Five Hundred Patients With Gut Malrotation: Thirty Years of Experience With the Introduction of a New Surgical Procedure.

OBJECTIVES: Define clinical spectrum and long-term outcomes of gut malrotation. With new insights, an innovative procedure was introduced and predictive models were established. METHODS: Over 30-years, 500 patients were managed at 2 institutions. Of these, 274 (55%) were children at time of diagnosis. At referral, 204 (41%) patients suffered midgut-loss and the remaining 296 (59%) had intact gut with a wide range of digestive symptoms. With midgut-loss, 189 (93%) patients underwent surgery with gut transplantation in 174 (92%) including 16 of 31 (16%) who had autologous gut reconstruction. Ladd's procedure was documented in 192 (38%) patients with recurrent or de novo volvulus in 41 (21%). For 80 patients with disabling gastrointestinal symptoms, gut malrotation correction (GMC) surgery "Kareem's procedure" was offered with completion of the 270° embryonic counterclockwise-rotation, reversal of vascular-inversion, and fixation of mesenteric-attachments. Concomitant colonic dysmotility was observed in 25 (31%) patients. RESULTS: The cumulative risk of midgut-loss increased with volvulus, prematurity, gastroschisis, and intestinal atresia whereas reduced with Ladd's and increasing age. Transplant cumulative survival was 63% at 10-years and 54% at 20-years with best outcome among infants and liver-containing allografts. Autologous gut reconstruction achieved 78% and GMC had 100% 10-year survival. Ladd's was associated with 21% recurrent/de novo volvulus and worsening (P > 0.05) of the preoperative National Institute of Health patient-reported outcomes measurement information system gastrointestinal symptom scales. GMC significantly (P ≤ 0.001) improved all of the symptomatology domains with no technical complications or development of volvulus. GMC improved quality of life with restored nutritional autonomy (P < 0.0001) and daily activities (P < 0.0001). CONCLUSIONS: Gut malrotation is a clinicopathologic syndrome affecting all ages. The introduced herein definitive correction procedure is safe, effective, and easy to perform. Accordingly, the current standard of care practice should be redefined in this orphan population.

The Macrophages and Intestinal Symbiosis.

The human intestinal tract is inhabited by trillions of microorganisms and houses the largest pool of macrophages in the human body. Being a part of the innate immune system, the macrophages, the professional phagocytes, vigorously respond to the microbial and dietary antigens present in the intestine. Because such a robust immune response poses the danger to the survival of the non-harmful and beneficial gut microbiota, the macrophages developed mechanisms of recognition and hyposensitivity toward the non-harmful/beneficial inhabitants of the gut. We will discuss the evolution and identity of some of these mechanisms in the following chapter.

Tranexamic Acid for Melasma Treatment: A Split-Face Study.

BACKGROUND: Melasma is an acquired hyperpigmented skin disorder. Tranexamic acid (TXA) prevents ultraviolet radiation induced pigmentation in melasma through interfering with the plasminogen-plasmin pathway. OBJECTIVE: This study was conducted to evaluate the therapeutic effect and safety of TXA by intradermal injection versus TXA with microneedling for melasma treatment. METHODS: Fifty-six female patients with bilateral symmetrical melasma were recruited in a split-face study. All patients received an intradermal injection of TXA on one side of the face, and the other side received TXA with microneedling for 6 sessions at 2 weeks intervals. Clinical efficacy was assessed using a modified Melasma Area Severity Index (mMASI) score at the baseline and after treatment. Global photographs underwent blinded review by 2 dermatologists. Patient self-assessment and satisfaction were recorded. RESULTS: After the treatment, the mMASI score was significantly reduced compared with the baseline in both treated sides (p < .001). No significant difference between both treated sides (p > .05). Patient satisfaction was higher in the microneedling-treated side than the intradermal-injected side (p < .001). No significant adverse effects were observed in both treated sides. CONCLUSION: Intradermal injection and microneedling of TXA could be safe and effective in melasma treatment. Microneedling of TXA was significantly more satisfying to the patients.

Siponimod (Mayzent) Downregulates RhoA and Cell Surface Expression of the S1P1 and CX3CR1 Receptors in Mouse RAW 264.7 Macrophages.

