Nipple-sparing mastectomy and immediate breast reconstruction by prepectoral implant for the management of giant phyllodes tumors: A case series.

Phyllodes tumor is an uncommon breast neoplasm that is present in variable sizes. Giant phyllodes are those larger than 10 cm in diameter. Clinically, giant phyllodes tumors present as a visible, rapidly growing mass distorting the breast contour. Such tumors with large size and rapid growth rate suggest a phyllode diagnosis of fibroadenoma. Planning a standard treatment strategy for these tumors is quite challenging. While adequate surgical excision with tumor-free resection margins is the standard of care for most giant phyllodes cases, borderline and malignant giant phyllodes tumors might require wider resections given their high recurrence rates. Some authors described total mastectomy as the treatment option for giant borderline and malignant phyllodes to obtain wide, clear margins. Between March 2022 and September 2023, our surgical oncology department presented and operated on three cases of giant phyllodes. They underwent a nipple-sparing mastectomy and immediate breast reconstruction using pre-pectoral silicone implants. We think that with such a procedure, we can benefit from the wide, safe margins of mastectomy that have been proven to decrease local recurrence rates while considering the aesthetic outcome.

Magnetic resonance imaging of pilonidal sinus disease: interobserver agreement and practical MRI reporting tips.

OBJECTIVE: To evaluate the interobserver agreement for the features of natal cleft pilonidal sinus disease (PSD) on magnetic resonance imaging (MRI) and propose a standardized checklist for reporting PSD on MRI. MATERIALS AND METHODS: Forty MRI studies of 39 discrete patients with PSD were retrospectively evaluated by five independent radiologists using a standardized checklist. Fleiss' Kappa (k) coefficients of agreement were used to test the agreement between categorical variables. The MRI features of the natal cleft sepsis associated with PSD were classified into four main categories: morphology, branching and extensions, external skin openings, and the relationship of the PSD to the coccyx. A survey was created and disseminated online among general surgeons who treat patients with PSD to assess the relevance of the MRI features proposed in the standardized checklist. RESULTS: The overall agreement regarding the identification of morphology of the natal cleft sepsis was moderate (k = 0.59). Lateral and caudal extensions interobserver agreement was substantial (k = 0.64 and 0.71, respectively). However, the overall agreement regarding the individual parts of anal sphincter involved was moderate (k = 0.47). Substantial interobserver agreement was found in assessing the proximity of the PSD to the coccyx (k = 0.62). CONCLUSION: Preoperative MRI can delineate the extensions and branching of PSD with substantial agreement. MRI is superior in describing the deep extensions of PSD with better reliability than assessing the number and locations of the external openings. Expert consensus agreement is needed to establish the MRI features necessary for optimal reporting of PSD. CLINICAL RELEVANCE STATEMENT: MRI can offer valuable information about the extent of sepsis associated with pilonidal sinus disease, particularly in cases with involvement of critical anatomical structures such as the coccyx and anal triangle. MRI can potentially contribute to more accurate patient stratification and surgical planning. KEY POINTS: • The interobserver agreement for assessing PSD's lateral and caudal extension on MRI is substantial. • MRI can describe deep extensions and branching of PSD with superior reliability than assessing the number and site of external openings. • Reporting the relationship between natal cleft sepsis in PSD and the anal region may influence the surgical approach and postoperative healing.

Is it essential to remove the submandibular gland in neck dissection in tongue cancer patients?

INTRODUCTION: Submandibular sialadenectomy is a part of the classic technique of neck dissection for oral cavity cancers. However, its removal is associated with a reduction in the salivary outflow in many patients, as well as, some uncommon complications such as lingual and hypoglossal nerve injuries. Assessment of the necessity of such maneuvers should be addressed. PATIENTS AND METHODS: The data of 105 patients with tongue cancer who underwent neck dissection in the Oncology Center, Mansoura University from January 2008 to March 2019 were reviewed and analyzed retrospectively. RESULTS: In all the included patients, whether showing pathologic positive or negative lymph nodes, none showed capsular or parenchymal submandibular gland metastasis except for one patient who showed direct infiltration of the gland by the primary tumor. CONCLUSION: Submandibular sialadenectomy may not be indicated as a part of neck dissection in tongue cancer patients. Further research should be conducted to focus on the effect of its preservation on disease-free and overall survival.

