Mini-HoLEP (MILEP) vs HoLEP: a propensity score-matched analysis

BACKGROUND AND PURPOSE

Minimal invasiveness improves outcome in many surgical fields including urology. We aimed to assess intraoperative performance and clinical outcome of miniaturized holmium laser enucleation of prostate (MiLEP) (22FR).

METHODS

We ran a propensity score-matched analysis among all consecutive laser enucleations of prostate performed between 9/2022 and 2/2023. It resulted in two matched comparison groups: MiLEP 22 FR (n = 40) and holmium laser enucleation of prostate (HoLEP 26 Fr) (n = 40). Statistical analysis was performed.

RESULTS

MiLEP was associated with significantly less intraoperative irrigation (20.5 L vs 15 L, p = 0.002E-3), less decrease in body core temperature (0.6°C vs 0.1°C, p = 0.003E-5), and less need for meatal dilation (25% vs 78%, p = 0.01E-3). These parameters were identified as being independent in the multivariate analysis. There was a trend toward less and a shorter period of postoperative stress incontinence (SI) for the MiLEP group compared to the HoLEP group: 15% and 42% (p = 0.01) at 1 month, 8% and 14% (p = 0.07) at 2 months, and 0 and 0.3% (p = 1) at 3 months, respectively. There were no differences in prostatic enucleation effectiveness, operative time, hospital stay, complications, and improvement in the international prostate symptom score and quality of life score.

CONCLUSIONS

MiLEP is feasible and provides better maintenance of body core temperature, reduction in amount of fluid irrigation, and decrease in need for meatal dilation without affecting effectiveness in comparison with HoLEP. MiLEP may reduce early postoperative stress incontinence, thereby shortening the recovery period.

En bloc holmium laser enucleation of prostate in octogenarians and nonagenarians: clinical characteristics and outcome

Extended longevity leads to greater numbers of elderly patients with benign prostatic hyperplasia (BPH) who seek surgical solutions. We assessed the clinical characteristics and outcomes of octogenarians and nonagenarians with BPH who underwent en bloc holmium laser enucleation of prostate (HoLEP). Retrospective cohort of all consecutive HoLEP patients treated in our medical center between January 2020 and January 2023. Cohort was divided into group aged < 80 years (n = 290) and group aged ≥ 80 years (n = 77). Their demographics, presentations, indications, and outcomes were compared. Octogenarians and nonagenarians had higher rates of indwelling catheters (p = 0.00001), chronic retention (p = 0.00006), larger prostates (p = 0.03), higher American Anesthesiology Association scores (p = 0.000001), and more antiplatelet medications (p = 0.0003) at presentation. They had longer operations (median 115 vs 90 min, respectively, p = 0.0008), longer hospital stay (median 2 vs 1 day, p = 0.01E-7), a higher complication rate (17% vs 7%, p = 0.02), and a higher transitory urinary incontinence (TUI) rate (54% vs 9%, p = 0.00001). TUI was more prevalent in the older group with indwelling catheters (61% vs, 13%, p = 0.00001). The functional outcome was similar for both age groups, and all patients could void spontaneously after the procedure. En-bloc HoLEP improves urinary symptoms and quality of life in patients ≥ 80 years of age despite larger prostates, more comorbidities, and higher complications rate, compared to younger men. HoLEP bestows a significant improvement in urologic quality of life regardless of age.

Can lymphocytes serve as a predictor of response to preoperative chemoradiation therapy for locally advanced rectal cancer?

Introduction

The aim of this study is to identify factors that may predict the response of locally advanced rectal cancer tumors (LARC) to neoadjuvant chemoradiotherapy (CRT) and to evaluate the effect of circulating lymphocytes on pathological tumor response.

Methods

This retrospective study included neoadjuvant CRT-treated, LARC-diagnosed patients at the Rambam Health Care Campus in Haifa, Israel. CHAID analysis, t-test, χ2 test, and ROC curve analyses were performed to explore the association between pathological complete response (pCR) and several factors including patient demographics, tumor characteristics, type of treatment, and levels of circulating lymphocytes measured on a weekly basis.

