The use of tamsulosin to prevent postoperative urinary retention in laparoscopic inguinal hernia repair: a randomized double-blind placebo-controlled study.

PURPOSE: The rate of postoperative urinary retention (POUR) in laparoscopic inguinal hernia repairs is 1-22%. POUR may cause patient anxiety, discomfort, and increased hospital costs. Currently there is no standard prophylaxis for POUR. Preoperative administration of tamsulosin has been shown to decrease POUR rates in urologic studies. This study aims to evaluate the efficacy of tamsulosin on the incidence of POUR in patients undergoing totally extraperitoneal (TEP) LIHR. METHODS: A randomized, double-blinded, placebo-controlled trial was initiated and accrued patients from 2017 to 2019. A total of 169 males undergoing elective TEP LIHR were included. Patients were administered tamsulosin 2 h before surgery and followed for up to 24 h postoperatively for episodes of POUR. Analysis was performed to quantify the association between patient, surgical, and perioperative factors with POUR. RESULTS: The overall rate of POUR was 9%. There was no difference in the rate of POUR between the placebo (9.9%) and tamsulosin groups (7.9%) (p = 0.433). Univariate analysis showed a trend toward POUR in patients with history of benign prostatic hypertrophy (BPH) (p = 0.058). Previously reported risk factors of older age, total IVF, length of procedure and opioid use were not associated with increased rates of POUR. Tamsulosin reduced the time to discharge by 4 to 68 min when compared to placebo. CONCLUSIONS: This study suggests that preoperative administration of tamsulosin may not reduce the risk of POUR in males undergoing elective TEP LIHR. Further study with a larger sample size may be needed to show a statistically significant difference.

Central role of liver in anticancer and radioprotective activities of Toll-like receptor 5 agonist.

Vertebrate Toll-like receptor 5 (TLR5) recognizes bacterial flagellin proteins and activates innate immune responses to motile bacteria. In addition, activation of TLR5 signaling can inhibit growth of TLR5-expressing tumors and protect normal tissues from radiation and ischemia-reperfusion injuries. To understand the mechanisms behind these phenomena at the organismal level, we assessed nuclear factor kappa B (NF-κB) activation (indicative of TLR5 signaling) in tissues and cells of mice treated with CBLB502, a pharmacologically optimized flagellin derivative. This identified the liver and gastrointestinal tract as primary CBLB502 target organs. In particular, liver hepatocytes were the main cell type directly and specifically responding to systemic administration of CBLB502 but not to that of the TLR4 agonist LPS. To assess CBLB502 impact on other pathways, we created multireporter mice with hepatocytes transduced in vivo with reporters for 46 inducible transcription factor families and found that along with NF-κB, CBLB502 strongly activated STAT3-, phenobarbital-responsive enhancer module (PREM), and activator protein 1 (AP-1-) -driven pathways. Livers of CBLB502-treated mice displayed induction of numerous immunomodulatory factors and massive recruitment of various types of immune cells. This led to inhibition of growth of liver metastases of multiple tumors regardless of their TLR5 status. The changed liver microenvironment was not, however, hepatotoxic, because CBLB502 induced resistance to Fas-mediated apoptosis in normal liver cells. Temporary occlusion of liver blood circulation prevented CBLB502 from protecting hematopoietic progenitors in lethally irradiated mice, indicating involvement of a factor secreted by responding liver cells. These results define the liver as the key mediator of TLR5-dependent effects in vivo and suggest clinical applications for TLR5 agonists as hepatoprotective and antimetastatic agents.

Eccrine Porocarcinoma Presenting as a Hand Cyst.

