Utility of Cilefa Pink B, a foodstuff dye as a fluoro-substrate in the devising of the first facile green Molecular-mass-Related Fluorescence Sensor for quantifying amlodipine in batched material and dosage forms; content uniformity evaluation

This study introduces the first and unique Molecular-mass-Related Fluorescence Sensor as the first fluorimetric strategy for determining amlodipine. An environmentally friendly, single-step, and direct spectrofluorimetric approach was utilized to evaluate the analyte. In an acidic setting, combining the amlodipine medication and the fluorescent dye Cilefa Pink B generated an instantaneous ultra-fluorescent product. An increase in dye response after adding amlodipine was proportional to the molecular weight of the generated complex, as measured at 329 nm. was the idea ofthe applied fluorimetric analysis. The complexing process increased the molecular mass from 879.86 to 1288.739 g mol-1. The medication's range of 0.050-1.00 µg mL-1 is directly correlated with this molecular massenlargement. The ideal settings for the changeable parameters of the system were established through an analysis of the response of the amlodipine-Cilefa Pink B system. Furthermore, the developed sensor complied with ICH (International Council for Harmonization) standards. The sensitivity limits were 0.0139 µg mL-1 (for the detection limit, LOD) and 0.042 µg mL-1 (for the quantification limit, LOQ). Additionally, this method effectively recovered the drug in its original and therapeutic dosage forms. Finally, the proposed process's environmental impact was also assessed through different modern greenness evaluation tools.

Lipase as a Chiral Selector Immobilised on Carboxylated Single-Walled Carbon Nanotubes and Encapsulated in the Organic Polymer Monolithic Capillary for Nano-High Performance Liquid Chromatography Enantioseparation of Racemic Pharmaceuticals

Herein, we report the preparation of lipase immobilised on single-walled carbon nanotubes (SWCNTs) as an enantioselector for capillary monolithic columns and their application in the chiral separation of racemic pharmaceuticals. The columns were prepared through the encapsulation of functionalised SWCNTs (c-SWCNTs) within an organic monolithic polymer, followed by the immobilisation of lipase over the obtained monolith, over a three-day (L1) and five-day (L2) period. The prepared columns were tested for the enantioselective nano-HPLC separation of 50 racemic drugs. A suitable resolution was achieved for 25 drugs using nano-RP-HPLC conditions for both the L1 and L2 capillaries, while no specific resolution was detected under normal-phase HPLC conditions. The developed c-SWCNT-lipase-based polymeric monolithic capillaries are a promising expansion for separating pharmaceutical enantiomers' using nano-HPLC.

Macrocyclic Antibiotics as Effective Chiral Selectors in Liquid Chromatography for Enantiomeric Separation of Pharmaceutical Compounds: A Review

Chiral separation techniques play a crucial role in the pharmaceutical industry, where the enantiomeric purity of drugs can have a significant impact on their efficacy and safety. Macrocyclic antibiotics are highly effective chiral selectors used in various chiral separation techniques, including LC, HPLC, SMB, and TLC, offering reproducible results and a wide range of applications. However, developing robust and efficient immobilization mechanisms for these chiral selectors remains a challenge. This review article focuses on various immobilization approaches, such as immobilization, coating, encapsulation, and photosynthesis, that have been applied to immobilize macrocyclic antibiotics on their support. Commercially available macrocyclic antibiotics for conventional liquid chromatography include Vancomycin, Norvancomycin, Eremomycin, Teicoplanin, Ristocetin A, Rifamycin, Avoparcin, Bacitracin, and others. In addition, capillary (nano) liquid chromatography has also been used in chiral separation utilizing Vancomycin, Polymyxin B, Daptomycin, and Colistin Sulfate. Macrocyclic antibiotic-based CSPs have been extensively applied due to their reproducible results, ease of use, and broad range of applications, capable of separating a large number of racemates.

