The impact of cotrimoxazole in idiopathic granulomatous mastitis treatment.

INTRODUCTION AND IMPORTANCE: Idiopathic granulomatous mastitis (IGM) is a benign inflammatory breast disease, commonly presented with a sensitive breast lump and developing scars. Currently, there is no definitive treatment for IGM but Antibiotics, steroids, immunosuppressive drugs or a surgical treatments are the usual options. This case series aimed to evaluate the effectiveness of cotrimoxazole in treatment of IGM as there is no clinical consensus on the best and most widely acknowledged therapeutic management for IGM. CASE PRESENTATION: All IGM patients were treated by Cotrimoxazole (800 mg BD for one week), and they were assessed at a month, 3 months, and 6 months after that. The primary outcome was an improvement in presenting complaints and symptoms such as palpable mass, bulging, pain, erythema and hypersensitivity of breast skin, breast discharge and fluctuation. The secondary outcome was the refractory rate within 6 months. Number of 20 patients were included. At the baseline, participants exhibited various symptoms such as bulging, pain and erythema (100 %), breast discharge (80 %), and fluctuation (30 %). After the intervention, there was a significant decrease in the prevalence of symptoms over the study period. The prevalence of bulging and pain, erythema, discharge, and fluctuation symptoms were decreasedto 5 %, 0 %, and 0 %, respectively. The refractory rate of IGM within six months of cotrimoxazole treatment was estimated 30 %. CLINICAL DISCUSSION: In this study, the treatment approach did not involve corticosteroids and invasive procedures and the recurrence rate of IGM within the six months was lower than in similar studies that employed steroids alone or any more invasive treatments. Additionally, our study showed a high healing rate with resolution of inflammation, pain, discharge, and fluctuation. These results suggest that cotrimoxazole may be a more favorable option than high-dose corticosteroids and a comparable alternative to low-dose corticosteroids regarding recurrence rates. CONCLUSION: Cotrimoxazole may be an effective treatment option for idiopathic granulomatous mastitis. However, further research is needed on different treatment options.

The omphalomesenteric duct fibrous band as a rare cause of bowel obstruction: A case report and literature review.

INTRODUCTION AND IMPORTANCE: The omphalomesenteric duct (OMD) is an embryonic structure that normally undergoes obliteration during embryonic development, typically not persisting after birth. Failure of complete or partial obliteration can result in a type of malformation known as OMD remnant. CASE PRESENTATION: We report a case of a 24-year-old male patient diagnosed with bowel obstruction. Abdominal computed tomography (CT) scan revealed the presence of an adhesion band. During surgery, a fibrous band connecting from the umbilicus to the mesentery of terminal ileum was found and resected. Pathological investigation confirmed the presence of an OMD remnant fibrous band. CLINICAL DISCUSSION: OMD remnant can manifest in different forms such as Meckel's diverticulum, umbilical polyp, OMD cyst, OMD fistula, and fibrous band, occurring in approximately 2 % of infants and often presenting symptoms in early childhood. These conditions rarely cause complications in adults. Complications may include obstruction, gastrointestinal bleeding, bowel perforation, and omphalitis which can present with symptoms such as abdominal pain, vomiting, melena, lack of defecation, umbilical discharge, and dermal manifestations. Diagnostic approaches vary depending on the type of OMD remnant and associated complications, but ultrasonography and CT scan can be useful. While asymptomatic OMD remnants generally do not require further intervention, surgical treatment is the main option for complicated and symptomatic cases. CONCLUSION: OMD remnant is a rare condition in adults that can lead to complications. Given that obstruction is a common complication of OMD remnant, OMD remnant should be considered in the differential diagnosis of patients presenting with bowel obstruction.

Jejunal adenocarcinoma; a case report and literature review.

INTRODUCTION AND IMPORTANCE: Small bowel carcinoma (SBC) is a rare malignancy comprising mainly of adenocarcinoma and carcinoid tumors. Among SBCs, small bowel adenocarcinoma (SBA) accounts for 30-40 % and is predominantly found in the duodenum, while jejunal and ileal presence considered rare. CASE PRESENTATION: We have presented a case of jejunal adenocarcinoma in a patient with obstruction symptoms. Prior to the obstruction, the patient mainly suffered from weakness and weight loss, in addition to iron deficiency anemia. During the investigation of underlying causes, we observed evidence of mass. However, before any additional evaluation could take place, the obstruction necessitated surgical intervention. CLINICAL DISCUSSION: Small bowel adenocarcinomas, particularly in the jejunum and ileum, are exceedingly rare and often present with complications such as obstruction, gastrointestinal bleeding, or perforation. Due to the non-specific symptoms, SBAs are challenging to diagnose before complications occur. SBAs are frequently diagnosed at advanced stages, so early diagnosis is crucial, as it can significantly impact patient survival. Thus, efforts should be made to expedite the diagnosis process to avoid complications and improve survival rates. CONCLUSION: SBAs are a rare condition, often diagnosed by related complications. Recognizing the importance of early diagnosis and its positive influence on patient survival, physicians and surgeons should consider SBA in patients presenting with relevant symptoms or cases of obstruction.

