A rare case of massive hepatic abscess 6 years after ERCP due to retained biliary stent.

BACKROUND: ERCP combined with the insertion of biliary endoprosthesis is considered a daily practice endoscopic intervention for the treatment of choledocholithiasis. Nevertheless, retained biliary stents for a prolonged period without follow up may cause serious complications. CASE PRESENTATION: We present the case of a 62-year-old man who was hospitalized with symptoms of vomiting, abdominal pain, fatigue and fever. Clinical examination and laboratory results were indicative of an intra abdominal infection. Ultrasound and CT scans were performed, identifying a 17x11.3x7.7 cm. The cause of this lesion was a retained stent in the common bile duct which was placed 6 years ago via endoscopic retrograde cholangiopancreatography. The patient did not attend his follow up appointments after his initial ERCP. Patient's clinical status deteriorated, and an urgent ERCP was performed replacing the retained stent, followed by ultrasound-guided pigtail stent insertion into the hepatic abscess and administration of antibiotics intravenously. Patient's clinical condition was improved and after two months of surveillance complete resolution of the hepatic abscess was achieved. CONCLUSION: The insertion of biliary stents is common endoscopic technique, but close follow up is of outmost importance. J. Med. Invest. 70 : 508-512, August, 2023.

Zuska's disease in a male patient. The critical role of ultrasound imaging in diagnosis and management of this rare entity.

Zuska's disease is a pathologic entity characterized by the formation of subareolar breast abscess caused by the obstruction of lactiferous ducts. Although Zuska's disease is found relatively often in female patients, only 19 male cases have been reported. That makes Zuska's diagnosis challenging in males, leading to significant morbidity and high recurrence rates. Clinical evaluation and imaging techniques, especially ultrasound and mammography, are considered the cornerstones for the diagnosis of Zuska's disease, whereas fine-needle aspiration cytology is necessary in order to exclude malignancy. Multiple treatment approaches have been used including conservative antibiotic therapy, drainage of the abscess and surgical excision of the lactiferous ducts. We present the case of a 57 year old male who was diagnosed with Zuska's disease and treated via ultrasound-guided drainage of the abscess. Having a high level of suspicion, performing appropriate imaging tests and offering definite treatment, is the only way to decrease morbidity and recurrence.

An unusual case of mechanical bowel obstruction due to cholecysto-intestinal fistula and impacted gallstone: A case report and literature review.

Gallstone ileus is a rare entity and constitutes an uncommon complication of gallstone disease. It is caused by the impaction of a gallstone in the gastrointestinal tract and may cause serious symptoms or even life-threatening complications. It should be part of the differential diagnosis of acute abdomen especially in patients presenting with signs and symptoms of bowel obstruction and known gallstone disease. An early diagnosis is essential, and surgical treatment is the gold standard in order to relieve the obstruction. We present the case of an 84-year-old male patient with gallstone ileus due to cholecysto-intestinal fistula and impacted gallstone at jejunum. He was treated via urgent enterolithotomy, and his post-operative period was uneventful. This report aims to further educate clinical doctors on this rare medical condition which may pose a potentially serious health risk.

Anatomic Distribution of Benign Ovarian Tumors in Perimenopausal and Postmenopausal Women.