Eccrine porocarcinoma is a rare tumor that arises from the epithelium of the eccrine ducts, with a tendency for metastatic spread and a high rate of local recurrence after excision. It was first described in 1963 by Pinkus and Mehregan and can present clinically as a nodule, erosive plaque or a polypoid growth that may ulcerate. The variable clinical appearance of these lesions can make diagnosis challenging and could delay appropriate treatment. If metastasis occurs the prognosis is poor, with a reported mortality rate of up to 80%. We report an uncommon presentation of porocarcinoma as a cyst on the dorsum of the right hand in a 37-year-old man. Only 8% of porocarcinomas occur in the upper extremity and only 3% are on the hand. Furthermore, the tumor is more common in females and mean age at diagnosis is 67 years. Treatment is with wide local excision with free tumor borders confirmed by biopsy, which has been shown to be curative in 70% to 80% of patients.

Photodynamic therapy (PDT) using HPPH for the treatment of precancerous lesions associated with Barrett's esophagus.

BACKGROUND AND OBJECTIVES: Photodynamic therapy (PDT) with porfimer sodium, FDA approved to treat premalignant lesions in Barrett's esophagus, causes photosensitivity for 6-8 weeks. HPPH (2-[1-hexyloxyethyl]-2-devinyl pyropheophorbide-a) shows minimal photosensitization of short duration and promising efficacy in preclinical studies. Here we explore toxicity and optimal drug and light dose with endoscopic HPPH-PDT. We also want to know the efficacy of one time treatment with HPPH-PDT. STUDY DESIGN/MATERIALS AND METHODS: Two nonrandomized dose escalation studies were performed (18 patients each) with biopsy-proven high grade dysplasia or early intramucosal adenocarcinoma of esophagus. HPPH doses ranged from 3 to 6 mg/m2 . At 24 or 48 hours after HPPH administration the lesions received one endoscopic exposure to 150, 175, or 200 J/cm of 665 nm light. RESULTS: Most patients experienced mild to moderate chest pain requiring symptomatic treatment only. Six patients experienced grade 3 and 4 adverse events (16.6%). Three esophageal strictures were treated with dilatation. No clear pattern of dose dependence of toxicities emerged. In the drug dose ranging study (light dose of 150 J/cm at 48 hours), 3 and 4 mg/m2 of HPPH emerged as most effective. In the light dose ranging study (3 or 4 mg/m2 HPPH, light at 24 hours), complete response rates (disappearance of high grade dysplasia and early carcinoma) of 72% were achieved at 1 year, with all patients treated with 3 mg/m2 HPPH plus 175 J/cm and 4 mg/m2 HPPH plus 150 J/cm showing complete responses at 1 year. CONCLUSIONS: HPPH-PDT for precancerous lesions in Barrett's esophagus appears to be safe and showing promising efficacy. Further clinical studies are required to establish the use of HPPH-PDT.

Establishment of a definitive protocol for the diagnosis and management of body packers (drug mules).

BACKGROUND: 'Mules' or body packers are people who transport illegal drugs by packet ingestion into the gastrointestinal tract. These people are otherwise healthy and their management should maintain minimal morbidity. In this study, experience with body packers is presented and an algorithm for conservative and surgical management is provided. METHODS: The clinical patient database for all body packer admissions at Mary Immaculate Hospital of the Caritas Health Care Inc. from 1993 to 2005 was interrogated. 56 patients (4.5%) required admission out of a total of 1250 subjects confirmed to be body packers and apprehended by United State Customs officials at JFK International Airport, New York. The retrieved patient data were analysed retrospectively. RESULTS: 70% of the body packers were men, with a male to female ratio of 2.8 to 1. The mean age was 33 years and 52% were from Columbia. Heroin was the most common illegally transported substance (73%). 25 patients (45%) required surgical intervention, whereas 31 patients (55%) were successfully managed conservatively. Indications for intervention included: bowel obstruction, packet rupture/toxicity, and delayed progression of packet transit on conservative management. Multiple intraoperative manoeuvres were used to remove the foreign bodies: gastrotomy, enterotomy and colotomy. Wound infection was the most common complication and is associated with distal enterotomy and colotomy. CONCLUSIONS: Men were more likely to present as body packers than women. Proximal enterotomies are preferred and multiple enterotomies should be avoided. A confirmatory radiological study is needed to demonstrate complete clearance of packets. A systematic protocol for the management of body packers results in minimal morbidity and no mortality.