Cecal Perforation Induced by Migrated Biliary Stent as a Rare Complication of ERCP: A Case Report and Literature Review.

Introduction and Importance. Endoscopic retrograde cholangiopancreatography (ERCP) is a non-surgical method utilized to manage biliary tract obstruction, but the complication of biliary stent migration occurs in 5-10% of patients. Though migrated stents are commonly passed through the gastrointestinal tract without harm, intestinal perforation is a rare but severe complication, affecting less than 1% of cases. Case Presentation. We report a case of a 65-year-old woman who presented to the emergency department with symptoms of abdominal pain, nausea, and loss of appetite. According to clinical examination and evidence, the patient underwent surgery with high suspicion of appendicitis, which unexpectedly uncovered a perforated cecum with a protruding biliary stent. Clinical Discussion. Our report describes a unique and unexpected finding of cecal perforation caused by a migrated biliary stent in a patient. We also conducted a review of current literature on ERCP complications, including risk factors for stent migration, relevant statistics, and appropriate interventions. Conclusion. Surgeons should be aware of the risk of stent migration and complications in patients with a history of ERCP. Removal of migrated biliary stents is recommended, regardless of the presence of complications. Additional assessments for alternative diagnoses are recommended for older patients with abdominal pain complaints. Flexible plastic stents should be used for patients at risk of stent passage.

Spontaneous perforation as a fatal presentation of esophageal tuberculosis: A case report.

INTRODUCTION: Tuberculosis is a multisystematic disease and is the most common cause of infectious disease-related mortality worldwide. Gastrointestinal tract is an uncommon site for extrapulmonary tuberculosis (TB). Esophageal TB is exceedingly rare. PRESENTATION OF CASE: We report a 22-years-old male with esophageal TB that presented in septic shock from esophageal perforation. Despite all measures including surgical intervention and aggressive support in the intensive care unit, patient passed away. DISCUSSION: The most common mechanism for esophageal involvement is secondary to direct spread from mediastinal structures and/or spreading the inoculation of swallowed sputum, or hematogenous or lymphatic spread. Once the diagnosis of TB is established, antibiosis is the cornerstone of treatment. Surgery is reserved only for complications of TB such as fistula, abscess, strictures or perforation. Less than 50% of cases are diagnosed within 24 h, and delay in diagnosis lead to significant increases in the mortality. CONCLUSION: In countries with high prevalence of TB, this diagnosis should be considered in those with esophageal perforation with no underlying etiology and medical treatment for TB should be initiated in addition to conventional treatment in appropriate group of patients.

COVID-19 outbreak and surgical practice: The rationale for suspending non-urgent surgeries and role of testing modalities.

One-hundred years after the 1918-19 H1N1 flu pandemic and 10 years after the 2009 H1N1 flu pandemic, another respiratory virus has now inserted itself into the human population. Severe acute respiratory syndrome coronavirus has become a critical challenge to global health with immense economic and social disruption. In this article we review salient aspects of the coronavirus disease 2019 (COVID-19) outbreak that are relevant to surgical practice. The emphasis is on considerations during the pre-operative and post-operative periods as well as the utility and limitations of COVID-19 testing. The focus of the media during this pandemic is centered on predictive epidemiologic curves and models. While epidemiologists and infectious disease physicians are at the forefront in the fight against COVID-19, this pandemic is also a "stress test" to evaluate the capacity and resilience of our surgical community in dealing with the challenges imposed to our health system and society. As recently pointed out by Dr. Anthony Fauci, the virus decides the timelines in the models. However, the models can also change based on our decisions and behavior. It is our role as surgeons, to make every effort to bend the curves against the virus' will.

COVID-19 Pneumonia in Asymptomatic Trauma Patients; Report of 8 Cases.

We are currently involved in the novel coronavirus 2019 (COVID-19) pandemic. A considerable number of COVID-19 infected cases are asymptomatic but they can transmit the disease to others, especially healthcare workers. In this study, we reported 8 incidentally detected cases of COVID-19 pneumonia in chest computed tomography (CT) scan of patients referred to emergency department following multiple trauma without any respiratory symptoms.

Elimination of ghost peaks by optimization of anion exchange chromatography method for determination of gamma-carboxyglutamic acid (Gla)-domainless impurity in recombinant activated clotting factor VII drug products.