Introduction We aim to report the histotypes and reassess the anatomic distribution of benign ovarian tumors in perimenopausal and postmenopausal women. Methods Medical and pathology reports of women with histologically confirmed benign ovarian pathology were investigated. Data were collected, retrospectively between 2000 and 2020, and analyzed from perimenopausal and postmenopausal women with benign ovarian tumors, after bilateral salpingo-oophorectomy (BSO) with or without total abdominal hysterectomy (TAH). The ovarian masses histology and the distribution of locations were further evaluated. Results The total sample consisted of 1,355 women with benign ovarian tumors; 929 (68.6%) of the perimenopausal and 426 (31.4%) of the postmenopausal age. A dermoid cyst was prominent in the right ovary (52.8%), compared to the left side (41%) (p<0.01). Conversely, in patients with endometriomas and cysts of Morgagni, the observed proportion was more prominent in the left-sided ovary (61.8% vs 27%; p<0.001 and 52.3% vs 36.4%; p<0.01, respectively). Moreover, in the perimenopausal women, we mostly detected endometrioma (18.3%), dermoid cyst (15.5%) and cyst of Morgagni (4%) compared to postmenopausal women, where serous cysts (29.8%) and ovarian fibroids (8%) were the most common tumors. Conclusions Benign ovarian tumors are frequently seen in perimenopausal women and most histotypes present anatomical differences between the left and right ovaries. Serous cysts, followed by paraovarian, dermoid cysts and endometrioma present the commonest ovarian benign masses. Gynecologists should pay special attention to adnexal tumors in the postmenopausal period to choose the right operating setting for women at risk for ovarian cancer.

Post-operative antibiotics for cutaneous abscess after incision and drainage: Variations in clinical practice.

Background: Acute cutaneous abscess is a common surgical condition that mostly requires incision and drainage. Despite this, there is no standardized national or international guidance on post-operative antibiotics prescription. Traditionally, antibiotics are not indicated unless complications and/or risk factors such as immunocompromisation, diabetes or cellulitis exist. We aimed to study the local practice for post-operative antibiotics prescription for cutaneous abscesses in a UK university teaching hospital. Methods: Retrospective data collection for emergency general surgical admissions for a period of 6 months was carried out. All patients with cutaneous abscesses were included in this analysis. Scrotal, breast and limb abscesses were excluded. Patients' demographics, co-morbidities and complications, including local (cellulitis, necrosis) and systemic (e.g sepsis), were studied. Approval for access to patient data was granted by the local clinical governance department prior to the commencement of this study. Computations were performed using IBM SPSS version 26. Chi square (X 2), Pearson correlation (r), one or two samples t-test (one or two tailed) were applied. Results: A total of 148 patients were included. The mean age was 40 years (55 % males). The most common site of abscess was perianal (27.7 %), followed by pilonidal (20.3 %) and axilla (16.9 %). A total of 107 (73 %) were managed surgically with incision and drainage, and of these 92 (86 %) were managed within 24 h. Altogether, 83 (76 %) were prescribed post-operative antibiotics, while only 25 (23 %) had indications. The most used post-operative empirical antibiotics was co-amoxiclav (59 %). There was a significant relationship between 'abscess site' × 'antibiotics' [X 2 (36)=54.8, P=0.023]. A total of 103 patients' average duration of post-operative antibiotics was 7.2 (sd 2.9) days. Ten patients subject to readmission spent an average of 8.4 (sd 3.8) days on antibiotics. Conclusions: There were variations in clinical practice regarding post-operative antibiotic prescription for cutaneous abscesses. Research is required in the future in cooperation with microbiologists to develop a standardized evidence-based treatment protocol for the management of such a common surgical condition.

Abdominal hernia mesh repair in patients with inflammatory bowel disease: A systematic review.

BACKGROUND: Postoperative hernia-repair complications are frequent in patients with inflammatory bowel disease (IBD). This fact challenges surgeons' decision about hernia mesh management in these patients. Therefore, we systematically reviewed the hernia mesh repair in IBD patients with emphasis on risk factors for postoperative complications. METHOD: A systematic review was done in compliance with the PRISMA guidelines. A search was carried out on PubMed and ScienceDirect databases. English language articles published from inception to October 2021 were included in this study. MERSQI scores were applied along with evidence grades in agreement with GRADE's recommendations. The research protocol was registered with PROSPERO (CRD42021247185). RESULTS: The present systematic search resulted in 11,243 citations with a final inclusion of 10 citations. One paper reached high and 4 moderate quality. Patients with IBD exhibit about 27% recurrence after hernia repair. Risk factors for overall abdominal septic morbidity in Crohn's disease comprised enteroprosthetic fistula, mesh withdrawals, surgery duration, malnutrition biological mesh, and gastrointestinal concomitant procedure. CONCLUSION: Patients with IBD were subject, more so than controls to postoperative complications and hernia recurrence. The use of a diversity of mesh types, a variety of position techniques, and several surgical choices in the citations left room for less explicit and more implicit inferences as regards best surgical option for hernia repair in patients with IBD.

