Multidisciplinary consensus recommendations for management of hepatocellular carcinoma in Middle East and North Africa region.

Hepatocellular carcinoma (HCC) is a growing health concern projected to cross over a million cases worldwide by 2025. HCC presents a significant burden of disease in Middle East and North African (MENA) countries due to a high prevalence of risk factors such as hepatitis C and B infections and rising incidence of non-alcoholic steatohepatitis and non-alcoholic fatty liver disease. In August 2022, an advisory meeting consisting of experts from 5 MENA countries was convened in an attempt to provide consensus recommendations on HCC screening, early diagnosis, current treatment modalities and unmet medical needs in the region. Data were collected from a pre-meeting survey questionnaire and responses analysed and presented during the advisory meeting. This review summarizes the evidence discussed at the meeting and provides expert recommendations on the management of HCC. The 2022 update of Barcelona clinic liver cancer (BCLC) staging and treatment strategy and its implementation in the MENA region was extensively discussed. A key consensus of the expert panel was that multidisciplinary care is crucial to effective patient management that results in better clinical outcomes and overall survival of the patient. The panel recommended the use of predictive and early response biomarkers to guide clinicians in arriving at more effective therapeutic decisions. The experts also emphasized the role of robust screening/surveillance systems, population-based registries, effective referral pathways and standardization of guidelines to ensure the successful management of HCC in the region.

Evaluation of vestibular function in patients with chronic suppurative otitis media.

OBJECTIVE: The objective of this study was to assess vestibular functions in patients with chronic suppurative otitis media (CSOM) with and without sensorineural hearing loss. STUDY DESIGN: This was a prospective case study performed at a tertiary referral university hospital. Sixty patients with CSOM were included, and patients with a history of head trauma, diabetes, hypertension, previous ear surgery, use of ototoxic drugs, neurological deficits and suspected fistulae were excluded. PATIENTS AND METHODS: The patients underwent basic audiological evaluation, and clinical and instrumental vestibular evaluation. The incidence and extent of vestibular dysfunction in patients with CSOM were analyzed. RESULTS: A total of 42 males and 16 females with a mean age of 29.5 years were included in this study. Forty ears had tubotympanic disease and 19 had cholesteatoma. There were 14 ears with sensorineural hearing loss. A positive history of vertigo was reported in 53.5% of the cases. Rotatory chair abnormalities were found in 70% of the cases, caloric hypofunction was found in 61.6%, and vestibular myogenic evoked potentials were abnormal in 25%. The only positive correlation with vestibular dysfunction was the duration of disease. CONCLUSIONS: The vestibular system is significantly affected in cases with CSOM. Both semicircular canals and the saccule are affected. All patients with long-standing CSOM should be evaluated for vestibular dysfunction irrespective of their hearing levels.

Consensus Recommendations for the Diagnosis, Biomarker Testing, and Clinical Management of Advanced or Metastatic Non-small Cell Lung Cancer With Mesenchymal-Epithelial Transition Exon 14 Skipping Mutations in the Middle East, Africa, and Russia.

Mesenchymal-epithelial transition exon 14 (METex14) skipping mutations occur in about 3%-4% of patients with non-small cell lung cancer (NSCLC). This is an aggressive subtype associated with poor prognosis. METex14 skipping is a potentially targetable mutation. Targeted therapy is a promising treatment modality for patients with advanced/metastatic METex14-mutant NSCLC. Performing systematic molecular testing to detect the driver mutation is essential for initiating targeted therapy. However, there is a lack of guidelines on molecular testing for assessing the eligibility of patients for targeted therapy. Therefore, a multidisciplinary panel consisting of experts from the Middle East, Africa, and Russia convened via a virtual advisory board meeting to provide their insights on various molecular testing techniques for the diagnosis of METex14 skipping mutation, management of patients with targeted therapies, and developing consensus recommendations for improving the processes. The expert panel emphasized performing molecular testing and liquid biopsy before treatment initiation and tissue re-biopsy for patients with failed molecular testing. Liquid biopsy was recommended as complementary to tissue biopsy for disease monitoring and prognosis. Selective MET inhibitors were recommended as the first and subsequent lines of therapy. These consensus recommendations will facilitate the management of METex14 skipping NSCLC in routine practice and warrant optimum outcomes for these patients.

A multi-criteria decision analysis (MCDA) tool for purchasing off-patent oncology medicines in Egypt.

