Regional assessment of aortic valve calcification using topographic maps in contrast-enhanced CT: in-vivo sex and severity-based differences in calcific presentation.

Background: Procedural planning for transcatheter aortic valve replacement (TAVR) is routinely performed using contrast computed tomography (CT) in patients with severe aortic stenosis (AS). Despite its potential, little investigation has been done into the possibility of aortic valve calcification (AVC) scoring in contrast-enhanced CT. Contrast CT has superior spatial and contrast resolution compared to the non-contrast Agatston score protocol, which would allow for development of better pattern and distribution descriptors of calcific lesions in the aortic valve (AV). Methods: We developed a new false positive rate (FPR) based method that can quantify leaflet calcification based on shape overlap metrics. We also introduce a novel regional scheme for quantifying the shape and structure of calcification using topographic maps. The study was designed to: (I) determine the feasibility of using a novel method based on FPR to detect AVC using contrast-enhanced CT images by assessing the volume scores measured using FPR versus non-contrast methods and alternative contrast methods for volume scoring based on fixed or dynamic HU thresholds. (II) Develop a new scheme for assessing calcific geometry and structure and evaluate patterns of calcification in the varied presentation of AS. Results: Our results show a very strong correlation with non-contrast volume (r=0.919, P<0.001; n=178) and Agatston scores (r=0.913, P<0.001; n=178) that were evaluated using a standard calcium scoring technique. Finally, we analyzed the differences and similarities in the patterns of calcific deposition with respect to sex and degree of severity. Conclusions: The FPR method demonstrates the best overall agreement with non-contrast scores across both low and high ends of calcific density compared to luminal attenuation methods. In addition, we showed that leaflet calcific deposition follows distinctive patterns across the belly of the leaflet, with the rate of calcific progression peaking at the non-coronary cusp (NCC) leaflet and lowest for the right-coronary cusp. Females experience significantly lower calcific deposition compared to males despite showing similar patterns and symptoms. Our findings suggest that precise regional assessment of calcific progression could be an important tool for monitoring AS development as well as predicting peri-procedural complications in TAVR.

Boosting weight loss after conversional Roux-en-Y Gastric Bypass with liraglutide and placebo use. A double-blind-randomized controlled trial.

BACKGROUND: Conversional bariatric surgery inherently has less weight loss (WL) compared to primary procedures. Adjunctive use of the GLP-1 analog, liraglutide with conversional Roux-en-Y Gastric Bypass (cRYGB) may maximize the WL benefits of surgery. MATERIAL AND METHODS: This single-center randomized double-blind placebo-controlled trial included 80 patients randomized into two groups; the liraglutide group (40 patients) who received daily injections of liraglutide, and the placebo group (40 patients) who received normal saline starting at 6 weeks from cRYGB and continued for 6 months. After discontinuing the drugs at 6 months and unblinding, the patient were followed up to 12 months. The endpoints were percentage of total weight loss (%TWL) and percentage of excess weight loss (%EWL), and changes in the metabolic biomarkers, and complications within 30 and 90 days according to the global outcome benchmark (GOB) stratification. RESULTS: In total, 38 patients in the liraglutide group and 31 in the placebo group completed the 24 weeks. Liraglutide group experienced better WL with a significantly higher mean %TWL at 1 month (10.27±1.39 vs. 8.41±2.08), at 6 weeks (12.65±1.77 vs. 10.47±2.23), at 6 months (18.29 ±1.74 vs. 15.58 ±1.65), and at 12 months 24.15±2.35 versus 22.70±2.13 (all P <0.001). For %EWL, this was also significantly higher in the liraglutide group at all time points. A %TWL of greater than 20% at 6 months of treatment was recorded in six (15.8%) patients in the liraglutide group and none in the placebo group ( P =0.029). Both groups had comparable changes in metabolic biomarkers. Adverse events were recorded in 11 (27.5%) patients in the liraglutide, with no adverse events in the placebo group ( P <0.001). Both groups had Clavien-Dindo scores I and II (5.0 and 2.5%), and GOB values indicated that 90.0 and 97.5% were low-risk patients. CONCLUSION: Adjunctive use of liraglutide with cRYGB gives significantly higher WL and resolution of associated medical problems.