A Rare Case of Extended Retroperitoneal Biloma Due to Spontaneous Perforation of Common Bile Duct, Mimicking a Strangulated Right Inguinal Hernia: A Case Report and Literature Review.

BACKGROUND Biloma is the collection of bile outside the biliary tree as a result of visceral perforation. The most common site of disruption is the gallbladder, whereas common bile duct lesions usually occur following medical procedures or trauma. Spontaneous perforation of the common bile duct has been previously reported in the literature. Retroperitoneal biloma secondary to spontaneous perforation of the common bile duct is an extremely rare pathological entity. The purpose of this report is to inform clinical doctors of this rare entity, which can have fatal consequences for the patient. CASE REPORT We present the case of an 89-year-old man who was hospitalized with symptoms of vomiting, nausea, fatigue, and diffuse abdominal pain. The clinical examination and blood tests revealed peritonitis, a finding which was confirmed by the computed tomography of the abdomen as a retroperitoneal fluid collection, extending from the region posterior to the duodenum and head of the pancreas to the right inguinal fossa. As the patient's clinical status deteriorated, an urgent laparotomy was performed, revealing the presence of retroperitoneal biloma secondary to spontaneous perforation of the common bile duct. The operation was never completed as the patient died during the operation. CONCLUSIONS The diagnosis of this entity is difficult and is made during surgery. A large spectrum of treatment approaches has been used, but, regardless of the method, the goal is to halt the spreading abdominal contamination with bile and to treat the associated biliary pathology.

Laparoscopic Repair of a Rare Abdominal Wall Deformity and Review of the Literature.

Linea arcuate herniae (LAH) are rare and usually asymptomatic but can present with generalized abdominal pain in the absence of bulging and are impalpable. Diagnosis is dependent on cross-sectional imaging, and operative approach to their management is debatable. Here, we report the case of a 56-year-old female with abdominal pain diagnosed with a linea arcuate hernia by computed tomography (CT) scan. She went on to have laparoscopic primary suture closure of the hernial defect with reinforcing underlay mesh. LAH are effectively elucidated with CT. Although there are concerns regarding mesh-related complications, we advocate a laparoscopic approach and repair with prosthetic mesh reinforcement, fixated with sutures. Long-term follow-up of these patients is still required.

Co-existence of benign gynecological tumors with endometriosis in a group of 1,000 women.

The purpose of this study was two-fold, first to investigate the association between endometriosis and the risk of benign gynecologic tumors and, secondly, to evaluate the distribution of endometrioma and ovarian cysts in women with endometriosis. The medical and pathological reports of 1,000 women with endometriosis were retrospectively reviewed. The incidence of ovarian cysts, uterine leiomyomas and adenomyosis, as well as the side of ovarian cysts were further compared. A total of 295 cases of endometriomas, 172 cases of adenomyosis, 173 cases of ovarian cysts and 89 cases of uterine leiomyomas were confirmed histologically in patients with endometriosis. Serous cysts represented the most frequent diagnosis (n=81, 8.1%) in women with ovarian cysts, followed by dermoid cysts (n=15, 1.2%). In women with unilateral endometriomas, the observed proportion of left-sided cysts was found in 65.6% (164 of 250), significantly higher compared with right-sided cysts (86 out of 250, 34.4%) (P<0.001). Moreover, patients with other ovarian cysts were recognized as left-sided in 60% (96 out of 160) of cases, significantly higher compared with right-sided cysts (64 out of 160, 40%) (P<0.01). On the whole, the current study indicates that endometriosis may be associated with an increased risk of benign gynecological tumors, such as ovarian cysts, adenomyosis and leiomyomas. The results of this study confirm a left lateral predisposition of endometriomas and ovarian cysts.