A Polymer-based Monolithic Capillary Column with Polymyxin-B Chiral Selector for the Enantioselective Nano-High Performance Liquid Chromatographic Pharmaceutical Analysis

Herein, we report the first use of Polymyxin-B antibiotic as a enantio-selector in polymer monolithic capillary. The capillaries were functionalised, characterized and tested for the enantioselective nano-HPLC separation of 50 racemic pharmaceutical drugs. They have been easily prepared by immobilizing Polymyxin-B over the organic polymer for 48 h (P1) or encapsulating Polymyxin-B within the organic polymer (P2) and tested for the enantioselective resolution of racemic drugs. Acceptable resolution was achieved for 21 drugs using RP-HPLC conditions on both (P1) and (P2) capillary columns, while no separation was observed under NP-HPLC conditions. Polymyxin-B is commercially available, easily solubilized and stable in both acidic and neutral media. The developed Polymyxin-B-based polymer monolithic capillaries provide a promising expansion of platform in enantioselective HPLC separations.

RP-HPLC stability-indicating method for simultaneous determination of sodium valproate, methylparaben and propylparaben in oral solution

A new, sensitive, stability-indicating reversed-phase HPLC method was validated and applied for the simultaneous quantitation of sodium valproate and two paraben preservatives; methylparaben, and propylparaben in the liquid dosage form. Stability tests were carried out through exposure of the analyte's solution to stress conditions. Separation of the analytes was achieved on (waters) C18 Column (150 mm × 3.9 mm, 5 μm). A mixture of 0.05 M monobasic potassium phosphate pH 3.5 and acetonitrile (50:50; v/v) was applied at 1.5 ml/min flow rate and UV detection wavelength at 210 nm. The degradation products and the analytes were completely separated. The linearity was performed in the range of 50–150 % from a target concentration of 10 μg/ml propylparaben, 90 μg/ml methylparaben, and 2.88 mg/ml sodium valproate with a coefficient correlation (R2) 1.0 for methylparaben, propylparaben and sodium valproate. The validation results of the suggested method were in a good agreement with ICH guidelines. Application of the proposed method for analysis of liquid dosage forms was successfully carried out in the routine quality control process.

Structure-based design, synthesis, and biological evaluation of novel piperine-resveratrol hybrids as antiproliferative agents targeting SIRT-2

A series of novel piperine–resveratrol hybrids 5a–h was designed, synthesized, and structurally elucidated by IR, and ¹H, ¹³C, and ¹⁹F NMR. Antiproliferative activities of 5a–h were evaluated by NCI against sixty cancer cell lines. Compound 5b, possessing resveratrol pharmacophoric phenolic moieties, showed a complete cell death against leukemia HL-60 (TB) and Breast cancer MDA-MB-468 with growth inhibition percentage of −0.49 and −2.83, respectively. In addition, 5b recorded significant activity against the other cancer cell lines with growth inhibition percentage between 80 to 95. New 5a–h hybrids were evaluated for their inhibitory activities against Sirt-1 and Sirt-2 as molecular targets for their antiproliferative action. Results showed that compounds 5a–h were more potent inhibitors of Sirt-2 than Sirt-1 at 5 μm and 50 μm. Compound 5b showed the strongest inhibition of Sirt-2 (78 ± 3% and 26 ± 3% inhibition at 50 μM and 5 μM, respectively). Investigation of intermolecular interaction via Hirschfeld surface analysis indicates that these close contacts are mainly ascribed to the O–H⋯O hydrogen bonding. To get insights into the Sirt-2 inhibitory mechanism, a docking study was performed where 5b was found to fit nicely inside both extended C-pocket and selectivity pocket and could compete with the substrate acyl-Lys. Another possible binding pattern showed that 5b could act by partial occlusion of the NAD⁺ C-pocket. Collectively, these findings would contribute significantly to better understanding the Sirt-2 inhibitory mechanism in order to develop a new generation of refined and selective Sirt-2 inhibitors.

A series of novel piperine–resveratrol hybrids 5a–h was designed, synthesized, and structurally elucidated by IR, and ¹H, ¹³C, and ¹⁹F NMR.

Daptomycin: A Novel Macrocyclic Antibiotic as a Chiral Selector in an Organic Polymer Monolithic Capillary for the Enantioselective Analysis of a Set of Pharmaceuticals

Daptomycin, a macrocyclic antibiotic, is here used as a new chiral selector in preparation of chiral stationary phase (CSP) in a recently prepared polymer monolithic capillary. The latter is prepared using the copolymerization of the monomers glycidyl methacrylate (GMA) and ethylene glycol dimethacrylate (EGDMA) in the presence of daptomycin in water. Under reversed phase conditions (RP), the prepared capillaries were tested for the enantioselective nanoliquid chromatographic separation of fifty of the racemic drugs of different pharmacological groups, such as adrenergic blockers, H1-blockers, NSAIDs, antifungal drugs, and others. Baseline separation was attained for many drugs under RP-HPLC. Daptomycin expands the horizon of chiral selectors in HPLC.

