Primary and isolated cutaneous precursor B-lymphoblastic lymphoma in an infant.

Cutaneous lesions may represent the initial sign of various neoplasms in children, including histiocytosis, neuroblastomas, and lymphomas. Primary cutaneous lymphoblastic lymphomas are rare and involve mostly the B-cell phenotype. Herein, we report a case of isolated, primary B-lymphoblastic lymphoma in a 7-month-old infant and emphasize the importance of early diagnosis.

Prognostic impact of the 2015 world health organisation classification of lung adenocarcinoma : a study in departement specialized in thoracic pathology.

BACKGROUND: The 2015 WHO classification of primary lung adenocarcinomas idendified not only new subtypes but also new prognostic groups. Solid and micropapillary adenocarcinomas are considered of bad prognosis, lepidici adenocarcinomas are considered of good prognosis and acinary and papillary ones are considered of intermediate prognosis. We aimed to assess the prognostic relevance of this classification through the experience of a specialized Department in Thoracic Oncology. METHODS: We described a survival study about 101 patients presenting primary adenocarcinomas diagnosed between 2008 and 2011. Survival curves were compared using the Log-Rank test. In order to assess the prognostic impact of the classification, 3 groups were formes: group 1 included lepidic adenocarcinomas, le group 2 included acinary and papillary subtypes and group 3 included solid subtype. A univariate analysis was performed to assess the age, sex, size, vascular emboli, lymph nodes, pTNM, histologic subtypes, neoadjuvant treatment and adjuvant treatment. Multivariate analysis using COX model was performed. RESULTS: There was no significant difference between the different subtypes. Besides, the multivariate analysis revealed the pTNM (p=0,02)  stage and the adjuvant treatment (p=0,007) as relevant prognostic factors. CONCLUSION: Our results are discordant with those reported in the literature. It seems that including large series is necessary in order to assess this prognostic classification.

[The 2015 classification of lung adenocarcinomas: Reproducibility in a Tunisian department specialised in thoracic pathology]. / La nouvelle classification 2015 des adénocarcinomes pulmonaires : reproductibilité au sein d'un service Tunisien spécialisé en pathologie thoracique.

INTRODUCTION: The new classification of lung cancer contains modifications of terminology and a new subdivision of the tumors with the most relevant modifications concerning the group of adenocarcinomas. The latter has been increasing and represents nowadays the most frequent type. Our aim was to assess the reproducibility of the new classification through the experience of a Department of Pathology specialized in thoracic pathology. METHODS: Our study included initially 106 cases diagnosed as adenocarcinomas and reviewed by 2 pathologists and 1 referee. Five cases were ruled out because they corresponded to squamous carcinoma according to the immunohistochemical findings. The same number of slides was reviewed without a limit of time. Statistical analysis was performed using the SPSS software. The Kappa index was estimated and a second coefficient: rho was analyzed. RESULTS: A total concordance was noticed in 82 cases (81.2%) and a discordance was noticed in 19 cases (18.8%). The agreement degree was good with an index Kappa estimated to 0.743 and a rho index reaching 0.763. CONCLUSION: Our study highlights the good reproducibility of the 2015 WHO classification of lung cancer among a trained team. Whereas, in order to improve the reproducibility of such a classification, even in non specialised departments, a training of the pathologists is necessary in order to highlight the prognostic impact of this classification.

Is CD10 antibody useful in the diagnosis of angioimmunoblastic T-cell lymphoma?

Angioimmunoblastic T-cell lymphoma (AITL) is a rare lymphoma accounting for less than 1% of non Hodgkin lymphomas. The lack of specific clinical and histologic features in addition to the multiplicity of morphologic mimickers makes the diagnosis challenging. Some authors reported the utility of CD10 antibody as a diagnostic marker. Our aim is to explore the value of this marker through a presentation of a study about four cases diagnosed over a six-year-period and a mini-review of the literature. We present a study of 4 cases of AITL diagnosed in lymph node biopsies. Microscopic findings showed in all cases early AITL characterized by a pattern I. The diagnosis of AITL was made in all cases based on the morphologic and immunohistochemical features. The CD3 antibody was expressed in all cases but CD10 antibody was negative in all cases. All the patients died and the initiation of a conventional chemotherapy wasn't possible in all cases because of the rapid course of the disease. Because of the small number of our cases, we can't rule out a possible diagnostic value of CD10 but its negativity in all our cases makes us doubt its sensitivity.