Exploring Neoadjuvant Chemotherapy, Predictive Models, Radiomic, and Pathological Markers in Breast Cancer: A Comprehensive Review.

Breast cancer retains its position as the most prevalent form of malignancy among females on a global scale. The careful selection of appropriate treatment for each patient holds paramount importance in effectively managing breast cancer. Neoadjuvant chemotherapy (NACT) plays a pivotal role in the comprehensive treatment of this disease. Administering chemotherapy before surgery, NACT becomes a powerful tool in reducing tumor size, potentially enabling fewer invasive surgical procedures and even rendering initially inoperable tumors amenable to surgery. However, a significant challenge lies in the varying responses exhibited by different patients towards NACT. To address this challenge, researchers have focused on developing prediction models that can identify those who would benefit from NACT and those who would not. Such models have the potential to reduce treatment costs and contribute to a more efficient and accurate management of breast cancer. Therefore, this review has two objectives: first, to identify the most effective radiomic markers correlated with NACT response, and second, to explore whether integrating radiomic markers extracted from radiological images with pathological markers can enhance the predictive accuracy of NACT response. This review will delve into addressing these research questions and also shed light on the emerging research direction of leveraging artificial intelligence techniques for predicting NACT response, thereby shaping the future landscape of breast cancer treatment.

Early Detection of Risk of Neo-Sinus Blood Stasis Post-Transcatheter Aortic Valve Replacement Using Personalized Hemodynamic Analysis.

Background: Despite the demonstrated benefits of transcatheter aortic valve replacement (TAVR), subclinical leaflet thrombosis and hypoattenuated leaflet thickening are commonly seen as initial indications of decreased valve durability and augmented risk of transient ischemic attack. Methods: We developed a multiscale patient-specific computational framework to quantify metrics of global circulatory function, metrics of global cardiac function, and local cardiac fluid dynamics of the aortic root and coronary arteries. Results: Based on our findings, TAVR might be associated with a high risk of blood stagnation in the neo-sinus region due to the lack of sufficient blood flow washout during the diastole phase (e.g., maximum blood stasis volume increased by 13, 8, and 2.7 fold in the left coronary cusp, right coronary cusp, and noncoronary cusp, respectively [N = 26]). Moreover, in some patients, TAVR might not be associated with left ventricle load relief (e.g., left ventricle load reduced only by 1.2 % [N = 26]) and diastolic coronary flow improvement (e.g., maximum coronary flow reduced by 4.94%, 15.05%, and 23.59% in the left anterior descending, left circumflex coronary artery, and right coronary artery, respectively, [N = 26]). Conclusions: The transvalvular pressure gradient amelioration after TAVR might not translate into adequate sinus blood washout, optimal coronary flow, and reduced cardiac stress. Noninvasive personalized computational modeling can facilitate the determination of the most effective revascularization strategy pre-TAVR and monitor leaflet thrombosis and coronary plaque progression post-TAVR.

Effects of obstructive sleep apnea on non-alcoholic fatty liver disease in patients with obesity: a systematic review.

INTRODUCTION: Obesity has been linked to non-alcoholic fatty liver disease (NAFLD), a widespread chronic liver ailment, as well as obstructive sleep apnea (OSA). The development of NAFLD is influenced by repeated intermittent hypoxia, a feature of OSA. METHODS: This systematic review (SR) investigated CENTRAL, PubMed, and EMBASE databases. The endpoint of this SR was to assess which OSA-related indicators could predict the presence of NAFLD and the effect of bariatric metabolic surgery (BMS) on improving OSA and NAFLD over time. RESULTS: Compared to previous SRs published in 2013, 14 new publications were added to our SR, alongside studies conducted prior to 2013. The SR ultimately included 28 studies (18 cross-sectional and 10 cohort trials). In the majority of studies, significant correlations were observed between OSA, OSA-related outcomes, and NAFLD. However, the apnea-hypopnea index (AHI) alone proved to be an inadequate predictor of NAFLD. Instead, respiratory and metabolic changes were found to alleviate oxidative stress induced by hypoxemia. Six studies involved patients who underwent BMS, with one evaluating patients before and after BMS, revealing associations between increased OSA and NAFLD improvement following BMS. Six months after surgery, 100% of patients in the mild-to-moderate OSA group were free from fatty liver, and an 89% reduction was observed in the severe OSA group. CONCLUSION: For the first time, BMS has been tested in treating both OSA and NAFLD pre and postoperative with positive results. Further research, ideally with histological and functional data, is needed to confirm these findings. The SR identified 14 distinct liver outcome tests; however, high heterogeneity and incomplete data precluded a meta-analysis. It is imperative to pay greater attention to the influence of OSA-related factors and uniformity in liver outcomes testing concerning NAFLD. To accomplish this, study designs should be enhanced by incorporating more comprehensive pre- and postoperative evaluations, extending follow-up periods, and employing a more consistent methodology for liver diagnosis in patients with obesity.