Comparative study of tissue adhesive therapy versus band ligation in control of actively bleeding esophageal varices

BACKGROUND AND STUDY AIMS

Bleeding esophageal varices is a common life-threatening emergency that carries a significant morbidity and mortality. Acute variceal bleeding is considered active when spurting and/or oozing varix is seen at the time of endoscopy, or inactive in the presence of large esophageal varices with blood in the stomach with no other bleeding source at the time of endoscopy. Aim: comparing endoscopic variceal ligation (EVL) versus cyanoacrylate injection (CI) in active esophageal variceal bleeding control.

PATIENTS AND METHODS

a retrospective single tertiary center study from April 2014 to February 2018, including 401 patients with active esophageal variceal bleeding.

RESULTS

Endoscopic hemostasis was achieved by both endoscopic variceal ligation in 182 patients (91.9%) and cyanoacrylate injection in 197 patients (97.05%) without significant difference (P value 0. 15). Re-bleeding occurred more frequently in EVL group 20 patients (10.1%) compared to 14 patients (6.9%) in CI (P value 0.01). Early six-week Mortality was higher among EVL group (20.7%) compared to CI (17.2%) without statistical significance (P value 0.3).

CONCLUSION

Both EVL and CI are almost as effective in achieving endoscopic hemostasis. CI is more effective, feasible, and could be used as a salvage therapy and/or spared for risky active bleeding esophageal varices.

Differentiation Potential of Nestin (+) and Nestin (-) Cells Derived from Human Bone Marrow Mesenchymal Stem Cells into Functional Insulin Producing Cells

The feasibility of isolating and manipulating mesenchymal stem cells (MSCs) from human patients provides hope for curing numerous diseases and disorders. Recent phenotypic analysis has shown heterogeneity of MSCs. Nestin progenitor cell is a subpopulation within MSCs which plays a role in pancreas regeneration during embryogenesis. This study aimed to separate nestin ⁽⁺⁾ cells from human bone marrow MSCs, and differentiate these cells into functional insulin producing cells (IPCs) compared with nestin ^(-) cells. Manual magnetic separation was performed to obtain nestin ⁽⁺⁾ cells from MSCs. Approximately 91±3.3% of nestin ⁽⁺⁾ cells were positive for anti-nestin antibody. Pluripotent genes were overexpressed in nestin ⁽⁺⁾ cells compared with nestin ^(-) cells as revealed by quantitative real time-PCR (qRT-PCR). Following in vitro differentiation, flow cytometric analysis showed that 2.7±0.5% of differentiated nestin ⁽⁺⁾ cells were positive for anti-insulin antibody in comparison with 0.08±0.02% of nestin ^(-) cells. QRT-PCR showed higher expression of insulin and other endocrine genes in comparison with nestin ^(-) cells. While immunofluorescence technique showed the presence of insulin and C-peptide granules in nestin ⁽⁺⁾ cells. Therefore, our results introduced nestin ⁽⁺⁾ cells as a pluripotent subpopulation within human MSCs which is capable to differentiate and produce functional IPCs.

An insight into chiral monolithic stationary phases for enantioselective high-performance liquid chromatography applications

In this review, three main classes of chiral monolithic stationary phases, namely silica-, organic polymer-, and hybrid-based monolithic stationary phases, are covered. Their preparations, applications, and advantages compared with the conventional-packed and open-tubular capillary columns are discussed. A detailed description of the different types and techniques used for the introduction of chiral selectors into the monolithic matrices such as immobilization, functionalization, coating, encapsulation, and bonding. Special emphasis is given to the recent developments of chiral selectors in HPLC monolithic stationary phases during the past 18 years.