[Fatal pulmonary mycosis in a diabetic and cirrhotic patient]. / Une mycose pulmonaire d'issue fatale chez une patiente diabétique et cirrhotique.

Pulmonary mucormycosis is a rare, devastating, opportunistic fungal infection, caused by the ubiquitous filamentous fungi of the Mucorales order of the class of Zygomycetes. This infection occurs principally in some particular conditions, specially in diabetic patients and immunocompromised host, and rarely in cirrhotic patients. The diagnosis of mucormycosis can only be confirmed by pathological and mycological examination of biopsy specimens. We report a case of pulmonary mucormycosis in a 68-year-old woman with underlying liver cirrhosis and diabetes mellitus. Endoscopic and radiologic findings supported the diagnosis of hydatid cyst of the lung. The patient underwent surgical resection and was started on amphotericin B, after pathological examination. Unfortunately, she succumbed to the infection within one month of surgery.

Surgical management of a locally advanced jejunal stromal tumor: A case report of a challenging condition.

INTRODUCTION AND IMPORTANCE: Locally advanced jejunal stromal tumors stand as a captivating and relatively rare entity, garnering attention for several reasons. Their inaccessible location by conventional endoscopy poses a diagnostic challenge. Further, treatment decisions necessitate a multidisciplinary approach, compounded by the absence of high-level evidence studies. CASE PRESENTATION: A 54-year-old patient was admitted to our surgical department with abdominal pain and chronic anemia. Abdominal CT imaging confirmed the presence of a non-metastatic sizable jejunal tumor. The patient underwent laparotomy, revealing a locally advanced jejunal tumor contracting the ileum and the ascending colon. A monobloc oncological resection was performed, followed by the restoration of digestive continuity. Anatomopathological analysis delineated a locally advanced Stromal Tumor with a high risk of recurrence. The patient underwent a course of tyrosine kinase inhibitors for 3 years, with no reported recurrence during the subsequent 3-year follow-up. DISCUSSION: Locally advanced jejunal stromal tumors are rare. Most patients present with unspecific symptoms. Diagnosis remains challenging due to their intricate anatomical location. Decisions regarding management must be deliberated within a multidisciplinary framework, tailored to each patient's unique characteristics. While combined therapeutic modalities have demonstrated efficacy in recent studies, prudence is advised given the heightened incidence of both short and long-term complications. CONCLUSION: In the absence of randomized controlled trials, the management of locally advanced jejunal stromal tumors underscores the imperative of multidisciplinary collaboration in treatment deliberations. A wide, sometimes mutilating excision is only permissible if it is complete.

Large cell neuroendocrine carcinoma of the colon: An unexpected diagnosis: A case report.

INTRODUCTION AND IMPORTANCE: Large cell neuroendocrine carcinomas of the colon (LCNECC) are exceptionally rare, comprising only 0.2 % of all colonic carcinomas. Their diagnosis poses a significant challenge due to their propensity to mimic colonic adenocarcinomas. Typically diagnosed at advanced stages, LCNECCs carry a grim prognosis. Herein, we present a rare case of LCNECC and aim to elucidate its clinico-pathological characteristics. CASE PRESENTATION: A 56-year-old female patient presented with complaints of constipation, abdominal pain, and weight loss. On physical examination, a sizable mass was palpable in the right flank. Colonoscopy revealed a polyp in the descending colon and a friable multinodular stenosing mass in the ascending colon. Microscopic examination of the biopsy from the ascending colon mass exhibited a poorly differentiated large cell carcinomatous proliferation with positivity for synaptophysin and CD56, along with a Ki-67 proliferation index of 50 %. The polyp in the descending colon was consistent with a low-grade dysplastic tubular adenoma. A diagnosis of LCNECC with synchronous low-grade dysplastic tubular adenoma was established. A right hemicoloctomy was performed. Final pathological examination confirmed LCNECC invading the muscularis propria, with lymph node metastases. The tumor was classified as pT2N1M0 (Stage III). CLINICAL DISCUSSION: LCNECCs often mimic adenocarcinomas clinically, endoscopically, and radiologically. Pathological examination is the key for diagnosis. An immunohistochemical study using neuroendocrine markers is imperative to prevent overlooking the diagnosis of LCNECC. CONCLUSION: LCNECCs represent rare aggressive carcinomas. Their diagnosis might be challenging. A better knowledge of this rare entities would enable early diagnosis.