Temporary stomas after rectal cancer resection; predilection of being permanent and predictors of complications?

Stomas are essential for colorectal surgery and are widely used not only for selected cases for bowel obstructions but also in rectal cancer operations to divert stool away from low rectal anastomosis. On the other hand, complications with stomas/ stomas reversal are not uncommon. In this study, we aimed at studying the frequency and the predictors of temporary stomas being permanent, and the contributing factors of surgical stoma/stoma closure related complications. In our cohort, only about 40% of the patient closed their initially planned temporary stomas. The occurrence of intestinal leak, wound sepsis, or any type of morbidity with 30 days of operation were significant predictors of permanent stomas. In addition, alarmingly although Hartmann's procedure was uncommon in our practice, only 9% of those who underwent Hartmann's have had it reversed. Moreover, the only factor that significantly increased stoma related complications was having an end colostomy. There was a tendency toward late closure of stomas with median 8.2 months, however early closure did not correlate to complications. In conclusion, further studies are needed to delineate the low rate of stoma closure. Patients who develop postoperative complications, even wound sepsis, would be at a higher risk of living with permanent stomas. Hartmann's procedures are commonly associated with stoma problems, and reluctance to reverse the stomas. (AU)

Reducing Long-Term Mortality Post Transcatheter Aortic Valve Replacement Requires Systemic Differentiation of Patient-Specific Coronary Hemodynamics.

Background Despite the proven benefits of transcatheter aortic valve replacement (TAVR) and its recent expansion toward the whole risk spectrum, coronary artery disease is present in more than half of the candidates for TAVR. Many previous studies do not focus on the longer-term impact of TAVR on coronary arteries, and hemodynamic changes to the circulatory system in response to the anatomical changes caused by TAVR are not fully understood. Methods and Results We developed a multiscale patient-specific computational framework to examine the effect of TAVR on coronary and cardiac hemodynamics noninvasively. Based on our findings, TAVR might have an adverse impact on coronary hemodynamics due to the lack of sufficient coronary blood flow during diastole phase (eg, maximum coronary flow rate reduced by 8.98%, 16.83%, and 22.73% in the left anterior descending, left circumflex coronary artery, and right coronary artery, respectively [N=31]). Moreover, TAVR may increase the left ventricle workload (eg, left ventricle workload increased by 2.52% [N=31]) and decrease the coronary wall shear stress (eg, maximum time averaged wall shear stress reduced by 9.47%, 7.75%, 6.94%, 8.07%, and 6.28% for bifurcation, left main coronary artery, left anterior descending, left circumflex coronary artery, and right coronary artery branches, respectively). Conclusions The transvalvular pressure gradient relief after TAVR might not result in coronary flow improvement and reduced cardiac load. Optimal revascularization strategy pre-TAVR and progression of coronary artery disease after TAVR could be determined by noninvasive personalized computational modeling.

A Doppler-exclusive non-invasive computational diagnostic framework for personalized transcatheter aortic valve replacement.