Colistin Sulfate Chiral Stationary Phase for the Enantioselective Separation of Pharmaceuticals Using Organic Polymer Monolithic Capillary Chromatography

A new functionalized polymer monolithic capillary with a macrocyclic antibiotic, namely colistin sulfate, as chiral selector was prepared via the copolymerization of binary monomer mixtures consisting of glycidyl methacrylate (GMA) and ethylene glycol dimethacrylate (EGDMA) in porogenic solvents namely 1-propanol and 1,4-butanediol, in the presence of azobisiso-butyronitrile (AIBN) as initiator and colistin sulfate. The prepared capillaries were investigated for the enantioselective nano-LC separation of a group of racemic pharmaceuticals, namely, α- and β-blockers, anti-inflammatory drugs, antifungal drugs, norepinephrine-dopamine reuptake inhibitors, catecholamines, sedative hypnotics, antihistaminics, anticancer drugs, and antiarrhythmic drugs. Acceptable separation was achieved for many drugs using reversed phase chromatographic conditions with no separation achieved under normal phase conditions. Colistin sulfate appears to be useful addition to the available macrocyclic antibiotic chiral phases used in liquid chromatography.

Functionalized polymer monoliths with carbamylated amylose for the enantioselective reversed phase nano-liquid chromatographic separation of a set of racemic pharmaceuticals

Here we report the first encapsulation of three carbamylated amylose namely R-, S- and R/S-amylose 2,3(3,5-dimethylphenylcarbamate)-6-ethylphenylcarbamate in organic polymer monolith in situ capillary columns. The columns were investigated for the enantioselective nano-liquid chromatographic separation of a set of racemic pharmaceuticals, namely, α- and β-blockers, anti-inflammatory drugs, antifungal drugs, norepinephrine-dopamine reuptake inhibitors, catecholamines, sedative hypnotics, antihistaminics, anticancer drugs, and antiarrhythmic drugs. Baseline separation was achieved for several drugs under reversed phase chromatographic conditions and only few drugs were separated under normal phase conditions. The developed columns provide more economical analysis under environmentally benign conditions.

Surface and intracranial EEG spike detection based on discrete wavelet decomposition and random forest classification

Epilepsy is a neurological disorder for which the electroencephalogram (EEG) is the most important diagnostic tool. In particular, this diagnosis heavily depends on the detection of interictal (between seizures) paroxysmal epileptic discharges (IPED) in the EEG. This is a time-consuming task requiring significant training and experience. Automatic detection of these EEG patterns would greatly assist visual inspections of human readers. We present a new method, which allows automatic detection of IPED based on discrete wavelet decomposition and a random forest classifier. The algorithm was trained and cross validated using 17 subjects with scalp EEG and 10 subjects with intracranial EEG. The performance of this method reached 62% recall and 26% precision for surface EEG subjects and 63% recall and 53% precision for intracranial EEG subjects. Thus, the method hereby proposed has great potential for diagnosis support in clinical environments.

The accuracy and cost-effectiveness of hepatitis C core antigen assay in the monitoring of anti-viral therapy in patients with chronic hepatitis C genotype 4

BACKGROUND

Quantitative hepatitis C (HCV) polymerase chain reaction (qtHCV-PCR), the gold standard for monitoring HCV therapy, is an expensive, time-consuming procedure that requires equipped laboratories and trained personnel.

AIMS

To assess the accuracy and cost-effectiveness of the automated Abbott ARCHITECT HCV Ag assay (Wiesbaden, Germany) in monitoring response to pagylated interferon (PEG-IFN) and ribavirin therapy for chronic HCV genotype 4 (G4).

METHODS

This longitudinal, non-inferiority study compared the efficacy and cost benefit of an All-HCV core antigen assay protocol and a hybrid qtHCV RNA PCR and HCV core Ag assay protocol to the standard All-qtHCV-PCR protocol in chronic HCV G4 patients treated with pegylated interferon (PEG IFN) and ribavirin.

RESULTS

Four hundred and ten patients with chronic hepatitis C genotype 4 met inclusion criteria and were enrolled in the study. The sustained virological response rate (SVR) was 66.34%. The All-HCV core antigen and hybrid monitoring assays resulted in the significant cost savings without compromising performance. A good correlation existed between HCV viral load and HCV core antigen levels (r = 0.944; P < 0.0001). Baseline HCV RNA values <600 IU/mL, baseline HCV core Ag levels <2000 fmol/L, rapid virological response, rapid decline in HCV core antigen were strong predictors of SVR.