Results

Out of 198 patients enrolled in the study, pCR was achieved in 50 patients (25%). ROC curve and CHAID analyses showed that absolute lymphopenia was significantly associated with lower pCR rates (p=0.046 and p=0.001, respectively). Other factors that were found to have a significant impact were radiation therapy type (p=0.033) and tumor distance from the anal verge (p= 0.041).

Conclusion

An absolute decrease in the level of circulating lymphocytes during preoperative CRT to LARC is associated with poorer tumor response to treatment and thus may serve as a predictive biomarker for treatment resistance.

First-line programmed death-1 inhibitor treatment for locoregionally advanced or metastatic cutaneous squamous cell carcinoma - A real-world experience from Israel

Objective

Cutaneous squamous cell carcinoma (cSCC) is the second most common non-melanoma skin cancer worldwide. It is usually treated surgically, with very high cure rates. However, in 3%-7% of cases, cSCC metastasizes to lymph nodes or distant organs. Many of the affected patients are elderly with comorbidities who are not candidates for standard-of-care curative-intent treatment with surgery and/or radio-/chemotherapy. Immune checkpoint inhibitors, which target programmed cell death protein 1 (PD-1) pathways, have recently emerged as a potent therapeutic option. The present report presents the Israeli experience with PD-1 inhibitors for the treatment of loco-regionally advanced or metastatic cSCC in a diverse and elderly population, with or without the addition of radiotherapy.

Material and methods

The databases of two university medical centers were retrospectively searched for patients with cSCC treated with the PD-1 inhibitors cemiplimab or pembrolizumab between January 2019 and May 2022. Data on baseline, disease-related, treatment-related, and outcome parameters were collected and analyzed.

Results

The cohort included 102 patients of a median age 78.5 years. Evaluable response data were available for 93. The overall response rate was 80.6%: complete response in 42 patients (45.2%) and partial response in 33 (35.5%). Stable disease was recorded in 7 (7.5%) and progressive disease in 11 (11.8%). Median progression-free survival was 29.5 months. Radiotherapy was administered to the target lesion during PD-1 treatment in 22.5% of patients. mPFS was not significantly different in patients who treated with RT than patients how did not (NR vs 18.4 months, HR=0.93, 95%CI: 0.39 - 2.17, p<0.859). Any-grade toxicity was recorded in 57 patients (55%), including grade ‗3 in 25, of whom 5 (5% of cohort) died. Compared to toxicity-free patients, patients with drug toxicity had better progression-free survival (18.4 months vs not reached, HR=0.33, 95% CI: 0.13-0.82, p=0.012) and higher overall response rate (87% vs 71.8%, p=0.06).

Conclusion

This retrospective real-world study showed that PD-1 inhibitors were effective in the treatment of locally advanced or metastatic cSCC and appeared to be amenable for use in elderly or fragile patients with comorbidities. However, the high toxicity warrants consideration against other modalities. Induction or consolidation radiotherapy may improve the results. These findings need to be corroborated in a prospective trial.

Tyrosine kinase inhibitor treatment and long-term follow-up for metastatic malignant struma ovarii

Metastatic malignant struma ovarii (MMSO) is a very rare disease (in the United States, less than one case in 10 million females annually). However, this incidence rate is due to a paucity of data regarding diagnosis, treatment, and follow-up. Herein, we describe the case of a 14-year-old female who presented with MMSO, which later metastasized and was followed up on for over 10 years. The patient underwent right oophorectomy surgery and was then treated with a combination of radioactive iodine followed by iodine scans to detect the absorption of radioiodine in the metastatic sites, and radiation therapy to treat skeletal lesions. She subsequently received treatment with the tyrosine kinase inhibitors (TKIs), sorafenib and then lenvatinib, as treatments for advanced disease, thereby achieving long-term disease stability. This case report, which adds to the limited data available on MMSO treatment, suggests that patients treated with a combination of radioactive iodine, radiation therapy, and TKIs can result in good responses and long-term overall survival.