Given the associated risks with transcatheter aortic valve replacement (TAVR), it is crucial to determine how the implant will affect the valve dynamics and cardiac function, and if TAVR will improve or worsen the outcome of the patient. Effective treatment strategies, indeed, rely heavily on the complete understanding of the valve dynamics. We developed an innovative Doppler-exclusive non-invasive computational framework that can function as a diagnostic tool to assess valve dynamics in patients with aortic stenosis in both pre- and post-TAVR status. Clinical Doppler pressure was reduced by TAVR (52.2 ± 20.4 vs. 17.3 ± 13.8 [mmHg], p < 0.001), but it was not always accompanied by improvements in valve dynamics and left ventricle (LV) hemodynamics metrics. TAVR had no effect on LV workload in 4 patients, and LV workload post-TAVR significantly rose in 4 other patients. Despite the group level improvements in maximum LV pressure (166.4 ± 32.2 vs 131.4 ± 16.9 [mmHg], p < 0.05), only 5 of the 12 patients (41%) had a decrease in LV pressure. Moreover, TAVR did not always improve valve dynamics. TAVR did not necessarily result in a decrease (in 9 out of 12 patients investigated in this study) in major principal stress on the aortic valve leaflets which is one of the main contributors in valve degeneration and, consequently, failure of heart valves. Diastolic stresses increased significantly post-TAVR (34%, 109% and 81%, p < 0.001) for each left, right and non-coronary leaflets respectively. Moreover, we quantified the stiffness and material properties of aortic valve leaflets which correspond with the reduced calcified region average stiffness among leaflets (66%, 74% and 62%; p < 0.001; N = 12). Valve dynamics post-intervention should be quantified and monitored to ensure the improvement of patient conditions and prevent any further complications. Improper evaluation of biomechanical valve features pre-intervention as well as post-intervention may result in harmful effects post-TAVR in patients including paravalvular leaks, valve degeneration, failure of TAVR and heart failure.

The epidemiological and clinicopathological characteristics of multifocal/multicentric breast cancer in the Egyptian Delta and its impact on management strategies.

BACKGROUND: Multifocal (MFBC)/multicentric (MCBC) breast cancer is being more recognized due to the improved imaging modalities and the greater orientation with this form of breast cancer, however, optimal surgical treatment, still poses a challenge. The standard surgical treatment is mastectomy, however, breast-conserving surgeries (BCS) may be appropriate in certain situations. METHODS: A total of 464 cases of MF/MCBC out of 4798 cases of breast cancer were retrospectively analyzed from the database of the Oncology Center, Mansoura University (OCMU), between January 2008 and December 2019. RESULTS: Radiologic involvement of multiple quadrants was reported in 27.9% by ultrasonography, 19% by mammography, and 59.1% by magnetic resonance imaging. BCS was performed in 32 cases (6.9%) while 432 cases underwent a mastectomy. Postoperative pathology revealed infiltration of other quadrants grossly in 23.5%, and under the microscope in 63.6% of the examined cases. Mean disease-free and overall survival were 95.5 and 164.6 months, respectively. When compared with MFBC, MCBC showed higher pathologic tumor size (p < 0.001), higher stages (p < 0.001), higher recurrence rates (p = 0.006), and lower DFS (P = 0.009) but with similar OS (P = 0.8). CONCLUSION: Mastectomy is still the primary treatment option for MCBC with higher recurrence rates compared with MFBC. However, BCS for properly selected MFBC is considered oncologically safe, following the same rules of breast conservation for unifocal disease.

Hemodynamic Modeling, Medical Imaging, and Machine Learning and Their Applications to Cardiovascular Interventions.

Cardiovascular disease is a deadly global health crisis that carries a substantial financial burden. Innovative treatment and management of cardiovascular disease straddles medicine, personalized hemodynamic modeling, machine learning, and modern imaging to help improve patient outcomes and reduce the economic impact. Hemodynamic modeling offers a non-invasive method to provide clinicians with new pre- and post- procedural metrics and aid in the selection of treatment options. Medical imaging is an integral part in clinical workflows for understanding and managing cardiac disease and interventions. Coupling machine learning with modeling, and cardiovascular imaging, provides faster modeling, improved data fidelity, and an enhanced understanding and earlier detection of cardiovascular anomalies, leading to the development of patient-specific diagnostic and predictive tools for characterizing and assessing cardiovascular outcomes. Herein, we provide a scoping review of translational hemodynamic modeling, medical imaging, and machine learning and their applications to cardiovascular interventions. We particularly focus on providing an intuitive understanding of each of these approaches and their ability to support decision making during important clinical milestones.

Surviving rectal cancer at the cost of a colostomy: global survey of long-term health-related quality of life in 10 countries.