BACKGROUND: Multi- criteria decision analysis (MCDA) can assist policymakers in objectively choosing between alternative therapeutic options based on multiple value attributes. Our aim was to create an MCDA tool for the national tenders of off-patent oncology medicines in Egypt. METHODS: An initial list of criteria was developed through a literature review complemented by local expert interviews. Price or cost-related criteria were excluded to abide by the national regulations of the tender process. Next, a workshop hosting diversified stakeholders representing different governmental bodies was held. Anonymous voting was used to rank and weigh the criteria as well as assigning scores. Price was added as a separate step to identify best option based on price per point. The tool was then tested on a national tender sample of off-patent oncology medicines to assess its performance, and it was readjusted accordingly in a second workshop. RESULTS: Seven non-price criteria were selected, including use in reference countries (23.49% weight), equivalence with the reference product (18.79%), manufacturing quality (15.53%), provision of pharmacovigilance services (12.94%), supply reliability (10.78%), previous use in local settings (9.8%) and macroeconomic benefit (8.67%). A medicine receives a score ranging from 0 to 100% of each criterion's weight. The aggregated score is calculated on a hundred-point scale. Based on participants' consensus, an overall score of 65 was set as a cut-off for passing the technical eligibility phase of the tendering process. Any product receiving a lower score would be disqualified from the tender. For qualified products, the lower price per point represents preferential option for the national tender. CONCLUSIONS: The created MCDA tool is capable of objectively comparing similar off-patent oncology medicines by considering multiple value attributes and providing reliable scoring functions for each.

Voice Rehabilitation by Voice Prostheses After Total Laryngectomy: A Systematic Review and Network Meta-Analysis for 11,918 Patients.

Purpose Our aim was to assess the different voice prostheses (VPs) to identify the most efficient, safest, patient-tailored, longest lifetime, and inexpensive VPs and assess the different factors affecting their quality. Method In September 2017, 15 databases were searched to include all randomized controlled trials. A new search was done in May 2019 to include all other study design articles, which include all the new-era VPs subtypes. Network meta-analysis (NMA) was applied to all 27 outcomes, besides NMA overall and partial order setting was done by using Hasse scatter plots. p values were used in NMA, where the best VPs are approaching one and the least approaches zero. Meta-analysis was done for the rest of the outcomes. Results Two hundred one articles were eligible for inclusion in our study (N = 11,918). Provox-2 was significantly the most efficient and safest device concerning the most patient preference (odds ratio [OR] = 33.88 [0.65, 1762.24]; p = .92), the least dislodgement (risk ratio [RR] = 0.27 [0.13, 0.57]; p = .79), the least airflow resistance (RR = 0.42 [0.08, 2.11]; p = .84), the least granulation formation (RR = 0.73 [0.02, 26.32]; p = .60), and the least VPs' inaccurate size (RR = 0.77 (0.23, 2.61); p = .66). Heat and moisture exchanger addition showed a significant increase in maximum phonation time and breathing experience, with p values (1 and .59), respectively. While heat and moisture exchanger addition showed a significant decline in stoma cleaning frequency, coughing frequency, forced expectoration, sputum production, sleeping problems, and loosening of adhesive, with p values (.99, .72, .69, .96, 1, and 0.96), respectively, Groningen low resistance and Nijdam were considered the worst devices with both overall mean p value of .44. Conclusions Provox-2 is considered the best choice as being the most preferable for patients, with the least airflow resistance, dislodgment, granulation formation, and prosthesis inaccurate size. Groningen low resistance and Nijdam were considered the worst devices according to our analysis. Supplemental Material https://doi.org/10.23641/asha.14802903.

Computed tomography evaluation of internal nasal valve angle and area and its correlation with NOSE scale for symptomatic improvement in rhinoplasty.

INTRODUCTION: Nasal obstruction is one of the most frequent otolaryngologic complaints; and the collapse of the internal nasal valve is one the main causes of the nasal air flow obstruction. OBJECTIVE: We aimed to evaluate internal nasal valve by using reformatted CT-scans pre- and post- rhinoplasty at 3 months and to assess its correlation to symptomatic improvement of nasal obstruction using the NOSE scale. METHODS: A prospective observational study was conducted between March 2017-May 2018 in a tertiary care otorhinolaryngology center. We included patients suffering from nasal obstruction secondary to internal nasal angle collapse and nasal deformity. Patients with sinusitis, nasal polyposis, and nasal masses were excluded. RESULTS: Twenty consecutive patients underwent rhinoplasty, with a mean age (22.2 ±â€¯2.8), with majority of males (n = 14; 70%). There was no significant correlation between pre- and post- CT-scans of the internal nasal valve angle/area and NOSE scores. A high significant difference was detected between mean pre- and post- NOSE scores (p < 0.0001), which was absent in CT-scan results. CONCLUSION: Reformatted CT-scans measurements of internal nasal valve area and angle were not of value. NOSE scores pre- and post- rhinoplasty had a significant value to determine degree of obstructive symptom improvement.