Management of a small bowel hemangioma causing intussusception in an infant: A rare case report and literature review.

INTRODUCTION: Hemangiomas of the small intestine are rare and usually present in young people. They are very difficult to diagnose preoperatively. We report a rare case of mixed intestinal hemangioma (IH) causing intussusception in a pediatric patient. CASE PRESENTATION: A 3-month-old girl, with no prior medical or surgical history, was admitted with rectal bleeding and paroxysmal crying due to intermittent abdominal pain. An urgent abdominal ultrasound revealed ileo-ileal intussusception. Operative findings confirmed the intussusception, and a segmental resection of the intussuscepted jejunum was performed. Histopathological examination found a mixed hemangioma. The postoperative course was uneventful. DISCUSSION: Clinical presentation may include intestinal bleeding leading to anemia, obstruction, intussusception and perforation. Intussusception caused by small bowel hemangioma is extremely rare. Notably, we didn't find any cases of small bowel hemangioma revealed by intussusception in children. The main treatment for hemangiomas is surgical resection of the affected segment. No evidence in the literature on postoperative recurrence of hemangiomas. CONCLUSION: Intussusception secondary to intestinal hemangiomas is extremely rare. Preoperative diagnosis is challenging as they are often undetectable with traditional techniques. Enhanced awareness and understanding of this condition can facilitate earlier diagnosis and improve management outcomes.

Spontaneous rupture of a normal spleen: A case report and a review of the literature emphasizing diagnostic and surgical challenges.

INTRODUCTION: Spontaneous splenic rupture (SSR) is a rare but potentially fatal condition. It is commonly linked to underlying conditions such as infections, neoplasms, or hematologic diseases. SSR can also occur in a healthy spleen without any associated pathology, termed idiopathic splenic rupture. Symptoms range from non-specific abdominal pain to hemodynamic instability, often requiring emergency splenectomy. Early recognition using CT is crucial for improving outcomes. CASE PRESENTATION: A 32-year-old male presented with severe abdominal pain for 24 h. Examination showed stable hemodynamics but tenderness in the left upper quadrant. CT revealed a subcapsular hematoma and moderate hemoperitoneum, leading to a diagnosis of SSR. Initially managed conservatively, the patient developed hemorrhagic shock 24 h later, with hemoglobin decreasing to 6.2 g/dL. An exploratory laparotomy confirmed a superior pole splenic fracture with significant hemoperitoneum, necessitating a total splenectomy. Postoperative recovery was uneventful, and the patient was discharged on postoperative day 6 with prophylactic vaccinations and lifelong penicillin. DISCUSSION: SSR in a normal spleen is extremely rare and poses significant diagnostic and therapeutic challenges. The exact mechanisms are unclear, with theories including vascular anomalies, microtrauma, increased splenic pressure, and idiopathic factors. SSR symptoms are often non-specific, leading to misdiagnosis. Timely diagnosis using imaging, particularly contrast-enhanced CT, is essential. Management varies from conservative approaches to splenectomy, based on hemodynamic stability and splenic damage. CONCLUSION: Spontaneous rupture of a normal spleen is a critical condition requiring high clinical suspicion for timely diagnosis and management. Further research is needed to understand its pathophysiology and risk factors.

Epidemiological and histopathological characteristics of thyroid carcinoma in a Tunisian health care center.

Background: Thyroid carcinoma (TC) accounts for almost 0.5%-1% of total malignancies. Its incidence is increasing rapidly worldwide. Several studies have drawn up the epidemiological profile of TC and its clinical and pathological features. However, to date, no similar studies have been conducted in Tunisia. Aims: To establish an epidemiological profile of TC in a Tunisian health care institute and to analyze its clinical and histopathological characteristics in our institute. Materials and Methods: We present a retrospective study reviewing the cases of TC diagnosed in our institution in a 4-year period. Results: We collected a sample of 192 cases of TC. It consisted of 31 males and 161 females (83.8%) with a sex-ratio M/F of 0.19. The mean age was 46.4 years. Papillary thyroid carcinoma was the most frequent histological subtype. The multifocality rate was 33.8%. The mean size of TC was 2.2 ± 1.9 cm. 60.9% of TC were staged pT1 and 20.3% had nodal involvement. Papillary thyroid microcarcinomas were noted in 37.5% of cases. Conclusion: Our results were consistent with those of the literature. A high proportion of pT1 and pN0 tumors were noted in our series, suggesting that TC's diagnosis and management was performed at an early stage of the disease in our institution. In addition, our study enabled us to notice the impact of the Coronavirus disease 19 crisis on the management of TC in our institution. Further studies are needed to establish the epidemiological profile of TC in Tunisia and to assess its clinical and pathological features.