BACKGROUND: Colorectal cancer management may require an ostomy formation; however, a stoma may negatively impact health-related quality of life (HRQoL). This study aimed to compare generic and stoma-specific HRQoL in patients with a permanent colostomy after rectal cancer across different countries. METHOD: A cross-sectional cohorts of patients with a colostomy after rectal cancer in Denmark, Sweden, Spain, the Netherlands, China, Portugal, Australia, Lithuania, Egypt, and Israel were invited to complete questionnaires regarding demographic and socioeconomic factors along with the Colostomy Impact (CI) score, European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30) and five anchor questions assessing colostomy impact on HRQoL. The background characteristics of the cohorts from each country were compared and generic HRQoL was measured with the EORTC QLQ-C30 presented for the total cohort. Results were compared with normative data of reference European populations. The predictors of reduced HRQoL were investigated by multivariable logistic regression, including demographic and socioeconomic factors and stoma-related problems. RESULTS: A total of 2557 patients were included. Response rates varied between 51-93 per cent. Mean time from stoma creation was 2.5-6.2 (range 1.1-39.2) years. A total of 25.8 per cent of patients reported that their colostomy impairs their HRQoL 'some'/'a lot'. This group had significantly unfavourable scores across all EORTC subscales compared with patients reporting 'no'/'a little' impaired HRQoL. Generic HRQoL differed significantly between countries, but resembled the HRQoL of reference populations. Multivariable logistic regression showed that stoma dysfunction, including high CI score (OR 3.32), financial burden from the stoma (OR 1.98), unemployment (OR 2.74), being single/widowed (OR 1.35) and young age (OR 1.01 per year) predicted reduced stoma-related HRQoL. CONCLUSION: Overall HRQoL is preserved in patients with a colostomy after rectal cancer, but a quarter of the patients interviewed reported impaired HRQoL. Differences among several countries were reported and socioeconomic factors correlated with reduced quality of life.

Impact of Morbid Obesity on the Outcomes of Type II Endometrial Cancer: a Cohort Study.

Obesity has long been associated with endometrial cancer. However, there is a paucity of studies addressing the impact of morbid obesity in type II endometrial cancer on oncologic and surgical outcomes. In this study, the author retrospectively compared morbid to non-morbid obese in clinico-epidemiologic, surgical, and oncologic outcomes. Both groups were comparable as regards all clinico-epidemiologic parameters. Vaginal involvement, survival, and recurrence were also comparable between the 2 groups. Para-aortic adenopathy and treatment with preoperative therapy were the only significant predictors of DFS. Surgery is feasible with equivalent complications and oncologic outcomes in morbidly obese patients with type II endometrial cancer.

Management of borderline ovarian tumors: A tertiary referral center experience in Egypt.

Background: In this retrospective study, we discuss our experience as a large tertiary referral center in Egypt in the management and follow-up of borderline tumors. Patients and methods: This is a retrospective cohort study where all patients diagnosed with a borderline ovarian tumor at Oncology Center Mansoura University from November 2014 to June 2020 were included. Demographics, preoperative, operative, postoperative, pathologic, and oncologic follow-up data were retrieved from a prospectively maintained electronic database. The included patients were followed until April 2022. Results: We included 27 patients with borderline ovarian tumors. The mean age of the study patients was 47.67 ± 16.39 years. The median CA 125 was 33 (6-304 U/ml). Frozen section examination was utilized in 13 patients (48.14%), where a diagnosis of borderline ovarian tumors was revealed in 8 patients. Recurrence was reported in one patient with serous type after approximately 26 months. The most common pathological type in our cohort was the mucinous borderline type reported in 14 patients (51.9%), followed by the serous type reported in 11 patients (40.7%), and the seromucinous type in 1 patient only. Patients with mucinous borderline type were significantly younger (40.083 ± 18.47 vs. 53.73 ± 11.91 years, p = 0.028). Interestingly, Cancer Antigen 125 levels were significantly higher in mucinous than serous and seromucinous types [67(16-304) vs. 20(6-294.6) U/ml, p = 0.027]. On the other hand, the radiological tumor size of serous and seromucinous types was larger than that of the mucinous type [23(19-31) cm vs. 8(5-20) cm, p = 0.001]. Over a median follow-up period of 58.66 (54.16-63.16) months, only one postoperative mortality was reported, while only one recurrence was reported. Conclusion: Borderline ovarian tumors still represent a dilemma either in diagnosis or management. A frozen section examination could help to reach a preliminary diagnosis. Total abdominal hysterectomy and bilateral salpingo-oophorectomy are the cornerstone of surgical management; however, fertility-sparing surgery could be a valid option for women desiring fertility.