CONCLUSION

Hepatitis C core Ag assay is a point-of-care, reproducible, reliable, cost-effective monitoring tool with rapid turnaround time that, which can effectively replace or adjunct to qRT-PCR in monitoring interferon based or interferon-free anti-viral therapy in chronic hepatitis genotype 4 patients in resource-limited countries with a high burden of hepatitis C.

Surgical management of peri-ampullary tumors: a retrospective study

BACKGROUND/AIMS

Surgical resection still remains the best treatment for patients with periampullary tumors. This study aims to present the results of surgical treatment of this disease at our center.

METHODOLOGY

Between January 1995 and December 2004, 216 periampullary tumors were treated by surgical resection. The mean age was 58 years with male to female ratio 2:1. The most common symptom was jaundice (97.7%). Abdominal pain occurred in 74% of patients. Pancreaticogastrostomy was done in 183 patients and pancreaticojejunostomy in 33 patients.

RESULTS

Operative mortality occurred in 7 patients (3.2%). The median survival was 22.6 months for patients with ampullary tumors and 16.6 months for patients with pancreatic head tumors. Early operative complications occurred in 33% of patients; the most common one was wound infection (11.6%), pancreatic leak (10.6%), abdominal collection (10.6%) and delayed gastric emptying (8.8%). Factors associated with increased risk of developing complications were the type of pancreatico-enteric anastomosis (pancreatic leak was more frequent with pancraticojejunostomy), soft pancreatic texture and intraoperative blood transfusion of more than 4 units. Factors associated with better survival included tumor diameter (less than 3cm), origin (ampullary), differentiation (well differentiated) and margin status (negative resection margins).

CONCLUSIONS

Postoperative complications of pancreaticoduodenectomy, especially with the adoption of pancreaticogastrostomy, occur with reasonable incidence. Survival largely depends on the origin of the tumor.

216 cases of pancreaticoduodenectomy: risk factors for postoperative complications

BACKGROUND/AIMS

Surgical resection remains the best treatment for patients with periampullary tumors. Many series have been reported with low or zero mortality, however, high incidence of complications is the rule. This study aims to present the results of pancreaticoduodenectomy and factors predisposing to postoperative complications, especially pancreatic leak, at our center.

METHODOLOGY

Between January 2000 and December 2006, 216 periampullary tumors were treated by Whipple pancreaticoduodenectomy. Pancreaticogastrostomy was done in 183 patients and pancreaticojejunostomy in 33 patients. Hospital mortality and surgical complications were recorded with special emphasis on pancreatic leak. All specimens were histologically examined for the presence and origin of malignant tissue.

RESULTS

The mean age was 58 years and male to female ratio was 2:1. The commonest symptom was jaundice (97.7%) followed by abdominal pain (74%). Operative mortality in 7 patients (3.2%). 71 (33%) patients developed 1 or more complications, pancreatic leak occurred in 23 (10.6%) patients, abdominal collection in 23 patients (10.6%) and delayed gastric emptying in 19 (8.8%) patients. Factors that influenced the development of postoperative complications included type of pancreaticoenteric anastomosis, pancreatic texture and intraoperative blood transfusion of 4 or more blood units. Pancreatic leak was commoner with PJ (p=0.001), soft pancreatic texture (p=0.008), intraoperative blood transfusion of 4 or more units (p<0.0001). Periampullary adenocarcinoma was found in 204 (94.4%) patients, chronic pancreatitis in 9 (4.2%) patients, 2 patients with solid and papillary neoplasm, and 1 patient with NHL (Non-Hodgkin's Lymphoma).

CONCLUSIONS

Surgery is the only hope for patients with periampullary tumors. Postoperative complications after pancreaticoduodenectomy depend largely on surgical technique and can be reduced reasonably with the adoption of pancreaticogastrostomy, which is safer and easier to learn than pancreaticojejunostomy.

Short gastric vessels division in Laparoscopic Nissen Fundoplication

BACKGROUND/AIMS

To divide or not the short gastric vessels during Laparoscopic Fundoplication (LF) is still controversial. This retrospective study is based on short gastric vessels division (SGVsD), if necessary, during LF to construct a satisfactory loose wrap and to evaluate its effect upon the symptomatic and physiologic outcome in patients with proven GERD.