Respiratory epithelial adenomatoid hamartoma: A rare differential diagnosis of sinonasal mass.

Sino-nasal respiratory epithelial adenomatoid hamartomas (REAHs) are rare entity. They are benign tumors with excellent results after complete excision. We report a case of a 57-year-old male with a history of endoscopic surgery for right nasal polyps 20 years ago. The patient presented nasal obstruction that persisted for 10 years without anosmia nor epistaxis. Nasal endoscopy found a tissular mass filling the right nasal cavity extending to the nasopharynx. CT scan and MRI demonstrated soft tissue opacification of the right maxillary sinus and the homolateral anterior ethmoid cells with extension to the nasal cavity. The suspected diagnosis on imaging was an Inverted papilloma with a wide implantation base on the posterior part of the nasal septum. No endocranial or orbital extension was noted. The patient underwent endoscopic sinus surgery with complete extirpation of the tumor and a right ethmoidectomy. Histopathological assessment showed features consistent with REAH. No recurrence was noted at 1 year follow-up.

A rare coexistence of sarcoidosis with overlap syndrome and sarcoidosis with primary biliary cholangitis and Sjogren's syndrome: Two distinct case reports.

Sarcoidosis and the overlap syndrome of autoimmune hepatitis and primary biliary cholangitis (PBC) share common clinical, biological, and histological features. The simultaneous occurrence of these diseases have been reported in few cases and suggests that a common pathway which may contribute to granuloma formation in both conditions. We report the cases of two female patients having an association of sarcoidosis and inflammatory liver diseases. The first case is of a 61-year-old woman had been monitored for an overlap syndrome of PBC and autoimmune hepatitis (AIH). Therefore, treatment with azathiprine has been initiated associated with ursodeoxycholic acid (UDCA). Azathioprine had to be discontinued due to digestive intolerance, specifically chronic diarrhea and abdominal pain. The patient remained clinically stable on UDCA and her liver function tests were stable for years, until she developed symptoms of progressive dyspnea without any other associated signs. Chest computed tomography (CT) revealed mediastinal enlargement, bilateral pulmonary nodules, and symmetrical adenomegalies in the mediastinum. The bronchoalveolar lavage (BAL) revealed increased cellularity, with a notable elevation in lymphocyte count (48 %) and a CD4/CD8 ratio of 4. The patient underwent mediastinoscopy; a biopsy of the right laterotracheal (4R) adenomegaly was performed. Histological examination of the lymph node showed epithelioid and giant-cell tuberculoid lymphadenitis without necrosis, compatible with sarcoidosis. Ophthalmological and cardiac assessments were normal. Plethysmography test was normal and there was no need for corticosteroid treatment; a surveillance was planned. Treatment with UDCA was pursued. The second case is of a 50-year-old woman with no medical history presented symptoms including dry eyes and mouth, inflammatory-type polyarthralgia affecting knees and wrists, bilateral Raynaud's phenomenon, right hypochondrium pain, and worsening dyspnea over six months. Liver analysis showed elevation of alkaline phosphatase (ALP) to three times upper limit of normal (ULN) and gamma-glutamyltransferase (GGT) to 5 times ULN. This cholestasis was associated with an increase in transaminase activity to 5 times ULN for over six months. Immunological tests revealed positive anti-nuclear antibodies (ANA), anti-Ro52, anti-M23E, and anti-centromere antibodies. Chest-CT showed multiple bilateral bronchiolar parenchymal micronodules mostly in the upper and posterior regions without any mediastinal adenomegaly. Bronchial endoscopy was normal, and biopsies indicated chronic inflammation. The BAL revealed increased cellularity, characterized by a high lymphocyte count (51.7 %) and a CD4/CD8 ratio of 2.8. Biopsy of minor salivary gland revealed grade 4 lymphocytic sialadenitis. Skin biopsy revealed an epithelioid granuloma without caseous necrosis. Liver biopsy performed in the presence of cytolysis and moderate hepatic insufficiency, revealed granulomatous hepatitis and cholangitis lesions along with septal fibrosis suggestive of PBC. The diagnosis of cutaneous and pulmonary sarcoidosis with PBC and Sjögren's syndrome was retained. The spirometry and diffusing capacity for carbon monoxide value were normal. Treatment involved UDCA, corticosteroids, and azathioprine, leading to clinical and biological improvement. Sarcoidosis shares some clinical manifestations with autoimmune liver diseases, primarily PBC. A hepatic granuloma with a different appearance and location can guide the diagnosis. Early diagnosis and appropriate management can avoid serious complications and improve prognosis.

