between the two groups. This strategy can be safely implemented in cases of crisis. Further studies are needed to confirm these findings.

We aimed to determine a safe zone of intraoperative fluid management associated with the lowest postoperative complication rates without increased acute kidney injury (AKi) risk for elective colorectal surgery patients. To date, standard practice within institutions, let alone national expectations related to fluid administration, are limited. This fact has perpetuated a quality gap. Elective colorectal surgeries between 2018 and 2020 were included. Unadjusted odds ratios (ORs) for postoperative ileus, prolonged LOS, and AKi were plotted against the rate of intraoperative RL infusion (mL/ kg/h) and total intraoperative volume. Binary logistic regression analysis, including fluid volumes as a confounder, was used to identify risk factors for postoperative complications. A total of 2900 patients were identified. Of them, 503 (17.3%) patients had ileus, 772 (26.6%) patients had prolonged LOS, and 240 (8.3%) patients had AKI. The intraoperative fluid resuscitation rate (mg/kg/h) was less impactful on postoperative ileus, LOS, and AKI than the total amount of intraoperative fluid. A total fluid administration range between 300 mL and 2.7 L was associated with the lowest complication rate. Total intraoperative RL ≥2.7 L was independently associated with a higher risk of ileus (adjusted OR 1.465; 95% confidence interval 1.154-1.858) and prolonged LOS (adjusted OR 1.300; 95% confidence interval 1.047-1.613), but not AKI. Intraoperative RL ≤300 mL was not associated with an increased risk of AKI. Total intraoperative RL ≥2.7 L was independently associated with postoperative ileus and prolonged LOS in elective colorectal surgery patients. A new potential standard for intraoperative fluids will require anesthesia case planning (complexity and duration) to ensure total fluid volume meets this new opportunity to improve care.

Background Wheat is the most important crop around the world. Drought stresses affect wheat production and their characterization. Most of the traits that are affected by drought are quantitative traits, so detection of the quantitative trait’s loci (QTLs) related to these traits is very important for breeder and wheat producers. In this trend, 285 F2 individuals from crosses between four bread wheat genotypes (Triticum aestivum L.), i.e., Sakha93, Sids1, Sakha94, and Gemmiza9, were used for identified QTLs associated with plant height (PH) and leaf wilting (LW). Single marker analysis and composite interval mapping (CIM) were used. Results A total of 116 QTLs loci were detected which covered 19 chromosomes out of the 21 chromosomes of wheat. PH and LW had 74 and 42 QTLs loci, respectively. On the other hand, chromosome 7A showed to bear the highest number of QTLs loci (15 loci). While chromosome 1A beard the highest number of QTLs loci related to PH (10 loci), chromosome 2B and 7A beard the highest number of QTLs related LW. We highly recommend our finding to help breeders in wheat breeding programs to improve plant height and leaf wilting. Conclusion Our investigation concluded that SSR markers have high efficiency in the identification of QTLs related to abiotic stress; also the CIM method had more advanced priority for QTLs mapping.

Magnetic resonance imaging (MRI) is routinely used for preoperative tumor staging and to assess response to therapy in rectal cancer patients. The aim of our study was to evaluate the accuracy of MRI based restaging after neoadjuvant chemoradiotherapy (CRT) in predicting pathologic response. This multicenter cohort study included adult patients with histologically confirmed locally advanced rectal adenocarcinoma treated with neoadjuvant CRT followed by curative intent elective surgery between January 2014 and December 2019 at four academic high-volume institutions. Magnetic resonance tumor regression grade (mrTRG) and pathologic tumor regression grade (pTRG) were reviewed and compared for all the patients. The agreement between radiologist and pathologist was assessed with the weighted k test. Risk factors for poor agreement were investigated using logistic regression. A total of 309 patients were included. Modest agreement was found between mrTRG and pTRG when regression was classified according to standard five-tier systems (k = 0.386). When only two categories were considered for each regression system, (pTRG 0-3 vs pTRG 4; mrTRG 2-5 vs mrTRG 1) an accuracy of 78% (95% confidence interval [CI] 0.73-0.83) was found between radiologic and pathologic assessment with a k value of 0.185. The logistic regression model revealed that "T3 greater than 5 mm extent" was the only variable significantly impacting on disagreement (OR 0.33, 95% CI 0.15-0.68, P = .0034). Modest agreement exists between mrTRG and pTRG. The chances of appropriate assessment of the regression grade after neoadjuvant CRT appear to be higher in case of a T3 tumor with at least 5 mm extension in the mesorectal fat at the pretreatment MRI.