Primary thyroid chondrosarcoma: a case report of an extremely rare malignancy.

INTRODUCTION: There are different types of malignant tumors that can affect the thyroid gland where differentiated thyroid carcinomas (papillary and follicular) are the most common representing nearly 90% of cases. Non-epithelial malignancies were also reported to affect the thyroid gland particularly lymphomas and sarcomas that were reported in literature to range from 0.01 to 1.5% of thyroid carcinoma. Herein, we present a case with primary thyroid chondrosarcoma, an extremely rare malignancy of the thyroid gland. CASE PRESENTATION: We present a 79-year-old female patient complaining of hard thyroid swelling that was proved to be primary thyroid chondrosarcoma after histopathological assessment. CONCLUSION: Chondrosarcoma of the thyroid gland is extremely rare either in the primary or metastatic setting. Although the prognosis is bad, surgery is the main line of treatment after early prompt diagnosis.

Multicenter validation of the PREDICT score for prediction of local recurrence after total mesorectal excision of rectal cancer.

BACKGROUND: Total mesorectal excision (TME) is the gold standard treatment for rectal cancer. Although TME has managed to decrease the rates of local recurrence after rectal cancer resection, local recurrence is still recorded at varying rates. The present study aimed to validate the PREDICT score in the prediction of local recurrence of rectal cancer after TME with curative intent. METHODS: This was a retrospective multicenter study on patients with nonmetastatic low or middle rectal cancer who underwent TME. The total PREDICT score was calculated for every patient and related to the onset of local recurrence. According to the final score, patients were allocated to one of three risk groups: low, moderate, and high, and the rates of local recurrence in each group were calculated and compared. RESULTS: The present study included 262 patients (50.4% males) with a mean age of 47.1 years. The overall local recurrence rate was 12.6%. 29.4% of patients were in the low-risk group, 63.7% in the moderate-risk group, and 6.9% in the high-risk group. The local recurrence rate was 3.9% (95% confidence interval [CI]: 0.8-10.9) in the low-risk group, 13.2% (95% CI: 8.4-19.3) in the moderate risk group, and 44.4% (95% CI: 21.5-69.2) in the high-risk group (p < 0.0001). The sensitivity of the PREDICT score was 72.7%, the specificity was 88.1%, and the accuracy was 86.3%. CONCLUSIONS: The PREDICT score had good diagnostic accuracy in the prediction of local recurrence after TME and a good discriminatory ability in the differentiation between patients at different risks to develop local recurrence.

Resource Oriented Decision Making for Treatment of Metastatic Colorectal Cancer (mCRC) in a Lower-Middle Income Country: Egyptian Foundation of Medical Sciences (EFMS) Consensus Recommendations 2020.

PURPOSE: Colorectal cancer (CRC) is the third most commonly diagnosed cancer worldwide and the second cause of cancer related mortality. Treatment options for patients with metastatic CRC (mCRC) expanded during the last two decades, with introduction of new chemotherapeutic and targeted agents. Egypt is a lower middle-income country; Egyptian health care system is fragmented with wide diversity in drug availability and reimbursement policies across different health care providing facilities. We report the results of consensus recommendations for treatment of patients with metastatic colorectal cancer developed by Egyptian Foundation of Medical Sciences (EFMS), aiming to harmonize clinical practice through structured expert consensus-based recommendations consistent with the national status. EFMS recommendations could be utilized in other countries with similar economic status. METHODS: EFMS recommendations were developed using a modified Delphi process, with three rounds of voting till the final recommendations were approved. A non-systematic review of literature was conducted before generating the provisional statements. Content experts were asked to vote on some recommendations in two different resource groups (restricted resources and non-restricted resources). External review board of experts from a low income and lower-middle countries voted on the applicability of EFMS recommendations in their countries. RESULTS: The current recommendations highlighted the discrepancy in health care between restricted and non-restricted resources with expected survival loss and quality of life deterioration. Access to targeted agents in first line is very limited in governmental institutions, and no access to agents approved for third line in patients who failed oxaliplatin and irinotecan containing regimens for patients treated in restricted resource settings. CONCLUSION: Management of mCRC in developing countries is a challenge. The currently available resource-stratified guidelines developed by international cancer societies represent a valuable decision-making tool, adaptation to national status in each country based on healthcare system status is required.