Operative Outcomes of Single-Incision Laparoscopic Hysterectomy vs Conventional Laparoscopic Total Hysterectomy: A Prospective Randomized Controlled Study.

Background. Over time, there was an emerging need to shift from laparotomy to minimally invasive laparoscopic surgery, with the success of laparoscopic surgery in the last decade in gyne-oncology. Patients and Methods. This is a prospective randomized controlled trial conducted in Surgical Oncology Unit, Oncology Centre, Mansoura University, in the period between February 2016 and October 2019. Fifty female patients planned for total hysterectomy were randomized into two equal groups; the first underwent conventional laparoscopic hysterectomy (CLH), while the second underwent single-incision laparoscopic hysterectomy (SILH). Results. The mean operative time in the SILH group was 120.00 ± 28.72 minutes vs 103.20 ± 23.04 minutes in the CLH group (P= .027). Median hospital stay in the SILH group was 1 day (range: 1-3 days), the same as that in the CLH group, with no statistical significance (P= .384). Postoperative pain assessment using the Visual Analogue Scale (VAS) after 6 hours had a median score of 6 (2-8) in the SILH group and 6 (4-7) in the CLH group with significant increase in experienced pain in the SILH group (P= .004), while no significant difference was noted after 12 hours and 24 hours in both SILH and CLH groups. Conclusion. Single-incision laparoscopic hysterectomy (SILH) has similar outcomes when compared to conventional laparoscopic hysterectomy as regard blood loss, hospital stay, conversion to laparotomy, intraoperative and postoperative complications with the disadvantages of longer operative time, increased surgeon's workload, and relatively more postoperative pain.

Diabetic Mastopathy: Reporting an Unusual Scenario of a Rare Disease.

Diabetic mastopathy is a rare, benign breast disease that presents with fibrous breast lumps usually induced by the hyperglycemic state in diabetic patients and often associated with type 1 or 2 diabetes mellitus. Clinical and radiographic appearances are usually confusing and pathologic confirmation is essential for diagnosis mainly to rule out malignancy. However, a specialized breast pathologist often utilizes patient's history of diabetes as a guide to solve this diagnostic dilemma. We report a challenging scenario in which a case of diabetic fibrous mastopathy was pathologically identified with no previous given history of diabetes. This benign breast entity should be included in the differential diagnosis of breast lumps even without history of diabetes that may be overlooked before surgery.

Immune Profiling To Predict Outcome of Clostridioides difficile Infection.

There is a pressing need for biomarker-based models to predict mortality from and recurrence of Clostridioides difficile infection (CDI). Risk stratification would enable targeted interventions such as fecal microbiota transplant, antitoxin antibodies, and colectomy for those at highest risk. Because severity of CDI is associated with the immune response, we immune profiled patients at the time of diagnosis. The levels of 17 cytokines in plasma were measured in 341 CDI inpatients. The primary outcome of interest was 90-day mortality. Increased tumor necrosis factor alpha (TNF-α), interleukin 6 (IL-6), C-C motif chemokine ligand 5 (CCL-5), suppression of tumorigenicity 2 receptor (sST-2), IL-8, and IL-15 predicted mortality by univariate analysis. After adjusting for demographics and clinical characteristics, the mortality risk (as indicated by the hazard ratio [HR]) was higher for patients in the top 25th percentile for TNF-α (HR = 8.35, P = 0.005) and IL-8 (HR = 4.45, P = 0.01) and lower for CCL-5 (HR = 0.18, P ≤ 0.008). A logistic regression risk prediction model was developed and had an area under the receiver operating characteristic curve (AUC) of 0.91 for 90-day mortality and 0.77 for 90-day recurrence. While limited by being single site and retrospective, our work resulted in a model with a substantially greater predictive ability than white blood cell count. In conclusion, immune profiling demonstrated differences between patients in their response to CDI, offering the promise for precision medicine individualized treatment.IMPORTANCEClostridioides difficile infection is the most common health care-associated infection in the United States with more than 20% patients experiencing symptomatic recurrence. The complex nature of host-bacterium interactions makes it difficult to predict the course of the disease based solely on clinical parameters. In the present study, we built a robust prediction model using representative plasma biomarkers and clinical parameters for 90-day all-cause mortality. Risk prediction based on immune biomarkers and clinical variables may contribute to treatment selection for patients as well as provide insight into the role of immune system in C. difficile pathogenesis.