METHODOLOGY

150 patients (90 males, 60 females) with a mean age of 37 +/- 9 with typical symptoms of GERD, adequate motility study and positive 24-hour pH studies underwent LF; 100 (66.7%) were feasible after careful and complete fundal dissection without SGVsD while, 50 (33.3%) were not possible except with SGVsD. Outcome measures included assessment of the relief of the primary symptom responsible for surgery; repeated upper endoscopy and barium study. Postoperative 24-hour esophageal pH and LES manometry were performed in 110 patients.

RESULTS

The mean operative time was prolonged with short gastric division (130 +/- 60 vs. 90 +/- 40 minutes). At a mean period of follow-up of 35 +/- 12 months, relief of the primary symptom responsible for surgery was achieved in 92.2% of patients with division and 87.5% of patients without. Recurrent attacks of abdominal distension were documented in 2 patients (5.6%) with division and 12 patients (16%) without division. Occasional dysphagia not present before surgery occurred in 27 patients at 3 months; 11 (31.4%) with division and 16 (21.3%) without, and decreased to 11 patients by 12 months after surgery; 2 (5.7%) with division and 9 (12%) without; only one case of those without division required 5 sets of endoscopic dilatation. Endoscopic esophagitis healed in all patients with division and 71 of 75 patients (94.7%) without. LES pressures had returned to normal in all patients except one case without division (1.3%) with a higher mean pressure among those without division (22.3 mmHg vs. 18.5 mmHg) and a better relaxation with division (89.9% vs. 80.5%). 24-hour esophageal acid exposure had returned to normal in 33 of 35 patients (94.3%) with division and 66 of 75 patients (88%) without.

CONCLUSIONS

Construction of a satisfactory loose Nissen Fundoplication was feasible in two thirds of patients without SGVsD. Despite prolongation of the operative time, SGVsD provides a better symptomatic and physiologic outcome.

Laparoscopic cholecystectomy: a report on 2000 cases

BACKGROUND/AIMS

This is a retrospective study to evaluate the results of laparoscopic cholecystectomy after 2000 cases at a single center.

METHODOLOGY

Between June 1992 and February 2000, 2000 patients (1458 females and 542 males, mean age 39.8 years) with symptomatic gallstones underwent laparoscopic cholecystectomy. All cases were diagnosed by abdominal ultrasonography. Preoperative endoscopic retrograde cholangiopancreatography was done for 31 patients. Four trocars were used for all except 20 cases.

RESULTS

The mean operative time was 45 +/- 15 minutes. Conversion to open cholecystectomy occurred in 147 patients (7.35%). Adhesions were the commonest cause of conversion (2.9%). There was no technique-related mortality. Bile duct injury occurred in 7 cases (0.35%), reconstruction by Rouxen-Y hepaticojejunostomy was necessary in 5 cases and the injury was successfully managed by endoscopic stent in 2 cases. Bile leakage occurred in 11 cases (0.55%), peritonitis in 5 cases (0.25%), internal hemorrhage in 9 cases (0.45%), cystic artery injury in 17 cases (0.85%), pneumothorax in one case (0.05%) and subcutaneous emphysema in 3 cases (0.15%).

CONCLUSIONS

Laparoscopic cholecystectomy is a good alternative to open cholecystectomy with an acceptable morbidity. Conversion to open cholecystectomy at the proper time will prevent major complications.

Outcome after resection of central cholangiocarcinoma: preliminary experience with 46 patients in a single center

BACKGROUND/AIMS

Despite the enormous progress in surgery the management of cholangiocarcinoma remains a problem. In this study we present our preliminary experience in the surgical treatment of central cholangiocarcinoma.

METHODOLOGY

Between May 1997 and December 2001, 175 patients with central cholangiocarcinoma were admitted to our center. Of the 175 patients, 54 cases subjected to surgery, the remaining 131 patients did not undergo surgery because of advanced disease, advanced liver cirrhosis and poor general condition. Forty-six patients underwent surgical excision, their mean age was 53 +/- 3 years, and male to female ratio was 74-26%. All patients presented with jaundice associated with pain (30%) or biliary stones (32%). Surgical resection of the bile duct with or without part of segment IV were done in fourteen patients and bile duct resection together with major hepatectomy had been done in the remaining 28 patients.