Secreted recombinant activated clotting factor VII activated (rFVIIa) in cell culture media missing gamma-carboxyglutamic acid (Gla) domain as a result of failure in gamma-carboxylation or cell lysis is called Gla-domainless impurity which has less negative charge compared to native rFVIIa. Based on risk assessment, this type of impurity is considered as critical drug product quality attribute of rFVIIa and its quantitative analysis in product batches is a critical issue in quality control laboratories. Analysis of Gla-domainless impurity is accomplished by Strong Anion Exchange Chromatography (SAX) in recombinant factor VIIa using Tris and Bis-Tris propane salt buffers as equilibrating buffers and high concentration ammonium acetate as an eluent. Appearance of ghost peaks with notable intensity during elution time of Gla-domainless impurity caused distortion of the related peak and interference with robust and accurate quantification of this impurity. Subsequently, the ghost peak was analyzed by LC-ESI-MS to determine the structure which showed the m/z values at 905.27, 623.53 and 341.60 and 563.73. To find the source of these ghost peaks, quality of water, buffer salts and Chelex-100 together with ionic strength of mobile phase A (addition of 25 mM NaCl) were considered as affecting parameters and several experiments designed with DOE software to optimize the best condition of highest quality the method with lowest signal of ghost peak noises. By interpretation of DOE result, it is concluded that high grade water and buffer salt along with high quality Chelex-100 resins are important factors to achieve a method with lowest ghost peaks. However, addition of 25 mM NaCl to mobile phase A with either lower quality buffer salts or lower water grade yields high quality chromatogram peak with acceptable ghost peaks. LC/MS analysis indicates that macrostructures of Bis-Tris propane made up as a result of hydrogen bonds with each other or Tris molecules can be the source of ghost peaks.

Studies on the laccase-mediated decolorization, kinetic, and microtoxicity of some synthetic azo dyes.

BACKGROUND: Enzymatic elimination of synthetic dyes, one of the most environmentally hazardous chemicals, has gained a great interest during the two last decades. The present study was performed to evaluate the decolorization and detoxification potential of the purified laccase of Paraconiothyrium variabile in both non-assisted and hydroxybenzotriazole-aided form against six azo dyes. RESULTS: The obtained results showed that Acid Orange 67, Disperse Yellow 79, Basic Yellow 28, Basic Red 18, Direct Yellow 107, and Direct Black 166 were decolorized up to 65.3, 53.3, 46.7, 40.7, 34, and 26.2 %, respectively, after 1 h treatment with laccase (0.5 U/mL). Addition of HBT up to 5 mM enhanced decolorization percent of all the investigated dyes. The results of kinetic study introduced the monoazo dye of Acid Orange 67 as the most suitable substrate for laccase with K m of 0.49 mM and V max of 189 mmol/min/mg. Evaluation the toxic effect of laccase-treated dye sample based on the growth inhibition of standard bacterial strains revealed decrease in toxicity of all applied dyes after treatment by laccase. CONCLUSIONS: Application of the P. variabile laccase as biocatalyst efficiently decreased the toxicity of all studied synthetic azo dyes.

Laccase-catalyzed decolorization and detoxification of Acid Blue 92: statistical optimization, microtoxicity, kinetics, and energetics.

BACKGROUND: In recent years, enzymatic-assisted removal of hazardous dyes has been considered as an alternative and eco-friendly method compared to those of physicochemical techniques. The present study was designed in order to obtain the optimal condition for laccase-mediated (purified from the ascomycete Paraconiothyrium variabile) decolorization of Acid Blue 92; a monoazo dye, using response surface methodology (RSM). So, a D-optimal design with three variables, including pH, enzyme activity, and dye concentration, was applied to optimize the decolorization process. In addition, the kinetic and energetic parameters of the above mentioned enzymatic removal of Acid Blue 92 was investigated. RESULTS: Decolorization of Acid Blue 92 was maximally (94.1% ± 2.61) occurred at pH 8.0, laccase activity of 2.5 U/mL, and dye concentration of 75 mg/mL. The obtained results of kinetic and energetic studies introduced the laccase-catalyzed decolorization of Acid Blue 92 as an endothermic reaction (Ea, 39 kJ/mol; ΔS, 131 J/mol K; and ΔH, 40 kJ/mol) with K m and V max values of 0.48 mM and 227 mM/min mg, respectively. Furthermore, the results of microtoxicity study revealed that the toxicity of laccase-treated dye was significantly reduced compared to the untreated dye. CONCLUSIONS: To sum up, the present investigation introduced the Paraconiothyrium variabile laccase as an efficient biocatalyst for decolorization of synthetic dye Acid Blue 92.