Type 3 Immunity during Clostridioides difficile Infection: Too Much of a Good Thing?

Clostridioides (formerly known as Clostridium) difficile is the leading cause of hospital-acquired gastrointestinal infections in the United States and one of three urgent health care threats identified by the Centers for Disease Control and Prevention. C. difficile disease is mediated by the production of toxins that disrupt the epithelial barrier and cause a robust host inflammatory response. Studies in humans as well as animal models of disease have shown that the type of immune response generated against the infection dictates the outcome of disease, often irrespective of bacterial burden. Much of the focus on immunity during C. difficile infection (CDI) has been on type 3 immunity because of the established role for this arm of the immune system in other gastrointestinal inflammatory conditions such as inflammatory bowel disease (IBD). For example, interleukin-22 (IL-22) production by group 3 innate lymphoid cells (ILC3s) protects against pathobionts translocating across the epithelium during CDI. On the other hand, interleukin-17 (IL-17) production by Th17 cells increases CDI-associated mortality. Additionally, neutropenia has been associated with increased susceptibility to CDI in humans, but increased neutrophilia in mouse models correlates with host pathology. Taking the data together, these findings suggest dual roles for type 3 immune responses during infection. Here, we review the complex role of type 3 immunity during CDI and delineate what is known about innate and adaptive cellular immunity as well as the downstream effector cytokines known to be important during this infection.

IL-33 drives group 2 innate lymphoid cell-mediated protection during Clostridium difficile infection.

Clostridium difficile (C. difficile) incidence has tripled over the past 15 years and is attributed to the emergence of hypervirulent strains. While it is clear that C. difficile toxins cause damaging colonic inflammation, the immune mechanisms protecting from tissue damage require further investigation. Through a transcriptome analysis, we identify IL-33 as an immune target upregulated in response to hypervirulent C. difficile. We demonstrate that IL-33 prevents C. difficile-associated mortality and epithelial disruption independently of bacterial burden or toxin expression. IL-33 drives colonic group 2 innate lymphoid cell (ILC2) activation during infection and IL-33 activated ILC2s are sufficient to prevent disease. Furthermore, intestinal IL-33 expression is regulated by the microbiota as fecal microbiota transplantation (FMT) rescues antibiotic-associated depletion of IL-33. Lastly, dysregulated IL-33 signaling via the decoy receptor, sST2, predicts C. difficile-associated mortality in human patients. Thus, IL-33 signaling to ILC2s is an important mechanism of defense from C. difficile colitis.

Colitis-Induced Th17 Cells Increase the Risk for Severe Subsequent Clostridium difficile Infection.

Clostridium difficile infection (CDI) is the number one hospital-acquired infection in the United States. CDI is more common and severe in inflammatory bowel disease patients. Here, we studied the mechanism by which prior colitis exacerbates CDI. Mice were given dextran sulfate sodium (DSS) colitis, recovered for 2 weeks, and then were infected with C. difficile. Mortality and CDI severity were increased in DSS-treated mice compared to controls. Severe CDI is dependent on CD4+ T cells, which persist after colitis-associated inflammation subsides. Adoptive transfer of Th17 cells to naive mice is sufficient to increase CDI-associated mortality through elevated IL-17 production. Finally, in humans, the Th17 cytokines IL-6 and IL-23 associate with severe CDI, and patients with high serum IL-6 are 7.6 times more likely to die post infection. These findings establish a central role for Th17 cells in CDI pathogenesis following colitis and identify them as a potential target for preventing severe disease.

Axillary nodal metastasis in ovarian cancer: a report of three cases and review of literature.