Chemotherapy-Induced Peripheral Neuropathy in Egyptian Patients: Single Institution Retrospective Analysis

Background: Chemotherapy-induced peripheral neuropathy (CIPN) is a major toxicity that requires treatment modification or cessation and worsens patients' quality of life. Its incidence is 30­40%. Occurrence and severity depend on treatment- and patient-related factors. The symptoms are self-limiting with recovery rate about 50%. Methods: This retrospective analysis took place in our chemotherapy unit. We included patients treated between January 2014 and December 2015. Results: 250 patients were eligible. 53 received paclitaxel, 78 received docetaxel, 64 received cisplatin and 55 received oxaliplatin. Mean age was 50.11 years. Frequency of CIPN was 46.8% (Grade I 70.9%, GII 24.7%, GIII 4.4%). It was 74% with oxaliplatin, 73.5% with paclitaxel, 35.9% with cisplatin and 17.9% with docetaxel. After median of 6 months 24% of patients recovered completely. No significant correlation between occurrence of CIPN and age (p = 0.781), while was significant with cisplatin (p = 0.043). Diabetic patients had higher incidence (p = 0.007). With cisplatin, median cumulative dose of 450 mg/m2 and ≥ 6 cycles had higher incidence of CIPN (p 0.006 and 0.010; respectively). With oxaliplatin, none was correlated with CIPN frequence. With paclitaxel, CIPN was more frequent if ≥ 4 cycles were received (p = 0.005). With docetaxel, > 4 cycles or cumulative dose ≥ 360 mg/m2 had higher occurrence of GII CIPN (p < 0.001 for both). Conclusion: CIPN is common problem that affects patients' quality of life and leads to treatment interruption. There are many factors affecting its incidence and severity.

The role of flexible autofluorescence laryngoscopy in the diagnosis of malignant lesions of the larynx.

CONCLUSION: Autofluorescent endoscopy (AFE) combined with microlaryngoscopy (MLS) gives a more accurate diagnosis of laryngeal pathology and can be further refined to minimize the need for MLS under general anaesthesia. OBJECTIVE: The aim of the present study was to evaluate the diagnostic potential and limitations of autofluorescent flexible laryngoscopy in comparison to MLS. PATIENTS AND METHODS: We examined 40 patients using the Pentax SAFE 1000 system. All patients then underwent direct MLS and biopsy under general anaesthesia. Biopsies were taken from areas that were visually suspicious and then from areas that showed disturbed autofluorescent signals. RESULTS: The overall sensitivity of AFE for various pathologies was 90.625%, while the sensitivity of MLS was 75%. Combining the findings of AFL and MLS we had a 100% diagnostic yield.

Computed tomography evaluation of internal nasal valve angle and area and its correlation with NOSE scale for symptomatic improvement in rhinoplasty / Avaliação do ângulo e da área da válvula nasal interna por tomografia computadorizada e sua correlação com a escala NOSE na melhora sintomática pós rinoplastia

Abstract Introduction: Nasal obstruction is one of the most frequent otolaryngologic complaints; and the collapse of the internal nasal valve is one the main causes of the nasal air flow obstruction. Objective: We aimed to evaluate internal nasal valve by using reformatted CT-scans pre- and post- rhinoplasty at 3 months and to assess its correlation to symptomatic improvement of nasal obstruction using the NOSE scale. Methods: A prospective observational study was conducted between March 2017-May 2018 in a tertiary care otorhinolaryngology center. We included patients suffering from nasal obstruction secondary to internal nasal angle collapse and nasal deformity. Patients with sinusitis, nasal polyposis, and nasal masses were excluded. Results: Twenty consecutive patients underwent rhinoplasty, with a mean age (22.2 ± 2.8), with majority of males (n = 14; 70%). There was no significant correlation between pre- and post- CT-scans of the internal nasal valve angle/area and NOSE scores. A high significant difference was detected between mean pre- and post- NOSE scores (p < 0.0001), which was absent in CT-scan results. Conclusion: Reformatted CT-scans measurements of internal nasal valve area and angle were not of value. NOSE scores pre- and post- rhinoplasty had a significant value to determine degree of obstructive symptom improvement.