RESULTS

Hospital mortality occurred in 10.8%; the main cause of mortality was hepatic cell failure. The most common complications were hepatic cell failure that occurred in 7 cases (15%), biliary leakage in 8 cases (17%), gastrointestinal bleeding in 3 cases (6.5%) and wound infection in 3 cases (6.5%). Late complication in the form of recurrence occurred in 12 cases (29.5%). cholangitis in 8 cases (19.5%), hepatic cell failure in 5 (12%) and gastrointestinal bleeding in 2 (4.8%). At the end of the study, 19 patients (46%) were alive with mean follow-up of 16.6 +/- 9 months. The survival rate at 6, 12, 18, 24 months was 92, 82, 52, 25, 18%, respectively. Recurrence and cholangitis were found significantly higher in the group without hepatectomy than the group after hepatectomy (p < 0.0001, p < 0.0016, respectively).

CONCLUSIONS

From our results we can conclude that major hepatectomy with excision of the extrahepatic bile duct system and caudate lobe resection may be recommended for the surgical treatment of central cholangiocarcinoma in selected cases.

Modified pancreaticoduodenectomy: experience with 81 cases, Wahab modification

BACKGROUND/AIMS

Now pancreaticoduodenectomy is considered a safe and acceptable line of treatment for periampullary tumors. In spite of improvements in the surgical technique it still has a high morbidity rate. In this study we introduce new technical modifications for the original procedure aiming to decrease the incidence of morbidity.

METHODOLOGY

Between 1994-2000, 210 pancreaticoduodenectomies were done in the Gastroenterology Center, Mansoura University, Egypt for periampullary tumor. Eighty-one of these patients were subjected to modified pancreaticoduodenectomy. They were 57 men and 34 women with a mean age of 54 (+/- 8) years. Pancreatic carcinoma represented 54%, ampullary tumor 30%, bile duct carcinoma 5% and duodenal carcinoma 1.2%. The mean operative time was 3.7 +/- 0.5 hours and mean estimated blood loss during surgery was 733 +/- 48 mL.

RESULTS

Hospital mortality occurred in 3.7% with an overall morbidity rate of 32%. The most common complications were delayed gastric emptying 8.9%, pancreatic fistulae 3.8%, wound infection 6.4%, biliary leakage 3.8% and bleeding 5%. The mean postoperative hospital stay was 9.4 +/- 1 days, with mean time for starting oral feeding 6 +/- 0.9 days. Late mortality occurred in 46% for the entire group with mean follow-up 22 +/- 19 months with actuarial survival for 1, 2, 3, 4, and 5 years being 80, 45, 25, 15, and 10%, respectively.

CONCLUSIONS

It was found that this new modification made the operation easier with shorter operative time, less blood transfusion, low incidence of morbidity and short hospital stay. Moreover, it takes the advantages of lowering the incidence of biliary gastritis, cholangitis and peptic ulcer.

Is resection for large hepatocellular carcinoma in cirrhotic patients beneficial? Study of 38 cases

BACKGROUND/AIMS

Hepatocellular carcinoma in cirrhotic patients generally carries a poor prognosis either due to recurrence or to postoperative morbidity or both. Several factors affect the prognosis of hepatocellular carcinoma resection as presence of cirrhosis of the liver, tumor diameter and tumor capsulation.

METHODOLOGY

Thirty-eight patients with large hepatocellular carcinoma greater than 5 cm with a background of cirrhotic liver were divided into two groups according to tumor diameter. Group A (n = 20) with tumors less than 10 cm in diameter, and group B (n = 18) with tumors larger than 10 cm. All patients underwent preoperative investigations including clinical laboratory tests, sonography, computed tomography, selective angiography and upper gastrointestinal endoscopy. All patients were subjected to different types of hepatic resection.

RESULTS

A significant difference in tumor size, capsulation, and operation time were recorded between the two groups, of patients. No significant difference was detected between both groups regarding sex, age, viral markers, pathologic features, and Child classification. Hospital mortality occurred in 5% versus 11.1% of both groups, respectively. Postoperative jaundice and ascitis occurred in 30%, 35% versus 44.4%, 72.0%, respectively (P < 0.005, P < 0.04). Late mortality occurred in 65% of patients in group A and in 77% of group B. Recurrence was detected in 42% of group A and 62% in group B. Recurrence after resection in capsulated tumors was significantly lower than in noncapsulated tumors in group A (P < 0.01), but not significant in group B. Also, survival rate in patients with capsulated tumors was significantly better in both groups (P < 0.01) than that with noncapsulated tumors.