A dataset of tumour-infiltrating lymphocytes in colorectal cancer patients using limited resources.

In the realm of cancer research, specifically focusing on colorectal carcinomas (CRCs), a novel diagnostic test referred to as 'Immunoscore' (IS) has emerged. This test relies on assessing the density of tumour-infiltrating lymphocytes, specifically CD3 and CD8, in both the centre of the tumour (CT) and its invasive margin (IM). IS holds promise as a potential prognostic factor. A retrospective descriptive study was conducted within the Pathology Department of Habib Thameur Hospital in Tunis, Tunisia. The study's aim was to evaluate the prognostic efficacy of IS for patients with CRC by means of a comprehensive survival analysis. This publication introduces the immunoscore in colorectal cancer (ISCRC) dataset, which was meticulously compiled during the aforementioned study. The ISCRC dataset comprises digital slide images sourced from biopsies of 104 patients diagnosed with CRC. Using the tissue microarray technique, an immunohistochemical investigation involving anti-CD3 and anti-CD8 markers was performed in regions designated as 'Hot Spots' within the CT and IM. The images were captured using a smartphone camera. Each marker's percentage presence within its respective region was quantified. The IS was estimated utilizing a semi-quantitative method. The ISCRC dataset encompasses anonymized personal data, along with macroscopic and microscopic attributes. The captured images, acquired through manual efforts using smartphones, stand as a valuable asset for the advancement of predictive algorithms Importantly, the potential applications of these models extend beyond mere prediction capabilities. They lay the groundwork for innovative mobile applications that could potentially revolutionize the practices of pathologists, particularly in healthcare settings constrained by resources and the absence of specialized scanning equipment. Database URL: https://figshare.com/s/5b4fa3e58c247a4851d4.

Pelvic leiomyoma associated with intermediate risk prostate cancer: A case report.

Pelvic leiomyoma in male patients is a very rare occurrence and its association with prostate cancer is a unique clinical situation. This study reports a new case of a 9 cm pelvic Leiomyoma associated with intermediate-risk localized prostate cancer in a 68-year-old patient. The leiomyoma was discovered fortuitously after an MRI was performed in the context of prostate cancer work-up. Surgical excision of the pelvic mass along with a radical prostatectomy were performed and the diagnosis of leiomyoma was confirmed by histopathology.

Incidental discovery of a Hodgkin lymphoma synchronous to a papillary thyroid carcinoma.

Papillary thyroid carcinoma is the most common type of thyroid cancer and accounts for almost 89.4% of all thyroid carcinomas. Hodgkin lymphoma is a heterogeneous group of neoplasms and represents 10% of lymphomas. These two cancers do not share the same risk factors. Some studies have reported the association of thyroid papillary carcinoma with lymphomas, mainly Hodgkin's lymphoma, treated with radiotherapy. However, to our knowledge less than 10 cases have illustrated synchronous papillary thyroid carcinoma and Hodgkin lymphoma with no history of radiotherapy. We present the case of a 49-year-old female patient, with no history of past exposure to radiation, who was incidentally diagnosed with Hodgkin lymphoma during the work up for papillary thyroid carcinoma. Our patient had total thyroïdectomy with cervical lymphadenectomy. The histopathologic examination concluded to a papillary thyroid carcinoma of classical variant. And the lymph node dissection enabled us to diagnose not only papillary thyroid carcinoma's lymph node metastasis, but also Hodgkin Lymphoma. This discovery of the Hodgkin lymphoma was totally incidental. The discovery of synchronous tumors in patients with papillary thyroid carcinoma has been reported in the literature. However, the diagnosis of Hodgkin through lymph node dissection for papillary thyroid carcinoma is extremely rare. This underlines the singularity and the importance of our case. The synchronous papillary thyroid carcinoma and Hodgkin lymphoma is a rare condition, which may pose significant diagnostic and treatment dilemmas. To date, there is no standardized approach due to lack of experience. The molecular mechanisms of this link are poorly understood and yet remain to be elucidated.