Resumo Introdução: A obstrução nasal é uma das queixas otorrinolaringológicas mais comuns, e o colapso ou obstrução da válvula nasal interna é a principal causa da obstrução das vias aéreas nasais. Objetivo: Objetivamos avaliar a válvula nasal interna pré, e 3 meses pós-rinoplastia utilizandotomografias computadorizadas reformatadas e avaliar sua correlação com a melhora do sintoma obstrutivo utilizando a escala NOSE, do Inglês Nasal Obstruction Symptom Evaluation. Método: Um estudo observacional prospectivo foi realizado entre março de 2017 e maio de 2018 em um centro de otorrinolaringologia de atenção terciária. Foram incluídos pacientes que apresentavam obstrução nasal secundário a colapso da valva nasal interna e deformidade nasal. Pacientes com sinusite, polipose nasal e tumores nasais foram excluídos. Resultados: Vinte pacientes consecutivos, a maioria do sexo masculino (n = 14; 70%) com média de idade de 22,2 ± 2,8 anos, foram submetidos a rinoplastia eincluídos no estudo. Não houve correlação significante entre as avaliações tomográficas pré / pós cirúrgicas do ângulo/área da valva nasal interna e os escores NOSE. Foi detectada uma diferençã altamente significante entre os escores médios da escala NOSE entre o pré e pós-operatório (p < 0,0001), mas não nos resultados da avaliação por tomografia computadorizada. Conclusão: As medidas reformatadas de tomografias computadorizadas da área e ângulo da valva nasal interna pré e pós cirúrgicas não tiveram valor. Entretanto, os escores da escala NOSE pré e pós-rinoplastia mostraram uma diferença significante ao determinar o grau de melhora do sintoma obstrutivo.

Benefit of combined endoscopic sinus surgery and aesthetic rhinoplasty.

INTRODUCTION: Rhinoplasty is one of the most commonly performed aesthetic procedures today. Although nasal airway obstruction is frequently treated concomitantly with the aesthetic procedure, chronic sinusitis has typically postponed until full resolution of inflammatory symptoms. AIM OF THE STUDY: To investigate the feasibility of combining FESS with septorhinoplasty by measuring different outcomes including operative time, blood loss, post-operative edema of the upper and lower eyelids, periorbital ecchymosis, patient discomfort and complication rates. PATIENTS AND METHODS: The study included 20 patients with deformed nose associated with chronic rhinosinusitis (CRS) not responding to medical treatment for at least 3 continuous months, irrespective to sex, of ages 20-60, and without any systemic diseases (study group), and 20 patients with deformed nose without any sinus problems (control group). RESULTS: There was no significant difference between the two groups in the different measured outcomes (P>0.05) except for the operative time which was significantly less in the control group (P<0.05). CONCLUSION: Concurrent rhinoplasty and endoscopic sinus surgery may be performed safely and effectively with minimal risks. Proper patient selection and sound intraoperative judgment can avoid potential complications.

Effect of intratympanic dexamethasone administration on cisplatin-induced ototoxicity in adult guinea pigs.

OBJECTIVE: To evaluate the effect and safety of intratympanic dexamethasone administration on cisplatin-induced ototoxicity in adult male guinea pigs and to assess the differences between early and late protection from this ototoxicity. METHODS: Forty eight adult male guinea pigs were divided as follows: group I served as control group. Group II was subjected to intratympanic saline (subgroup IIa) or dexamethasone (subgroup IIb) injection. Group III was intraperitoneally injected with cisplatin. Groups IV and V were subjected first to intratympanic dexamethasone administration in both ears for 5 days starting 1 day and 1h - respectively - before cisplatin intraperitoneal injection. RESULTS: Dexamethasone intratympanic injection revealed similar functional and structural results compared with control. Cisplatin intraperitoneal injection resulted in a profound cochlear functional and structural damage in group III. Non-significant otoprotection resulted from intratympanic dexamethasone administration one day before cisplatin. Intratympanic dexamethasone injection 1h before cisplatin treatment resulted in a significant preservation of the functional and structural properties of the cochlea. CONCLUSION: Intratympanic dexamethasone administration is a safe, easy and efficient way to protect from cisplatin ototoxicity especially when administered 1h before cisplatin treatment.