BACKGROUND: Ovarian cancer represents a major global health burden that is rarely associated with distant metastasis. Axillary lymph node metastasis from ovarian cancer is rare and is reported only in few case reports in literature. CASE PRESENTATION: We report three cases of ovarian carcinoma associated with axillary lymph node metastasis as well as a brief literature review. The pathologic subtype in one case was malignant mixed Mullerian tumor, while the other two cases were high-grade serous ovarian carcinoma. Axillary nodal metastasis was reported as a synchronous event in one case, while it was reported as recurrence events in the other two cases. CONCLUSION: Physicians should be aware of this uncommon mode of metastasis in ovarian cancer cases. Multi-disciplinary discussion is crucial in the management of these cases to offer them the best suitable treatment.

Removal of urea from dilute streams using RVC/nano-NiOx-modified electrode.

Reticulated vitreous carbon (RVC), a high surface area electrode (40 cm2/cm3), has been modified with nickel oxide nanoparticles (nano-NiOx) and used for electrochemical oxidation of urea from alkaline solution. For the cyclic voltammetry measurements, the used dimensions are 0.8 cm × 0.8 cm × 0.3 cm. The purpose was to offer high specific surface area using a porous open network structure to accelerate the electrochemical conversion. NiOx nanoparticles have been synthesized via an electrochemical route at some experimental conditions. The morphological, structural, and electrochemical properties of the RVC/nano-NiOx are characterized by using scanning electron microscopy (SEM), energy dispersive X-ray spectroscopy (EDX), cyclic voltammetry (CV), and potentiostatic measurements. The fabricated electrode, RVC/nano-NiOx, demonstrates high electrocatalytic activity towards urea oxidation in an alkaline electrolyte. The onset potential of the RVC/nano-NiOx compared to that of the planar GC/NiOx is shifted to more negative value with higher specific activity. The different loadings of the NiOx have a substantial influence on the conversion of urea which has been evaluated from concentration-time curves. The urea concentration decreases with time to a limit dependent on the loading extent. Maximum conversion is obtained at 0.86 mg of NiOx per cm3 of the RVC matrix.

The binary toxin CDT enhances Clostridium difficile virulence by suppressing protective colonic eosinophilia.

Clostridium difficile is the most common hospital acquired pathogen in the USA, and infection is, in many cases, fatal. Toxins A and B are its major virulence factors, but expression of a third toxin, known as C. difficile transferase (CDT), is increasingly common. An adenosine diphosphate (ADP)-ribosyltransferase that causes actin cytoskeletal disruption, CDT is typically produced by the major, hypervirulent strains and has been associated with more severe disease. Here, we show that CDT enhances the virulence of two PCR-ribotype 027 strains in mice. The toxin induces pathogenic host inflammation via a Toll-like receptor 2 (TLR2)-dependent pathway, resulting in the suppression of a protective host eosinophilic response. Finally, we show that restoration of TLR2-deficient eosinophils is sufficient for protection from a strain producing CDT. These findings offer an explanation for the enhanced virulence of CDT-expressing C. difficile and demonstrate a mechanism by which this binary toxin subverts the host immune response.

Microbiota-Regulated IL-25 Increases Eosinophil Number to Provide Protection during Clostridium difficile Infection.

Clostridium difficile infection (CDI) is the most common cause of hospital-acquired infection in the United States. Host susceptibility and the severity of infection are influenced by disruption of the microbiota and the immune response. However, how the microbiota regulate immune responses to mediate CDI outcome remains unclear. Here, we have investigated the role of the microbiota-linked cytokine IL-25 during infection. Intestinal IL-25 was suppressed during CDI in humans and mice. Restoration of IL-25 reduced CDI-associated mortality and tissue pathology even though equivalent levels of C. difficile bacteria and toxin remained in the gut. IL-25 protection was mediated by gut eosinophils, as demonstrated by an increase in intestinal eosinophils and a loss of IL-25 protection upon eosinophil depletion. These findings support a mechanism whereby the induction of IL-25-mediated eosinophilia can reduce host mortality during active CDI. This work may provide targets for future development of microbial or immune-based therapies.