Importance of Leadership Style towards Quality of Care Measures in Healthcare Settings: A Systematic Review.

Effective leadership of healthcare professionals is critical for strengthening quality and integration of care. This study aimed to assess whether there exist an association between different leadership styles and healthcare quality measures. The search was performed in the Medline (National Library of Medicine, PubMed interface) and EMBASE databases for the time period 2004-2015. The research question that guided this review was posed as: "Is there any relationship between leadership style in healthcare settings and quality of care?" Eighteen articles were found relevant to our research question. Leadership styles were found to be strongly correlated with quality care and associated measures. Leadership was considered a core element for a well-coordinated and integrated provision of care, both from the patients and healthcare professionals.

Approaches to teach evidence-based practice among health professionals: an overview of the existing evidence.

Health care professionals' adoption of evidence-based practice (EBP) remains limited, although most health care professionals are familiar with EBP and believe in its value. This systematic review aimed to bring together the best methods used to teach EBP to health professionals. The authors conducted a systematic search for the period 2005-2015 (an update of the search took place in October 2016) using PubMed interface (Medline). MeSH terms as well as free-text keywords were used. Studies were analyzed and evaluated by title and abstract. Those studies which fulfilled the inclusion criteria were assessed by full text. References of articles were also taken into consideration for identifying relevant studies not found through algorithm search. Twenty articles were found to be relevant. The majority of the studies were conducted among nurses (n=7) and physicians (n=6), and only a few among professionals from mixed disciplines (n=5). Two studies were conducted among chiropractors (n=1) and faculty members from a naturopathic and classical Chinese medicine institution (n=1). Researchers used a variety of different approaches, which varied with respect to duration and organization. We divided interventions into two categories. Single interventions included either a workshop, or a journal club, or a conference, or a lecture, or online learning tools, whereas multiple interventions included a combination of these approaches. An increase in EBP competencies and attitudes was reported in nine studies. Teaching methods for optimizing EBP among health professionals could become a robust standardized procedure of the medical educational curricula and lifelong learning of health care professionals.

Readiness for and predictors of evidence base practice in Greek healthcare settings.

BACKGROUND: Implementation of evidence-based practice (EBP) remains limited in healthcare settings and knowledge of predictors of healthcare professionals' EBP activities is lacking. AIM: Describe nurses' readiness for EBP and identify related predictors in Greek healthcare settings we conducted a survey. RESULTS: Nurses scored high in the EBP readiness scale reflecting significant positive readiness toward EBP and consistently reported favourable attitudes toward and beliefs about EBP. However, half of them were unsure about their ability to engage in EBP despite the fact that they valued research-based practice as important. EBP specific domains including the "EBP-attitude", the "EBP-knowledge", the "Informational needs" and the "Workplace culture" and nurses' demographics as well, were found to be strong predictors of EBP readiness among Greek nurses. CONCLUSION: As nurses are now more aware of and open to the idea of EBP, diverse strategies and well-designed interventions to facilitate the desired change to practice are needed.

Readiness for and predictors of evidence-based practice in Greek healthcare settings.