The evolving treatment paradigm of locally advanced rectal cancer: a narrative review

Background and Objective

Surgery is still considered the mainstay of treatment of locally advanced rectal cancer (LARC). Nevertheless, “curable” disease may still pose a great risk for both local and distant relapses. Since the early eighties of the past century, we have witnessed mounting evidence supporting the multi-modality approach to tackle this disease effectively. The multi-modality approach is variable between different positive trials. In this review, we discuss the treatment evolution of LARC, highlighting the key differences between the different contemporary strategies utilized. Based on current evidence, we sought to define distinct patient subgroups and to propose a treatment algorithm that best fits patient’s risk.

Methods

We conducted a literature search through PubMed and Google scholar. Eligible papers were phase 2/3 trials [in organ preservation (OP), observational and retrospective studies were also acceptable] published in English. We used keywords such as “locally advanced rectal cancer”, “perioperative therapy in rectal cancer”, “short course radiotherapy”, “chemoradiation in rectal cancer”, “interval to surgery”, “Neoadjuvant therapy”, “Organ preservation” and “Total neoadjuvant treatment [TNT]”.

Key Content and Findings

Various trials consistently demonstrated the benefit of preoperative radiotherapy in LARC, the role of adjuvant chemotherapy is controversial based on published studies, TNT was associated with a risk reduction in distant metastasis, and more reassuring evidence is accumulating regarding OP.

Conclusions

The treatment landscape of LARC is rapidly changing. Clinicians should carefully tailor treatment strategy based on patient’s risk.

Transmission Electron Microscopy Study on the Effect of Thermal and Electrical Stimuli on Ge2Te3 Based Memristor Devices

Memristor devices fabricated using the chalcogenide Ge2Te3 phase change thin films in a metal-insulator-metal structure are characterized using thermal and electrical stimuli in this study. Once the thermal and electrical stimuli are applied, cross-sectional transmission electron microscopy (TEM) and X-ray energy-dispersive spectroscopy (XEDS) analyses are performed to determine structural and compositional changes in the devices. Electrical measurements on these devices showed a need for increasing compliance current between cycles to initiate switching from low resistance state (LRS) to high resistance state (HRS). The measured resistance in HRS also exhibited a steady decrease with increase in the compliance current. High resolution TEM studies on devices in HRS showed the presence of residual crystalline phase at the top-electrode/dielectric interface, which may explain the observed dependence on compliance current. XEDS study revealed diffusion related processes at dielectric-electrode interface characterized, by the separation of Ge2Te3 into Ge- and Te- enriched interfacial layers. This was also accompanied by spikes in O level at these regions. Furthermore, in-situ heating experiments on as-grown thin films revealed a deleterious effect of Ti adhesive layer, wherein the in-diffusion of Ti leads to further degradation of the dielectric layer. This experimental physics-based study shows that the large HRS/LRS ratio below the current compliance limit of 1 mA and the ability to control the HRS and LRS by varying the compliance current are attractive for memristor and neuromorphic computing applications.

Case report: ado-trastuzumab as second-line treatment in HER2 positive salivary duct carcinoma

The objective of this report is to present the use and efficacy of ado-trastuzumab as an advanced line of therapy in salivary duct carcinoma (SDC) patient. An 84-year-old gentleman diagnosed with metastatic salivary duct tumor harboring overexpressed human epidermal growth factor receptor-2 has gone through resection surgery. The first line of treatment included initial doublet chemotherapy combined with trastuzumab, which was continued later as maintenance. PET-CT follow-up for 4 years has demonstrated no evidence of disease. However, upon recurrence, use of Ado-trastuzumab emtansine was prompted as second-line of treatment. This targeted patient-tailored therapy has accomplished a complete response. The effectiveness of ado-trastuzumab emtansine was notable within a short time period of two treatment cycles leading to full recovery. Specific agents aimed at altered oncogenes should be considered as a potential drug of choice in neoadjuvant HER2 positive SDC.