Bouveret syndrome: A series of cases that illustrates a rare complication of chronic cholelithiasis.

Bouveret syndrome is defined as gastric outlet obstruction secondary to the impaction of a large gallstone in the proximal gastrointestinal tract. The obstruction occurs as result of a bilio-enteric or bilio-gastric fistula. This clinical entity is a rare variant of the more commonly recognized gallstone ileus, which tends to cause small bowel obstruction of the terminal ileum. The typical presentation of Bouveret syndrome consists of nausea, vomiting and abdominal pain secondary to obstruction. Diagnosis often requires radiographic imaging with computed tomography, which typically shows pneumobilia or a cholecystoduodenal fistula. Herein is a series consisting of three cases of Bouveret syndrome involving a bilioenteric, cholecystoduodenal, and choledochoduodenal fistula, respectfully, all of which required operative management. A discussion of the current literature regarding management of this rare syndrome follows.

Staging Melanoma: What's Old and New.

The melanoma expert panel devised the evidence-based eighth edition American Joint Committee on Cancer staging system by conducting vigorous analyses of stage I, II, and III patients from the International Melanoma Database and Discovery Platform. Key changes in the eighth edition are regarding subcategorization of T1, M1, pathologic stage grouping of stage I and III, and refining the definitions and terminologies used in the staging system. As the knowledge of tumor biology improves, the staging of melanoma will continue to evolve to enable betterment of care.

Well-Differentiated Papillary Mesothelioma with Omental Calcifications: A Case Report and Review of the Literature.

BACKGROUND Omental calcifications of the peritoneum are typically small and asymptomatic. However, larger psammomatous bodies that cause symptoms such as abdominal pain and bloating are often associated with tumors such as primary serous papillary carcinoma, mesothelioma, or metastatic ovarian cancer. CASE REPORT We describe omental calcifications in a 68-year-old woman who had been asymptomatic for the last 10 years. The case details the histomorphologic features and immunohistochemical signature of a 4.0×3.5×1.0 cm mass consisting of mature adipose tissue that was surgically removed together with an 8.5×6.5×1.8 cm irregular intra-abdominal/mesenteric mass composed of yellow-red fatty tissue. Microscopic sections contained fat with variable clustered classic/psammomatous calcifications, some with a thin epithelioid periphery, in association with a very focal and subtle papillary surface epithelial/mesothelial proliferation. Tumor cell invasion was not observed during examination. Immunohistochemical staining showed that mesothelial cells in the mass were strongly positive for calretinin and focally positive for EMA, CK903, and vimentin. Strong nuclear positivity for PAX8 was also reported. Additional stains were added in response to this pattern, showing strong positivity for CK8, moderate positivity for BAP1, focal positivity for ER, minimal positivity for CD56, and negativity for CK5/6 and D2-40. Three possible explanations are suggested for the phenomenon observed in the pathology slides: reactive mesothelial hyperplasia, well-differentiated papillary mesothelioma, or serous papillary carcinoma of the peritoneum. CONCLUSIONS Findings suggest that these calcifications are a benign, reactive phenomenon, and that the abundance of psammoma bodies may be related to ongoing crops of papillary mesothelial hyperplasia or benign well-differentiated papillary mesothelioma.

Hypervascular neck mass as the initial presentation of papillary thyroid cancer: A case report and review of current literature.

BACKGROUND: Papillary Thyroid Carcinoma presenting initially as a hypervascular mass is exceedingly rare. The objective of this paper was to present the rare pathology along with the utilization of multimodal imaging to establish a correct diagnosis along with current management and review of literature. CASE PRESENTATION: We describe a 33 year old male who presented with a left-sided neck mass. CT with contrast of the neck revealed a hypervascular, ring enhancing, complex cystic lesion in the left sub-clavicular and supraclavicular neck deep to the SCM, with accompanying edema. The differential diagnosis was broad and difficult to achieve given the fine needle aspiration biopsy was inconclusive. Eventually, the patient underwent a total thyroidectomy with a left modified radical neck dissection, central neck dissection, and partial resection of sternocleidomastoid muscle. CONCLUSION: A large hypervascular mass presenting as a papillary thyroid carcinoma is difficult to discern but with combination of ultrasonography, soft tissue CT and angiography imaging, along with fine needle aspiration, and possible use of MRI would be successful in narrowing down the differential list to the final diagnosis of papillary thyroid carcinoma, supporting the need for punctual surgical intervention.