CONCLUSIONS

Resection of hepatocellular carcinoma with diameter larger than 10 cm recorded bad prognosis regarding recurrence and mortality rates than tumors less than 10 cm. However, capsulated tumors gave better postoperative prognosis than noncapsulated ones.

Hepatocellular carcinoma in Mansoura-Egypt: experience of 385 patients at a single center

BACKGROUND/AIMS

Hepatocellular carcinoma is one of the commonest malignancies in the world. The two main etiological factors for hepatocellular carcinoma are cirrhosis and viral hepatitis. Although the first choice of treatment for hepatocellular carcinoma is surgical resection, most of them are unresectable at the time of diagnosis.

METHODOLOGY

From January 1994 to June 1999, 385 patients with hepatocellular carcinoma were presented to the Gastroenterology surgical center, Mansoura University, Egypt and subjected to similar diagnostic process. Forty-five (11.6%) of these patients (34 males and 13 females) with a mean age of 50.9 years (+/- 7.53 years) were subjected to different types of hepatic resection.

RESULTS

The underlying liver pathology was cirrhosis in 85%. Positive virology was found in 82.5% (HCV 61%, HBV 14.5% and combined 7%). The main presentation were asymptomatic in 144 (37.4%) patients, abdominal pain in 92 (23.9%) patients, ascites in 95 (24.6%) patients, jaundice in 53 (14%) patients and upper gastrointestinal hemorrhage in 26 (6.75%) patients. Only 45 (11.6%) were resectable, they were subjected to hepatic resection with operative mortality in 2 cases (4.4%) and with overall mortality in 29 (64.4%) cases after 48 months (32.8 +/- 19 months) of follow-up. The main causes of late mortality were recurrence in 14 (31.1%) cases, hepatic cell failure in 7 (15.5%) cases and other causes in 6 (13.3%).

CONCLUSIONS

Hepatocellular carcinoma is now a common malignancy in Egypt, which usually develops on top of cirrhosis of viral origin in 82%. Hepatic resection is the only method of treatment with a low resectability rate.

Endodontic interappointment flare-ups: a prospective study of incidence and related factors

Severe pain and/or swelling following a root canal treatment appointment are serious sequelae. Information varies or is incomplete as to the incidence of these conditions and related factors. In this study, data were collected at root canal treatment appointments on demographics, pulp/periapical diagnoses, presenting symptoms, treatment procedures, and number of appointments. Patients that then experienced a flare-up (a severe problem requiring an unscheduled visit and treatment) had the correlating factors examined. Statistical determinations were by chi-square analysis with significance at 0.05 or less. Nine hundred forty-six visits resulted in an incidence of 3.17% flare-ups. Flare-ups were positively correlated with more severe presenting symptoms, pulp necrosis with painful apical pathosis, and patients on analgesics. Fewer flare-ups occurred in undergraduate patients and following obturation procedures. There was no correlation between patient demographics or systemic conditions, number of appointments, treatment procedures, or taking antibiotics.

Central nervous system metastasis from breast carcinoma. Autopsy study

Central nervous system (CNS) metastasis was noted in 309 patients of 1044 autopsy cases of breast carcinoma. The brain was involved in 193 cases, and cranial dura in 167 cases. In 82 cases, the cranial dura was the sole site of CNS involvement. Metastasis to the leptomeninges was found in 59 cases, and to the spinal cord and dura in 32 cases. Metastases to the infratentorial portion of the brain was almost as frequent as to the cerebrum. Forty-two percent of the brain metastasis were single lesions, which is similar to the frequency of solitary metastasis to the brain from malignant tumors as a whole. CNS metastasis occurred more frequently in younger patients than older patients, and the clinical course of these patients was shorter than for those patients without CNS metastasis. CNS metastasis developed in the late stage of the disease, and often was not recognized clinically. Only 31% of the cases were clinically diagnosed or suspected before death. A median survival of these patients after clinical diagnosis of CNS metastasis was 33 days. However, a significant improvement was noted in the clinical diagnosis and median survival in the latter half of the study period. Eleven patients lived for more than 1 year after diagnosis of CNS metastasis. Only 14% of the 309 patients died from CNS failure.