The results of cardiac surgery during the COVID-19 pandemic compared with previous years: a propensity weighted study of outcomes at six months.

OBJECTIVES: In addition to excess mortality due to COVID-19, the pandemic has been characterised by excess mortality due to non-COVID diagnoses and consistent reports of patients delaying seeking medical treatment. This study seeks to compare the outcomes of cardiac surgery during and before the COVID-19 pandemic. DESIGN: Our institutional database was interrogated retrospectively to identify all patients undergoing one of three index procedures during the first six months of the pandemic and the corresponding epochs of the previous five years. SETTING: A regional cardiothoracic centre. PARTICIPANTS: All patients undergoing surgery during weeks #13-37, 2015-2020. MAIN OUTCOME MEASURES: Propensity score weighted analysis was employed to compare the incidence of major complications (stroke, renal failure, re-ventilation), 30-day mortality, six month survival and length of hospital stay between the two groups. RESULTS: There was no difference in 30-day mortality (HR = 0.76 [95% CI 0.27-2.20], p = 0.6211), 6-month survival (HR = 0.94 [95% CI 0.44-2.01], p = 0.8809) and duration of stay (SHR = 1.00 (95% CI 0.90-1.12), p = 0.959) between the two eras. There were no differences in the incidence of major complications (weighted chi-square test: renal failure: p = 0.923, stroke: p = 0.991, new respiratory failure: p = 0.856). CONCLUSIONS: Cardiac surgery is as safe now as in the previous five years. Concerns over the transmission of COVID-19 in hospital are understandable but patients should be encouraged not to delay seeking medical attention. All involved in healthcare and the wider public should be reassured by these findings.

Association between Epstein-Barr Virus Gene Polymorphism and Breast Cancer Risk among Egyptian Females.

BACKGROUND: Epstein-Barr virus (EBV) has been implicated in the development of breast cancer (BC) since 1995. It is classified into A/B genotypes, C/D subtypes, and F/f variants according to variations in its genome. AIM: To determine the distribution difference of EBV types between BC patients and healthy controls in Egypt and to detect the association between different EBV types and BC characteristics. METHODS: Three hundred and sixty-two participants (142 BC patients and 220 controls) were enrolled in this study. All participants were screened for EBV infection by determination of viral-capsid-IgG antibodies in their sera. EBNA-1 gene was detected by PCR in tumor biopsies of seropositive patients and in peripheral blood mononuclear cells of controls. A/B genotyping of EBV was performed by nested-PCR targeting the EBNA-2 gene. C/D subtypes and F/f variants were identified by Restriction fragment length polymorphism at BamHI-I W1/I1 and BamHI-F regions of EBV genome, respectively. RESULTS: Among 362 participants, 300(82.9%) were EBV-seropositive, including 120/142(84.5%) of the BC patients and 180/220(81.8 %) of the controls. EBNA-1 gene was positive in 54(45%) of seropositive BC patients and in 38(21.1%) of seropositive controls. There was a significant association of EBNA-1 gene with breast cancer (OR=3.05, 95%CI=1.84-5.07). Moreover, EBNA-1 gene positivity was significantly associated with the more aggressive tumors. Genotype-A and prototype-F were predominant among patients (90.4%, 100%, respectively) as well as among controls (91.7%, 100%, respectively) with no statistical significant association with BC risk.  However, subtype-D was significantly more frequent in patients (95.6%) than in controls (64.7%) and was significantly associated with a higher BC risk as compared to subtype-C (OR=11.7, 95%CI=2.4-57.08). Subtype-D was significantly associated with higher grades tumors (100% among grade III),  with progesteron receptor-negative tumors and with HER2-positive tumors (100% for each). The combined genotypes that significantly associated with BC risk were ADF (OR=4.9) and BDF (OR=5.5). CONCLUSIONS: Subtype-D of EBV could be the only EBV type implicated in BC development among Egyptian females and associated more with poor prognosis.