BACKGROUND: Implementation of evidence-based practice (EBP) remains limited in healthcare settings and knowledge of predictors of healthcare professionals' EBP activities is lacking. AIM: To describe nurses' readiness for EBP and identify related predictors in Greek healthcare settings. RESULTS: Nurses scored high in the EBP readiness scale reflecting significant positive readiness toward EBP and consistently reported favorable attitudes toward and beliefs about EBP. However, half of them were unsure about their ability to engage in EBP despite the fact that they valued research-based practice as important. EBP specific domains including the "EBP-attitude", the "EBP-knowledge", the "informational needs" and the "workplace culture" and nurses' demographics as well, were found to be strong predictors of EBP readiness among Greek nurses. CONCLUSION: As nurses are now more aware of and open to the idea of EBP, diverse strategies and well-designed interventions to facilitate the desired change to practice are needed.

Educational strategies for teaching evidence-based practice to undergraduate health students: systematic review.

PURPOSE: The aim of this systematic review was to find best teaching strategies for teaching evidence-based practice (EBP) to undergraduate health students that have been adopted over the last years in healthcare institutions worldwide. METHODS: The authors carried out a systematic, comprehensive bibliographic search using Medline database for the years 2005 to March 2015 (updated in March 2016). Search terms used were chosen from the USNLM Institutes of Health list of MeSH (Medical Subject Headings) and free text key terms were used as well. Selected articles were measured based on the inclusion criteria of this study and initially compared in terms of titles or abstracts. Finally, articles relevant to the subject of this review were retrieved in full text. Critical appraisal was done to determine the effects of strategy of teaching evidence-based medicine (EBM). RESULTS: Twenty articles were included in the review. The majority of the studies sampled medical students (n=13) and only few conducted among nursing (n=2), pharmacy (n=2), physiotherapy/therapy (n=1), dentistry (n=1), or mixed disciplines (n=1) students. Studies evaluated a variety of educational interventions of varying duration, frequency and format (lectures, tutorials, workshops, conferences, journal clubs, and online sessions), or combination of these to teach EBP. We categorized interventions into single interventions covering a workshop, conference, lecture, journal club, or e-learning and multifaceted interventions where a combination of strategies had been assessed. Seven studies reported an overall increase to all EBP domains indicating a higher EBP competence and two studies focused on the searching databases skill. CONCLUSION: Followings were deduced from above analysis: multifaceted approach may be best suited when teaching EBM to health students; the use of technology to promote EBP through mobile devices, simulation, and the web is on the rise; and the duration of the interventions varying form some hours to even months was not related to the students' EBP competence.

Single-stage laparoscopic management of acute gallstone pancreatitis: outcomes at different timings.

BACKGROUND: Definitive therapy for gallstone pancreatitis requires eradication of gallstones with cholecystectomy and common bile duct (CBD) clearance. Current guidelines recommend this be done within the same admission and preferably by laparoscopic cholecystectomy and CBD exploration. We report our experience of laparoscopic single-stage management with cholecystectomy and intraoperative cholangiogram followed by laparoscopic bile duct exploration (LBDE) when necessary performed at three different stages. METHODS: From January 1998 to December 2012, 134 patients (100 females and 34 males) underwent single-stage laparoscopic management of gallstone pancreatitis. Patients were classified according to the timing of surgery: "A", ≤7 days from symptom onset (n=27); "B", 8 to 30 days (n=58) and "C", >30 days (n=49). RESULTS: LBDE was performed in 30 patients with a success rate of 100%. CBD stones were found in 25 patients (A: 22.2%, B: 22.4%, C: 12.2%). CBD stones were more common in patients undergoing surgery within 30 days of presentation than after this time point (P=0.35). Multiple choledocholithiasis was more frequent in patients treated within 7 days (P=0.04). The 30-day mortality after surgery was 0, with no conversion to an open approach. Overall complication rate was 11.9%, which did not differ significantly between patients treated within 7 days or after this time point (P=0.83). CONCLUSIONS: This study demonstrated the feasibility and reproducibility of single-stage laparoscopic management of acute gallstone pancreatitis, which has a low complication rate at any stage. Patients undergoing early treatment have a higher incidence of choledocholithiasis and multiple stones than those treated after 30 days, supporting the passage of stones with time.