[ONCOLOGY CARE CHALLENGES TREATING COVID-19 CONFIRMED CANCER PATIENTS: A REVIEW AND RECOMMENDATIONS]

The highly contagious virus, SARS-CoV-2 causing a human respiratory disease, COVID-19, imposed a global pandemic with significant short- and long-term health consequences. It has challenged the active treatment of oncology patients, having protocols that require frequent monitoring. Some patients' anxiety of the COVID-19 pandemic led to delays in treatment and impaired the effectiveness of anti-cancer therapy. Moreover, the stage migration term was coined to newly referred patients who postponed their doctor's appointment leading to late diagnosis. Prevention of COVID-19 disease among oncology patients is a priority, in order to avert morbidity, complications and mortality. In a recently published article, Waissengrin et al. compared the incidence of COVID-19 disease in oncology patients at Tel-Aviv Medical Center to the general population between March 2020 and October 2020. A lower rate of confirmed cases was demonstrated among oncology patients in comparison to the general population. This difference was attributed to the oncology patients' adherence to COVID-19 avoidance guidelines. In addition, no association was found between a specific type of cancer or oncological treatment and mortality from COVID-19. However, a significant correlation was presented between severe COVID-19 disease, old age and the presence of metastases. Waissengrin et al., support the importance of continuing the oncological care routine to avoid the devastating consequences of postponing treatments. Despite the development of a number of FDA-approved vaccines against the virus, the world is still facing challenges associated with the COVID-19 pandemic, e.g. variant B.1.617.2 ominous of yet more lockdowns due to a rapid rising wave of morbidity.

Anti-androgen for myoepithelial tumor: a potent therapy yet a potential misleader

Myoepithelial tumor is a rare form of cancer, mainly arising from the salivary glands and extremities. Due to its rarity, no formal treatment guidelines exist. Here we report a case of a male patient diagnosed with metastatic myoepithelial tumor which was successfully treated with an androgen-receptor (AR) antagonist (bicalutamide), based on the results of molecular testing. Six years after the initiation of bicalutamide, patient was diagnosed with metastatic prostate cancer. To our knowledge, this is the first case described in literature that demonstrate the effectiveness of anti-androgens in treating myoepithelial tumor. Vigilance should be maintained when screening these patients for prostate cancer as their 'true' prostate specific antigen levels might be masked by the ongoing endocrine therapy.

Return to Play and Fracture Union After the Surgical Management of Jones Fractures in Athletes: A Systematic Review and Meta-analysis

BACKGROUND

Proximal fifth metatarsal fractures are among the most common forefoot injuries in athletes. The management of this injury can be challenging because of delayed union and refractures. Intramedullary (IM) screw fixation rather than nonoperative management has been recommended in the athletic population.

PURPOSE

To provide an updated summary of the return-to-play (RTP) rate and time to RTP after Jones fractures in athletes with regard to their management, whether operative or nonoperative, and to explore the union rate and time to union as well as the rate of complications such as refractures.

STUDY DESIGN

Meta-analysis.

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases including PubMed, MEDLINE, Embase, Google Scholar, Web of Science, Cochrane Library, and ClinicalTrials.gov through November 2019 to identify studies reporting on Jones fractures of the fifth metatarsal exclusively in athletes. The primary outcomes were the RTP rate and time to RTP, whereas the secondary outcomes were the number of games missed, time to union, and union rate as well as the rates of nonunion, delayed union, and refractures.