Hemangioma of the umbilical cord: A case report on a rare entity.

Several hundred cases of placental hemangiomas have been reported in the literature. However, the umbilical cord is extremely uncommon as a site of occurrence. We present a case of postnatal discovery of giant hemangioma of the umbilical cord (HUM) in a Coronavirus Disease 2019 (COVID 19) positive mother. To our knowledge, this is the first reported case of HUM synchronous to a maternal infection with COVID 19. We aim, through this case and a review of the literature, to study the clinicopathological characteristics of this singular entity. Our patient, a 37-year-old woman, presented to the Department Of Obstetrics And Gynecology for respiratory distress and loss of fetal movements. Ultrasound examination concluded to intrauterine fetal desmise. After stabilization of the patient, a cesarean section was performed. A macerated fetus was extracted. Placenta showed a giant mass attached to the cord. It was submitted for pathological examination. Gross examination showed that the umbilical cord was inserted eccentrically with a fusiform dilation. Near its placental end, three cohesive solid angiomatous nodules were noted. Microscopic examination revealed lobules of dilated blood-filled capillaries set in a myxoid stroma. The diagnosis of HUM have been established. HUM arise from endothelial cells of the umbilical vessels. Their etiology, physio-pathology and pathways of tumorigenesis are not yet well defined. Further studies are needed to explore the pathways of tumorigenesis and to determin the implication of COVID-19 in HUM.

Breast rescue after necrotizing fasciitis.

Necrotizing fasciitis is a dangerous and rapidly spreading infection of soft tissue involving skin, subcutaneous tissue and fascia; muscles can be concerned but often omitted. It's considered as emergency due to its fulminant nature. The necrotizing fasciitis of the breast is exceptional. Management is based on surgical debridement and, in the case of breast, mastectomy in most cases is inevitable. We describe a case-report of breast necrotizing fasciitis with prompt management and with satisfactory cosmetic result owing to dermal autograft.

Splenogonadal fusion: A case series of two challenging diagnoses.

Splenogonadal fusion is an abnormal connection between the spleen and gonads. This rare entity can be easily confused with testicular tumors. It usually accompanies congenital malformations, such as cryptorchidism, making diagnosis more difficult. Surgeons must be aware of this entity to avoid unnecessary orchiectomy. In some cases, biopsy may help with diagnosis.

Case Report: Incidental discovery of primary peritoneal psammocarcinoma.

Psammocarcinoma is an uncommon subtype of low-grade serous carcinoma. It is characterized by the presence of extensive psammoma bodies and can have either an ovarian or peritoneal origin. To our knowledge fewer than 30 cases of primary peritoneal psammocarcinoma (PPP) have been reported in the English literature. We report a rare case of  PPP in a 74-year-old female, discovered fortuitously within a laparotomy for gallbladder lithiasis. At laparotomy, multiple nodular implants involving the omentum, the peritoneum and a magma of intestinal loops in the right iliac fossa were noted. A biopsy from nodules was performed. Gross examination showed multiple nodules of different sizes in the fat tissue. Pathologic examination showed massive psammoma bodies representing more than 75% of the tumor. The final diagnosis was psammocarcinoma. Our patient was referred to the gynecologic department for further investigation and to ascertain whether the tumor arose from the ovaries or peritoneum. Hysterectomy, bilateral adnexectomy and omentectomy were performed. Macroscopic examination showed that both ovaries were intact having a normal size. No invasion of ovarian stroma was shown in microscopic examination. The patient died of SARS-CoV-2 (COVID-19) six days after the surgery. PPP is a rare type of  low-grade serous carcinoma. The behavior of this tumor is unclear, and the treatment is not standardized because of its rarity and lack of long-term follow-up. More cases need to be studied for better understanding and improvement of the management protocols.