The Siponimod (Mayzent) is a newly developed drug, similar to Fingolimod (FTY720) but with fewer side effects, approved by the Food and Drug Administration for the treatment of multiple sclerosis (MS). The therapeutic effect of siponimod and FTY720 in MS relies on their inhibitory effect on the sphingosine 1-phosphate (S1P) signaling. These drugs bind to the S1P receptors and block the CCL2 chemokine pathway that is responsible for the exit of the immune cells from the lymphoid organs, and circulation, thus preventing immune cell-dependent injury to the nervous system. We recently found that FTY720 beside its effect on the S1P pathway also blocks the RhoA pathway, which is involved in the actin cytoskeleton-related function of macrophages, such as expression/recycling of fractalkine (CX3CL1) receptors (CX3CR1), which direct macrophages to the transplanted organs during the development of the long-term (chronic) rejection. Here we tested the effects of siponimod on the RhoA pathway and the expression of the S1P1 and CX3CR1 receptors in mouse RAW 264.7 macrophages. We found that siponimod downregulates the expression of RhoA protein and decreases the cell surface expression of S1P1 and CX3CR1 receptors. This newly discovered crosstalk between S1P and RhoA/CX3CR1 pathways may help in the development of novel anti-chronic rejection therapies in clinical transplantation.

Correlations Between Optical Coherence Tomography Angiography Parameters and the Visual Acuity in Patients with Diabetic Retinopathy.

AIM: The aim of this study was to assess the correlation between different optical coherence tomography angiography (OCTA) parameters and the best corrected visual acuity (BCVA) in patients with diabetic retinopathy (DR). PATIENTS AND METHODS: Sixty eyes of 60 participants were included in this prospective study: 40 diabetic patients [20 with non-proliferative diabetic retinopathy (NPDR group), 20 with proliferative diabetic retinopathy (PDR group)] and 20 age- and gender-matched normal healthy subjects (control group). After full ophthalmological examination and fundus fluorescein angiography, OCTA was performed for all participants. Quantitative OCTA parameters, such as the foveal avascular zone (FAZ) area, the superficial capillary plexus vessel density (%) (SCP-VD) and the deep capillary plexus vessel density (%) (DCP-VD) in, whole and parafoveal areas were measured. Correlations between BCVA and OCTA parameters were analyzed. RESULTS: There were no statistically significant differences between groups regarding age, gender, refraction, macular thickness or intraocular pressure. The median (IQR) FAZ area was 0.42 (0.39-0.46) mm2 in the NPDR group, 0.54 (0.45-0.65) mm2 in the PDR group and 0.24 (0.21-0.26) mm2 in the control group (P<0.001). The FAZ area increased with increasing severity of DR. SCP-VD and DCP-VD showed significant differences between groups (P<0.001). Vessel density (VD) was decreased in both DCP and SCP as DR progressed. There was a significant positive correlation between BCVA (LogMAR) and FAZ area. There were significant negative correlations between BCVA (LogMAR) and VD in both SCP and DCP. Stepwise multiple linear regression analysis demonstrated that SCP-VD in the whole area and DCP-VD in the parafoveal area were the best predictive factors for BCVA in the NPDR and PDR groups. CONCLUSION: With progression of DR, the VD decreased and the FAZ area increased, and both parameters were correlated with poor visual acuity. OCTA is a non-invasive tool which can be used to detect diabetic macular ischemia and help in the prediction of visual prognosis.

Functional and Structural Changes of the Retinal Nerve Fiber Layer and Ganglion Cell Complex in Heavy Smokers.