A finite element study on stress distribution of two different attachment designs under implant supported overdenture.

OBJECTIVE: This study aimed to evaluate stress patterns generated within implant-supported mandibular overdentures retained by two different attachment types: ball and socket and locator attachments. MATERIALS AND METHODS: Commercial CAD/CAM and finite element analysis software packages were utilized to construct two 3D finite element models for the two attachment types. Unilateral masticatory compressive loads of 50, 100, and 150 N were applied vertically to the overdentures, parallel to the longitudinal axes of the implants. Loads were directed toward the central fossa in the molar region of each overdenture, that linear static analysis was carried out to find the generated stresses and deformation on each part of the studied model. RESULTS: According to FEA results the ball attachment neck is highly stressed in comparison to the locator one. On the other hand mucosa and cortical bone received less stresses under ball and socket attachment. CONCLUSIONS: Locator and ball and socket attachments induce equivalent stresses on bone surrounding implants. Locator attachment performance was superior to that of the ball and socket attachment in the implants, nylon caps, and overdenture. Locator attachments are highly recommended and can increase the interval between successive maintenance sessions.

A novel fabrication of a polymeric ionic liquid hybrid film modified electrode and its successful application to the electrogeneration of a superoxide anion in aqueous media.

A novel polymeric ionic liquid hybrid film-modified electrode, in which the electrode surface is coated with a hydrophobic hybrid material composed of an ionene polymer with quaternary ammonium sites in its polymeric backbone and ionic liquids, was fabricated by electropolymerization of N,N-dimethylaniline in a hydrophobic ionic liquid, which can be applied for the electrogeneration of a superoxide anion via one-electron reduction of O2 in aqueous media.

Inhibitory action of quaternary ammonium bromide on mild steel and synergistic effect with other halide ions in 0.5 M H2SO4.

The corrosion inhibition of mild steel in 0.5 M H2SO4 solution has been investigated using electrochemical methods, X-ray diffraction (XRD) and scanning electron microscope (SEM). The adsorption and inhibition action of acid corrosion of mild steel using cetyltrimethylammonium bromide (CTABr) and different halides (NaCl, NaBr and NaI) has shown synergetic effect. The results showed that the protection efficiency (P%) has high values at considerable high concentration of CTABr. However, in the presence of the different halides, the P increases dramatically at low concentration of CTABr. Physisorption was proposed from the the values of [Formula: see text]. The synergism parameter (S θ) is found to be greater than unity indicating that the enhanced P% caused by the addition of the halides to the CTABr is due to a co-operative adsorption of both species. Corrosion products phases and surface morphology were studied using X-ray diffraction (XRD) and scanning electron microscopy (SEM), respectively.

Assessment safety and efficacy of a combination therapy of topical amphotericin B and subconjunctival fluconazole for the treatment of fungal keratitis.

PURPOSE: The study was aimed at evaluating the treatment of fungal keratitis using a combination therapy of a low concentration of topical amphotericin B (0.2 mg/mL) eye drops together with subconjunctival injections of 2 mg/mL of fluconazole. METHODS: The study was carried out in the Ophthalmology Department of Zagazig University Hospital and included 12 patients with 12 pairs of eyes with resistant corneal ulcers that had the following clinical features suggesting fungal keratitis: thick elevated ulcer, feathery edge, and gutter formation. Cultures of corneal specimens were grown on Sabouraud agar medium. Topical amphotericin B eye drops in a concentration of 0.2 mg/mL in dextrose 5% were used every 2 hours for 21 days together with subconjunctival injections of fluconazole 2 mg/mL. RESULTS: Among the eyes subjected to culture of corneal specimens, 8 eyes had positive results: Candida was detected in 5 eyes (66%) and filamentous fungi grew from the cultures of 3 eyes. Nine eyes improved as a result of treatment, showing complete healing of the ulcers (75%). Three cases showed no improvement (25%); 2 cases developed endophthalmitis; and 1 case was negative. A single case with corneal perforation had negative results on culture. CONCLUSION: The use of a combination of topical amphotericin B eye drops at a concentration of 0.2 mg/mL in dextrose 5% with subconjunctival injection of fluconazole 2 mg/mL had the advantage of a lower incidence of the complications of local use of amphotericin B and a broader spectrum of antifungal coverage. This study reports a relatively high success rate of healing of fungal keratitis, with a significant reduction of the potential side effects of the local use of antifungal agents.