Tamoxifen induces a pluripotency signature in breast cancer cells and human tumors.

Tamoxifen is the treatment of choice in estrogen receptor alpha breast cancer patients that are eligible for adjuvant endocrine therapy. However, ∼50% of ERα-positive tumors exhibit intrinsic or rapidly acquire resistance to endocrine treatment. Unfortunately, prediction of de novo resistance to endocrine therapy and/or assessment of relapse likelihood remain difficult. While several mechanisms regulating the acquisition and the maintenance of endocrine resistance have been reported, there are several aspects of this phenomenon that need to be further elucidated. Altered metabolic fate of tamoxifen within patients and emergence of tamoxifen-resistant clones, driven by evolution of the disease phenotype during treatment, appear as the most compelling hypotheses so far. In addition, tamoxifen was reported to induce pluripotency in breast cancer cell lines, in vitro. In this context, we have performed a whole transcriptome analysis of an ERα-positive (T47D) and a triple-negative breast cancer cell line (MDA-MB-231), exposed to tamoxifen for a short time frame (hours), in order to identify how early pluripotency-related effects of tamoxifen may occur. Our ultimate goal was to identify whether the transcriptional actions of tamoxifen related to induction of pluripotency are mediated through specific ER-dependent or independent mechanisms. We report that even as early as 3 hours after the exposure of breast cancer cells to tamoxifen, a subset of ERα-dependent genes associated with developmental processes and pluripotency are induced and this is accompanied by specific phenotypic changes (expression of pluripotency-related proteins). Furthermore we report an association between the increased expression of pluripotency-related genes in ERα-positive breast cancer tissues samples and disease relapse after tamoxifen therapy. Finally we describe that in a small group of ERα-positive breast cancer patients, with disease relapse after surgery and tamoxifen treatment, ALDH1A1 (a marker of pluripotency in epithelial cancers which is absent in normal breast tissue) is increased in relapsing tumors, with a concurrent modification of its intra-cellular localization. Our data could be of value in the discrimination of patients susceptible to develop tamoxifen resistance and in the selection of optimized patient-tailored therapies.

A novel technique of needle-guided laparoscopic enucleation of insulinomas.

Insulinomas are rare, usually benign and solitary neuroendocrine tumors that cause oversecretion of insulin. Surgical excision remains the only treatment modality with the potential for cure. Compared to open extensive pancreatic resections, laparoscopic enucleation of these tumors offers effective treatment, and significantly reduced risks of complications. However, accurate tumor localization is extremely important, especially in cases of lesions deep seated into the head of the pancreas. We present here a novel technique of intraoperative localization of lesions that are not visible on the surface of pancreas. Using laparoscopic intraoperative ultrasound, tumors were located in the parenchyma of the pancreatic head and then an 18-G needle was inserted into the pancreatic lesion intraoperatively under laparoscopic sonographic guidance. The pancreatic parenchyma was then divided until the dome of tumor was visible, minimizing tissue trauma, and enucleation was performed. This technique is a useful tool that substantially improves the chances of successful laparoscopic enucleation of deep-seated small pancreatic insulinomas.

Co-existence of intramuscular spindle cell lipoma with an intramuscular ordinary lipoma:report of a case.

Spindle cell lipoma is a relatively rare adipocytic neoplasm, which usually occurs in the posterior neck, shoulder or upper back of male patients aged 45-65 years. We report here an unusual coexistence of ordinary and spindle cell lipoma. The patient presented with a painless mass in the area of the right scapula. Imaging was suggestive of a lipomatous mass, possibly liposarcoma. Histological examination revealed the concurrent existence of an intramuscular spindle cell lipoma and an ordinary lipoma. In the literature there are only fourteen cases of intramuscular spindle cell lipoma and only in four cases there was a coexisting mature lipoma. As exclusion of malignancy remains clinicians main concern,diagnosis and treatment of deep seated lipomatous tumors remains challenging.