PURPOSE: To assess the functional and structural changes in the retinal nerve fiber layer (RNFL) and the ganglion cell complex (GCC) in heavy smokers using pattern electroretinogram (PERG), photopic negative response(PhNR) and spectral domain optical coherence tomography (SD-OCT). PATIENTS AND METHODS: Sixty eyes of 30 heavy smokers (at least 15 cigarettes/day for 10 years) (study group) and 60 eyes of 30 age and gender-matched healthy non-smoker subjects (control group) were included. After full ophthalmologic examination (PERG), (PhNR) using RETI-port/scan 21 (Roland Consult, Brandenburg, Germany) and (SD-OCT using Topcon 3D OCT model 2000 FA version.8.30) were tested for all participants. Statistical analysis was performed to compare GCC, RNFL thicknesses, PERG and phNR values between groups. RESULTS: The mean age was 36.67±4.13 years in the study group and 36.0±4.76 years in the control group. There were no statistical significant differences between the two groups regarding intraocular pressure (p=0.43), axial length (p=0.37), and central corneal thickness (p=0.86). There were significant differences of GCC thickness values between the study group (88.4±6.6 µm) and control group (94.83±5.25 µm) (p<0.001). The mean RNFL values of study and control groups were 97.87±5.88 and 106.43±6.59 µm, respectively (p<0.001). In the study group the superior and inferior quadrants of RNFL were significantly thinner, but there were no significant differences between the two groups in nasal and temporal quadrants. There were no significant differences of PERG-P50 amplitude (p=0.49) and latency (p=0.71); however, PERG-N95 amplitude and latency showed significant differences between the two groups (p<0.001).There were significant differences of phNR amplitude and latency between the two groups (p<0.001). Multiple regression analyses demonstrated that the PhNR, PERG amplitude and latency are the most important determinants for both RNFL and GCC thicknesses. CONCLUSION: In heavy smokers RNFL thickness was decreased, the PhNR, PERG-N95 amplitudes were diminished and the implicit times were prolonged compared to non-smokers. PhNR and PERG reflect both dysfunction and loss of ganglion cells and their axons.

Treatment of chronic extensive alopecia areata by diphenylcyclopropenone alone versus in combination with anthralin.

Alopecia areata (AA) is a chronic inflammatory, recurrent, tissue-specific autoimmune disease, mediated by autoreactive CD8+ T cells, occurring in genetically predisposed individuals. Targeting intrabulbar and peribulbar lymphocytic infiltrate by using squaric acid dibutyl ester and diphenylcyclopropenone (DPCP) in contact immunotherapy is by far the best chemotherapy for AA. The aim of this work was to evaluate the efficacy and safety of combination therapy with DPCP and anthralin in chronic extensive AA. A total of 24 patients (12 were treated only with DPCP and 12 with DPCP and anthralin for at least 24 weeks) were evaluated. Complete hair regrowth was observed in 62.5 and 18.2% of the patients who received DPCP and combination therapy, respectively (p = .04). Hair regrowth duration was different in both groups. The DPCP therapy is superior to the combination therapy with DPCP and anthralin in terms of efficacy, the time of onset of hair regrowth, and the time of completion of hair regrowth, Moreover, combination therapy has more side effects in combination therapy group have been discussed in this work.

Sublingual vs vaginal misoprostol for completion of first trimester missed abortion: a randomised controlled trial.

OBJECTIVE: The study aimed to compare the efficacy and safety of sublingual and vaginal misoprostol for termination of pregnancy in women with first trimester missed abortion. METHODS: A single-blind, parallel group, randomised clinical trial (ClinicalTrials.gov NCT02686840) was conducted in a university hospital between 1 February 2016 and 31 January 2017. All women who presented with first trimester missed abortion were invited to participate in the study and were randomised to one of two groups: one group received sublingual misoprostol in three doses of 800 µg every 4 h, while a second group received vaginal misoprostol in the same dosage regimen. The primary outcome of the study was the rate of complete abortion within 7 days after initiation of treatment. RESULTS: The study included 200 women (100 in each arm). By day 7, successful complete abortion was significantly more frequent in the sublingual misoprostol group (71.4%) than in the vaginal misoprostol group (51.5%) (p = .006). By day 30, the rate of complete abortion was higher in the sublingual misoprostol group (90.6%) than in the vaginal misoprostol group (83.9%), but with no statistically significant difference (p = .164). The mean length of the induction-expulsion interval in the sublingual misoprostol group was significantly shorter compared with the vaginal misoprostol group (12.3 ± 3.1 h vs 16.4 ± 4.2 h, respectively; p = .001) and the sublingual misoprostol group had a smaller drop in haemoglobin level (p = .001). The side effects of misoprostol were significantly more frequent in the sublingual group compared with the vaginal group. CONCLUSION: Sublingual misoprostol is more effective than vaginal misoprostol in completing first trimester missed abortion, with a shorter induction-expulsion time. Sublingual misoprostol is, however, associated with more side effects, such as unpleasant taste, gastrointestinal symptoms and fever, compared with vaginal misoprostol.