Although the overall adoption of minimally invasive surgery in the nonemergent management of ulcerative colitis is established, little is known about its utilization in emergency settings.The goal of this study was to assess rates of urgent and emergent surgery over time in the era of emerging biologic therapies and to highlight the current practice in the United States regarding the utilization of minimally invasive surgery for urgent and emergent indications for ulcerative colitis.This was a retrospective analysis study.Data were collected from the American College of Surgeons National Quality Improvement Program database.All adult patients who underwent emergent or urgent colectomy for ulcerative colitis were included.Rates of emergency operations over time and utilization trends of minimally invasive surgery in urgent and emergent settings were assessed. Unadjusted and adjusted overall, surgical, and medical 30-day complication rates were compared between open and minimally invasive surgery.A total of 2219 patients were identified. Of those, 1515 patients (68.3%) underwent surgery in an urgent setting and 704 (31.7%) as an emergency. Emergent cases decreased over time (21% in 2006 to 8% in 2018; p0.0001). However, the rate of urgent surgeries has not significantly changed (42% in 2011 to 46% in 2018; p = 0.44). Minimally invasive surgery was offered to 70% of patients in the urgent group (1058/1515) and 22.6% of emergent indications (159/704). Overall, minimally invasive surgery was increasingly utilized over the study period in urgent (38% in 2011 to 71% in 2018; p0.0001) and emergent (0% in 2005 to 42% in 2018; p0.0001) groups. Compared to minimally invasive surgery, open surgery was associated with a higher risk of surgical, septic, and overall complications, and prolonged hospitalization.This study was limited by its retrospective nature of the analysis.Based on a nationwide analysis from the United States, minimally invasive surgery has been increasingly and safely implemented for emergent and urgent indications for ulcerative colitis. Although the sum of emergent and urgent cases remained the same over the study period, emergency cases decreased significantly over the study period, which may be related to improved medical treatment options and a collaborative, specialized team approach. See Video Abstract at http://links.lww.com/DCR/B847 .ANTECEDENTES:Si bien se ha establecido la adopción generalizada de la cirugía mínimamente invasiva en el tratamiento electivo de la colitis ulcerosa, se sabe poco sobre su utilización en situaciones de emergencia.OBJETIVO:Evaluar las tasas de cirugía de urgencia a lo largo del tiempo en la era de las terapias biológicas emergentes y destacar la práctica actual en los Estados Unidos con respecto a la utilización de la cirugía mínimamente invasiva para las indicaciones de urgencia y emergencia de la colitis ulcerosa.DISEÑO:Análisis retrospectivo.AJUSTES:Base de datos del Programa Nacional de Mejoramiento de la Calidad del Colegio Americano de Cirujanos.PACIENTES:Todos los pacientes adultos que se sometieron a colectomía de emergencia o urgencia por colitis ulcerosa.MEDIDAS DE RESULTADO:Se evaluaron las tasas de operaciones de emergencia a lo largo del tiempo y las tendencias de utilización de la cirugía mínimamente invasiva en entornos de urgencia y emergencia. Se compararon las tasas de complicaciones generales, quirúrgicas y médicas de 30 días no ajustadas y ajustadas entre la cirugía abierta y la mínimamente invasiva.RESULTADOS:Se identificaron un total de 2.219 pacientes. De ellos, 1.515 pacientes (68,3%) fueron intervenidos de urgencia y 704 (31,7%) de emergencia. Los casos emergentes disminuyeron con el tiempo (21% en 2006 a 8% en 2018; p0,0001). Sin embargo, la tasa de cirugías urgentes no ha cambiado significativamente (42% en 2011 a 46% en 2018, p = 0,44). Se ofreció cirugía mínimamente invasiva al 70% de los pacientes del grupo urgente (1.058 / 1.515) y al 22,6% de las emergencias (159/704). En general, la cirugía mínimamente invasiva se utilizó cada vez más durante el período de estudio en grupos urgentes (38% en 2011 a 71% en 2018; p0,0001) y emergentes (0% en 2005 a 42% en 2018; p0,0001). En comparación con la cirugía mínimamente invasiva, la cirugía abierta se asoció con un mayor riesgo de complicaciones generales, quirúrgicas, sépticas y hospitalización prolongada.LIMITACIONES:Carácter retrospectivo del análisis.CONCLUSIÓNES:Basado en un análisis nacional de los Estados Unidos, la cirugía mínimamente invasiva se ha implementado de manera creciente y segura para las indicaciones emergentes y urgentes de la colitis ulcerosa. Si bien la suma de casos emergentes y urgentes permaneció igual durante el período de estudio, los casos de emergencia disminuyeron significativamente, lo que puede estar relacionado con mejores opciones de tratamiento médico y un enfoque de equipo colaborativo y especializado. Consulte Video Resumen en http://links.lww.com/DCR/B847 . (Traducción-Dr. Felipe Bellolio ).