Surgical Duodenotomy Following Untreated Bouveret Syndrome.

Bouveret syndrome is caused by the impaction of a gallstone into the duodenum through a cholecystoduodenal fistula. This is typically followed by pyloric obstruction via retrograde migration of the stone, as opposed to anterograde migration, which can result in gallstone ileus. Bouveret syndrome usually presents with nausea, vomiting, and abdominal pain. Pneumobilia is seen on radiographic imaging. Herein, we describe a case of Bouveret syndrome where the diagnosis and treatment were delayed due to the initial patient desire for surgical intervention. Ultimately, duodenotomy was performed after several failed attempts of endoscopic stone extraction.

Serratia Liver Abscess Infection and Cardiomyopathy in a Patient with Diabetes Mellitus: A Case Report and Review of the Literature.

BACKGROUND Liver abscesses remain difficult to diagnose and treat. Risk factors include diabetes mellitus, liver cirrhosis, and immunodeficiency. The majority are pyogenic, resulting from bacterial infection. Research identifies species in the Serratia genus as the cause of pyogenic liver abscesses in only 0.25% of cases and only 1 Serratia species in each case appears to have been identified. To the best of our knowledge, the present case report is the first to involve overlapping Serratia species in a single liver abscess infection that induced cardiomyopathy. CASE REPORT A 45-year-old woman presented to our Emergency Department (ED) for severe generalized weakness. Initial test results indicated a diagnosis of microcytic anemia, hypomagnesemia, hypokalemia, hypocalcemia, hyperglycemia, type 2 diabetes mellitus, and severe heart failure. A computed tomography scan showed a 10-cm rim-enhancing fluid collection in the right hepatic lobe. Fluid drained from the suspected abscess tested positive for Serratia marcescens and Streptococcus viridans. The patient was treated with ceftriaxone and metronidazole, which she tolerated well. The abscess decreased to less than 9.8 mm. Twenty-one weeks after discharge, the patient received a cholecystectomy. Fluid drained from the residual abscess cultured positive for a different Serratia species, S. odorifera. CONCLUSIONS Diabetes mellitus and acute cholecystitis were key factors in the initial infections and abscess. We also suspect this is a rare case of cardiomyopathy induced by a Serratia infection. The source of the Serratia odorifera is less certain, as it postdates placement of a percutaneous drain, raising the potential for a nosocomial infection but not precluding the possibility that both Serratia species were previously present.

Prevention of Postoperative Pneumonia in Noncardiac Surgical Patients: A Prospective Study Using the National Surgical Quality Improvement Program Database.

Postoperative pneumonia increases morbidity, length of stay, and hospital readmission rates. Current data support the use of perioperative chlorhexidine gluconate in elective cardiac surgery patients to prevent postoperative pneumonia. The objectives of this study were to implement a resident-driven quality improvement project and determine the efficacy of an oral care bundle in preventing postoperative pneumonia among noncardiac surgical patients. A retrospective review of postoperative pneumonia occurrences at our hospital captured by the NSQIP database from 2014 to 2016 was conducted. A pre- and postoperative pulmonary care bundle was implemented in all surgical patients undergoing general anesthesia and outcomes were tracked by NSQIP for up to 90 days postoperatively for calendar year 2017. The NSQIP-reported incidence of postoperative pneumonia at our hospital was reduced from 0.8 to 0 per cent (P = 0). The risk-adjusted smoothed rate fell from 1.17 (95% confidence interval 0.77-1.66) in 2014 to 0.33 (95% confidence interval 0.03-0.98) in 2017. We encountered multiple systematic issues while conducting this study, which led to an imbalanced compliance to the preoperative (90%) and postoperative (31%) bundle; however, there was no significant difference between these two groups. Successful implementation of a resident-driven quality project resulted in a decreased rate of postoperative pneumonia.