Laser photocoagulation versus combined laser photocoagulation and posterior sub-Tenon's triamcinolone injection for the primary treatment of diffuse diabetic macular edema.

PURPOSE: To evaluate the effectiveness of combined treatment with posterior sub-Tenon's triamcinolone injection and focal laser photocoagulation, compared with laser treatment alone, in diffuse diabetic macular edema. METHODS: This was a nonrandomized, prospective, controlled study that involved 20 eyes with diffuse diabetic macular edema. The patients were divided into 2 groups: group I (10 eyes) received focal laser photocoagulation alone; and group II (10 eyes) received combined focal laser photocoagulation and posterior sub-Tenon's triamcinolone injection. All patients were followed for 6 months. Main outcome measures were final visual outcome and fluorescein leakage and retreatment rates at the end of the follow-up period. RESULTS: Combined therapy showed better visual and angiographic outcome at 6 months. The retreatment rate was significantly lower in the combined-therapy group compared with the laser-therapy-alone group, with more stable visual acuity. CONCLUSION: Improvement of visual acuity and decreased fluorescein leakage suggest that combination therapy with posterior sub-Tenon's triamcinolone injection and focal laser photocoagulation, particularly when used as a first-line therapy, is advantageous and merits further investigation.

Intrahepatic cholestasis of pregnancy: review of the literature and evaluation of current evidence.

OBJECTIVE: To provide an overview of the epidemiology, etiology, pathogenesis, diagnosis, and management of intrahepatic cholestasis of pregnancy. METHODS: We searched the Medline and PubMed database using the key words intrahepatic cholestasis of pregnancy, obstetric cholestasis, diagnosis, management, and complications. RESULTS: Intrahepatic cholestasis of pregnancy, or obstetric cholestasis, is a liver condition that develops during pregnancy. It is associated with increased perinatal morbidity and mortality. Pruritus and risk of postpartum hemorrhage are the main causes of maternal morbidity. Intrahepatic cholestasis of pregnancy is a diagnosis of exclusion. The current management policies depend on regular fetal and maternal monitoring and delivery at fetal maturity. The analysis of the quality of previous studies provided in this review highlights the areas of deficiency in evidence-based knowledge of this subject. CONCLUSIONS: More research is required into the etiology, pathogenesis, and monitoring modalities that can specifically predict fetal outcome in intrahepatic cholestasis of pregnancy. Clinical trials are required to identify the most suitable drugs for treatment.

On the removal of cationic surfactants from dilute streams by granular charcoal.

Adsorption of a cationic surfactant; cetylpyridinium chloride (CPyCl) on granular charcoal (GC) was used to remove the surfactant from dilute solutions. The removal process was performed using both batch and continuous processes. In the batch process, the effects of different operating parameters on the removal efficiency were studied. The GC was found to be efficient and removal efficiencies up to approximately 98% were obtained at certain conditions. The removal efficiency was found to increase with the amount of charcoal, shaking speed and temperature. It increased with the surfactant concentration and reaches quickly to maximum constant ranges but it decreases at higher concentrations near the cmc of the surfactant. The resistance for further decreases in the removal efficiency was dependent of the operating conditions. Adsorption of CPyCl on the GC was found to follow the kinetics of a first-order reaction. Activation energy of adsorption and SEM images suggested that diffusion inside the porous matrix could be a controlling step. Modified Frumkin isotherm was applied to the collected data at different temperatures. The results of removal of CPyCl using packed bed of GC at flowing conditions were also discussed. Higher values of the conversion efficiency, psi were obtained at low flow rates and thicker beds. The results were discussed on the light of a dimensionless conversion factor, phi = upsilonr2/2DLtheta, which includes important structural and hydrodynamic parameters. The experimental data showed a satisfactory agreement with the theoretical trends.