Urinary tract injuries during cesarean section in patients with morbid placental adherence: retrospective cohort study.

BACKGROUND/OBJECTIVE: The purpose of this study is to evaluate the cases of lower urinary tract injuries during cesarean section with or without hysterectomy in cases with morbid placental adherence. METHODS: This record based retrospective study was conducted at Ain Shams University Maternity Hospital in Cairo, Egypt during the period between January 2014 and December 2016. It included all patients who had urinary tract injuries during cesarean section with or without hysterectomy in the cases with morbid placental adherence and they were collected from files of pregnant women who were admitted at hospital planned for termination of pregnancy. Patients were enrolled in four groups, Group 1: cases without urinary tract injuries. Group 2: cases with injuries to the bladder. Group 3: cases with injuries of the ureter. Group 4: cases with injuries to the bladder and ureter. RESULTS: This study gave us new information about the incidence of urinary tract injuries during cesarean section with morbid adherence placenta was 21.7% (Bladder 11.7%, Ureter 4.7%, and bladder with ureter 5.3%). There were various types of repair of urinary tract injury, as the following, bladder repair 10.8%, ureteric catheterization 0.9%, ureterovesical repair or reimplantation 1.5%, bladder repair and ureterovesical 1.2%, bladder repair and ureteric catheterization 2.3%, ureteric catheterization and ureterovesical 1.5 and 6.4% of cases needed urologic consultations. There is a real relation between urinary tract injury and obesity (55.3%). Bladder invasion was found in only 26.9% of all cases according to sonography findings. Most of the cases were delivered by cesarean section in 67.5%, and the remainders were delivered by cesarean hysterectomy 32.5%. About 96.5% of cases needed a blood transfusion. CONCLUSIONS: The morbid adherent placenta is still a challenge, which faces us as obstetricians, due to high morbidity and mortality. A multidisciplinary team is mandatory to avoid complications.

Combination chemical peels are more effective than single chemical peel in treatment of mild-to-moderate acne vulgaris: A split face comparative clinical trial.

BACKGROUND: Successful management of acne involves choosing proper medication. Chemical peeling is a well-known option in treatment of acne vulgaris. OBJECTIVE: To evaluate and compare the clinical efficacy and safety of combination chemical peels vs single peel in treatment of mild-to-moderate acne. METHODS: The study included 45 patients with mild-to-moderate acne divided into three equal groups. Group A underwent combination sequential peels with modified Jessner's solution (MJ) followed by trichloro acetic acid (TCA20%) on the right (Rt) side of the face vs TCA 30% on the left (Lt) side. Group B was treated by combination peels of salicylic (20%) mandelic (10%) (SM) mixture on the Rt half vs salicylic acid 30% on the Lt half. Group C underwent combination sequential peeling of MJ and TCA on the Rt side vs SM combination peels on the Lt side. All patients received six sessions with 2-week intervals and followed up for 3 months after the last session. Side effects were reported. RESULTS: Both sides of the face showed significant improvement of acne lesions but improvement was significantly higher and earlier in sides treated by combination peels. Side effects were minimal. CONCLUSION: In conclusion, combination peels achieved a higher and earlier therapeutic response with a reasonable cost that is maintained for a relatively long periods than single peel. Combination sequential peels gave the best results.

Sweet's syndrome: diagnostic criteria revisited.

The diagnosis of Sweet's syndrome (SS) is based on a set of criteria that requires the presence of two major and at least two minor criteria. In some cases, however, the diagnosis is not as straightforward due to the absence of certain criteria. The objective of the present study was to review the clinical, histopathological, and laboratory features of the current diagnostic criteria for SS, and to evaluate their validity in the cases reported in the literature as well as in 40 patients treated at our institution. Our comprehensive review of the current criteria for SS reveals that the two major criteria have been consistently present in all cases - including ours - since the first description of SS in 1964. With regard to the minor criteria, on the other hand, there has been marked variability between different studies, and many cases failed to fulfill the requirement of showing two minor criteria. In order to simplify the diagnosis, avoid misdiagnosis, and allow for prompt treatment, we propose two sets of revised diagnostic criteria for SS. The first set comprises constant clinical and histopathological features that must be present and are by themselves sufficient for the diagnosis of SS to be established. The second set includes variable features whose absence does not warrant ruling out SS.