Use of biologic mesh at ostomy takedown to prevent incisional hernia: A case series.

INTRODUCTION: Incisional hernias are a relatively common occurrence after ostomy takedown with a incidence of 30-35%. The use of biologic mesh offers a means to bolster the stoma incision site with a lower risk of infection than synthetic mesh. METHODS: This study represents a retrospective chart review of six patients who underwent stoma takedown and had biologic mesh placed in the retrorectus position during repair from March 2015 until March 2016. RESULTS: There has been a zero-rate of hernia occurrence for the six patients who underwent stoma takedown. No incisional hernias were noted on physical exam with follow up ranging from 11 to 25 months. CONCLUSION: We conclude that placement of biologic mesh is a safe and effective way of preventing incisional hernias at stoma sites.

Metastatic recurrence to a solitary lymph node four years after hepatic lobectomy for primary hepatocellular carcinoma.

This report describes a patient that developed recurrent metastatic hepatocellular carcinoma (HCC) to a suprapancreatic lymph node four years after being treated for primary HCC via complete left hepatectomy. Metastatic HCC was proven by pathologic confirmation. The report addresses the role of surgical resection as a treatment modality for recurrent HCC to solitary lymph nodes. The role of biological chemotherapy as adjuvant treatment is also addressed.

Disruption of spermatogenesis by the cancer disease process.

In the past, cancer survivors tended to be most concerned about disease recurrence and treatment side effects. As survival rates have increased, however, patients are now also concerned about quality-of-life issues such as preserving fertility potential. It is well known that cancer treatment adversely affects male fertility via direct effects on the testis and/or through the endocrine glands. Evidence also suggests that the disease process itself may affect a man's fertility by influencing spermatogenesis. However, the causes of poor semen quality in cancer patients are not well understood. Multiple factors are likely involved, including preexisting defects in germ cells, systemic effects of cancer, and endocrine and immunological disturbances. This paper will summarize available evidence on different factors involved in impaired spermatogenesis in patients with various cancers with emphasis on testicular cancer and Hodgkin lymphoma. Cryopreservation of spermatozoa is a simple and practical approach available to all patients with cancer who wish to preserve their fertilizing potential before cancer therapy.

Characterization of oxidative stress status by evaluation of reactive oxygen species levels in whole semen and isolated spermatozoa.

We defined the basal levels of reactive oxygen species (ROS) in normal donors in neat (whole unprocessed) semen specimens, and in mature and immature spermatozoa isolated by a double-density gradient technique. In addition, we demonstrated that the ROS levels were significantly lower in neat semen compared with washed spermatozoa. The reference values of ROS in neat semen and mature spermatozoa can be used to define the pathologic levels of ROS in infertile men and may guide in therapeutic interventions.

Comparative study on density gradients and swim-up preparation techniques utilizing neat and cryopreserved spermatozoa.