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.

Robotic transanal minimally invasive surgery (R-TAMIS) is a novel and evolving technique with limited reported outcomes in the literature. Compared to the laparoscopic approach, R-TAMIS provides enhanced optics, increased degrees of motion, superior ergonomics, and easier maneuverability in the confines of the rectum. We report a single institution experience at a large quaternary referral academic medical center with R-TAMIS using the da Vinci Xi® platform. This is a retrospective review of electronic medical records at the Mayo Clinic from September 2017 to April 2020. It includes all available clinical documentations for patients undergoing R-TAMIS at our institution. Patient demographics, intraoperative data (procedure time, tumor size and distance), complications, and pathology reports were reviewed. A total of 28 patients underwent R-TAMIS. Median follow-up was 23.65 months. Sixteen patients underwent R-TAMIS for endoscopically unresectable rectal polyps, eight for rectal adenocarcinoma, two for rectal gastrointestinal stromal tumor, and two for rectal carcinoid tumor. The mean size of the lesions was 4.1 cm (range 0.2-13.8 cm). The mean location of lesions was 7.8 cm (range 0-16 cm) from the anal verge. The mean operative time was 132.5 ± 46.8 min. There was one 30-day complication, and no deaths. Twenty-three (82%) patients were discharged the day of surgery. R-TAMIS is a safe, feasible, and effective technique for the surgical treatment of a variety of rectal pathology. A hybrid technique can be used for the resecting tumors extending into the anal canal.

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.

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 0.001), but no statistical difference was found regarding ileus rate and length of stay. Overall, 30-day postoperative complication rate was 23.6% (ICA 22.2%, ECA 26.9%; p = 0.635). There were no abdominal septic complications, anastomotic leaks, or severe postoperative complications. In conclusion, robotic ileocolic resection for CD shows acceptable 30 days outcomes for both ICA and ECA. ICA was associated with a faster return to bowel function without impact on the length of stay or 30-day complications. Further studies are needed to confirm the benefits of ICA in the setting of ileocolic resections for CD.

Background There is controversy regarding the postoperative outcomes in Crohn’s disease [CD] patients exposed to vedolizumab [VDZ] or ustekinumab [UST]. We aimed to describe our surgical outcomes in patients who underwent minimally invasive ileocolonic resection [MIS-ICR] for CD who had preoperative biologic therapy. Methods All consecutive adult patients who had MIS-ICR for CD between 2014 and 2021 at our institution were included. Patients were divided into four groups: VDZ, UST, anti-tumour necrosis factor [anti-TNF], and no biologic group. Timing between the last dose of biologics and surgery was per surgeon’s discretion. The primary outcome was intra-abdominal septic complications. Secondary outcomes included all 30-day complications. Results A total of 274 patients were identified. Of these, 113 [41.2%] patients had received anti-TNF, 52 [19%] had received UST, and 19 [7%] had received VDZ. There was no difference between the four groups regarding baseline risk factors. There was no difference between the four groups regarding intra-abdominal septic complications [4.4% for no biologic, 5.3% for anti-TNF, 5.8% for UST, and 5.3% for VDZ; p = 0.987], surgical site infection rate, overall 30-day morbidity, overall 30-day readmission, overall surgical and medical complications, urinary tract infection, pulmonary infections, or length of stay. Those results were consistent after a subgroup analysis based on complexity of the disease. Conclusions This retrospective analysis demonstrates an equivalent postoperative safety profile for patients treated with preoperative anti-TNF, VDZ, or UST versus no biologic therapy within 3 months of MIS-ICR for Crohn’s disease. Preoperative biologic therapy may not increase complications after minimally invasive ileocolonic resection in Crohn’s disease. Further studies with larger sample sizes are needed to confirm results.

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.