AIM: To 1) compare post-wash and post-thaw parameters of sperm processed with PureSperm density gradient technique and swim-up method; and 2) test the efficacy of two commonly available density gradient media PureSperm and ISolate. METHODS: This prospective study used semen specimens from 22 patients. Specimens from nine patients were processed by both PureSperm density gradient and swim-up method. These specimens were then cryopreserved. Thirteen specimens were processed by both PureSperm (40 % and 80 %) and Isolate (50 % and 90 %) double density gradient techniques. The two fractions processed by both PureSperm and swim-up were analyzed for post-wash sperm characteristics. Post-thaw analysis was done after 24 hours. Sperm fractions obtained after processing with PureSperm and ISolate were compared for post-wash sperm characteristics and ROS levels. RESULTS: Specimens prepared with PureSperm had significantly higher median total motile sperm counts (TMSC) (32.2 x 10(6) vs. 17.6 x 10(6)), recovery rates (69.2 % vs. 50.0 %), and longevity at 4 hours (83.0 % vs. 55.0 %) compared to specimen prepared by swim-up. Post-thaw specimens also had a higher recovery and longevity at 4 hours with PureSperm as compared to the swim-up. Semen specimens processed by PureSperm had significantly higher total sperm count, TMSC, and percentage recovery rates (30.0 % vs. 19.7 %) than ISolate. CONCLUSION: Semen quality is better preserved in fresh and cryopreserved semen prepared with PureSperm density gradient compared to swim-up. A significant enrichment of sperm is observed with PureSperm compared to ISolate. Higher recovery rates of mature motile sperm obtained after PureSperm sperm preparation may be beneficial for successful ART.

Identification of male factor infertility using a novel semen quality score and reactive oxygen species levels.

PURPOSE: To determine whether patients with male factor infertility can be accurately identified by calculating a novel semen quality score and measuring levels of reactive oxygen species during routine infertility screening. METHODS: Semen samples from 133 patients and 91 healthy donors were evaluated with manual and computer-assisted semen analysis. A principal component analysis model was employed to calculate a semen quality score. In brief, this score was calculated by base 10 logarithms multiplied by varying weights given to 9 sperm parameters. Reactive oxygen species levels were measured using chemiluminescence assay. RESULTS: The semen quality score had a sensitivity of 80.45% and accuracy of 77% at a cutoff of 93.1 in identifying patients with male factor infertility. The area under the receiver operating characteristic curves for the semen quality score was 84.28% (95% CI: 65.22%-100%). Reactive oxygen species levels [log10 (reactive oxygen species +1)] were significantly higher in male factor infertility patients. Reactive oxygen species had a sensitivity of 83.47% and specificity of 60.52% with an accuracy of 75% at a cutoff of 1.25 in identifying male factor infertility patients. The area under the receiver operating characteristic curve for reactive oxygen species levels was 78.92% (95% CI: 72.60%-85.23%). Semen quality scores were significantly and negatively correlated with reactive oxygen species levels in the donors and the male factor infertility patients. CONCLUSIONS: The semen quality score and reactive oxygen species levels in semen samples appear to be strongly associated with male factor infertility. Because both of these parameters are more sensitive than individual sperm parameters in identifying male factor infertility, they should be included in routine infertility screening.

Use of semen quality scores to predict pregnancy rates in couples undergoing intrauterine insemination with donor sperm.

OBJECTIVE: To establish semen quality scores in a population of sperm donors and determine whether the scores can be used to predict pregnancy rates after donor insemination. DESIGN: Retrospective study. SETTING: Infertility clinic at a tertiary care teaching hospital between 1993-2001. PATIENT(S): One hundred eleven women who underwent IUI with sperm from 27 anonymous donors. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The semen analysis results before freezing and after thawing were analyzed, and overall donor insemination semen quality (DI-SQ) and donor insemination relative quality (DI-RQ) scores were calculated. After adjusting for female characteristics, the scores were compared with samples that did and did not result in pregnancy. RESULT(S): Of 111 patients, 70 had at least one pregnancy, and 60 had at least one live birth, with a mean of 6.52 +/- 4.67 IUI cycles per patient. Five significant risk factors for low pregnancy and live birth rates were identified: female infertility factor, positive laparoscopy, older maternal age, low number of previous births, and lack of ovulatory stimulation. After adjusting for these factors, both prefreeze and postthaw DI-SQ scores were statistically significantly associated with IUI live birth rates. Using only the samples with a DI-SQ score of >110 doubled the expected live birth rate, compared with using samples with a DI-SQ score less than 100, from 8.5% to 16.1%. CONCLUSION(S): The DI-SQ score was an effective predictor of pregnancy and live birth outcomes in IUI patients who underwent artificial insemination with anonymous donor semen. The DI-SQ score could also be used by sperm banks to help select donors.