RESULTS

Of 168 studies identified, 22 studies were eligible for meta-analysis with a total of 646 Jones fractures. The overall RTP rate was 98.4% (95% CI, 97.3%-99.4%) in 626 of 646 Jones fractures. The RTP rate with IM screw fixation only was 98.8% (95% CI, 97.8%-99.7%), with other surgical fixation methods (plate, Minifix) was 98.4% (95% CI, 95.8%-100.0%), and with nonoperative management was 71.6% (95% CI, 45.6%-97.6%). There were 3 studies directly comparing RTP rates with surgical versus nonoperative management, which showed significant superiority in favor of surgery (odds ratio, 0.033 [95% CI, 0.005-0.215]; P < .001). The RTP rate according to type of sport was 99.0% (95% CI, 97.5%-100.0%) in football, 91.1% (95% CI, 82.2%-99.4%) in basketball, and 96.6% (95% CI, 92.6%-100.0%) in soccer. The overall time to RTP was 9.6 weeks (95% CI, 8.5-10.7 weeks). The time to RTP in the surgical group (IM screw fixation) was 9.6 weeks (95% CI, 8.3-10.9 weeks), which was significantly less than that in the nonoperative group of 13.1 weeks (95% CI, 8.2-18.0 weeks). The pooled union rate in the operative group (excluding refractures) was 97.3% (95% CI, 95.1%-99.4%), whereas the pooled union rate in the nonoperative group was 71.4% (95% CI, 49.1%-93.7%). The overall time to union was 9.1 weeks (95% CI, 7.7-10.4 weeks). The time to union with IM screw fixation (8.2 weeks [95% CI, 7.5-9.0 weeks]) was shorter than that with nonoperative treatment (13.7 weeks [95% CI, 12.7-14.6 weeks]). The rate of delayed union was 2.5% (95% CI, 1.2%-3.7%), and the overall refracture rate was 10.2% (95% CI, 5.9%-14.5%).

CONCLUSION

The RTP rate and time to RTP after the surgical management of Jones fractures in athletes were excellent, regardless of the implant used and type of sport. IM screw fixation was superior to nonoperative management, as it led to a higher rate of RTP, shorter time to RTP, higher rate of union, shorter time to union, and improved functional outcomes. We recommend surgical fixation for all Jones fractures in athletes.

[VESICO-VAGINAL FISTULAS (VVF)]

INTRODUCTION

Vesico-vaginal fistula, is a known complication that can occur following damage to the bladder wall during pelvic surgery or prolonged birth. Prompt and accurate diagnosis and timely repair are essential for a quick solution to the problem, and a reduction in medico-legal claims. Successful treatment requires an accurate assessment of the size and the location of the fistula, determination of timing and the surgical technique. There is an approach that advocates postponing the surgery for several months until "tissue healing" subsides and some advocate immediate repair. In our department, the surgery is performed early, immediately upon diagnosis without delay. The aim of the work is to define the clinical manifestation of fistula after surgery, to analyze the factors, and to summarize the experience of an early intervention.

METHODS

We reviewed the records of consecutive patients undergoing repair of urogenital fistulas at our institution. Patients with only vesico-vaginal fistulas were included. We recorded demographic characteristics, as well as surgical data, and postoperative complications were also collected. The follow-up period was at least 3 months.

RESULTS

A total of 67 women with urogenital fistulas were identified, of whom 37 were only with vesico-vaginal fistulas. Iatrogenic injury, during hysterectomy was the main cause in 70.3%; 2 women were treated conservatively. A repair in the vaginal approach was performed in 31 women, and in 4 women the repair was performed in the abdominal approach, of them, two underwent urethral re-implantation simultaneously. Complications included sepsis in one case, and vaginal cuff dehiscence in another. The success rate of the repair was 92%. Recurrence occurred in 3 patients, of whom 2 had a history of previous radiation.

CONCLUSIONS

A vesico-vaginal fistula can be successfully repaired by early repair, without delay, thus saving the patient considerable distress and discomfort.

Efficacy of the mRNA-Based BNT162b2 COVID-19 Vaccine in Patients with Solid Malignancies Treated with Anti-Neoplastic Drugs

The BNT162b2 vaccine was shown to be highly effective in reducing the risk of COVID-19 infection in healthy individuals and patients with chronic disease. However, there are little data regarding its efficacy in patients treated for cancer. We analyzed the humoral response following vaccination with the second dose of BNT162b2 in 140 patients with solid malignancies who were receiving anti-cancer therapy at the time of vaccination and 215 participants who had not been diagnosed with cancer. Multivariate analysis was performed, followed by matching the two groups by age, gender and days from vaccination. The humoral response in the cancer patient group was significantly lower than in the non-cancer group: 20/140 seronegative (14.3%) vs. 3/215 (1.4%), p < 0.001; median IgG levels 2231 AU/mL (IQR 445-8023) vs. 4100 (IQR 2231-6774) p = 0.001 respectively. The odds ratio for negative serology results in cancer patients adjusted by age and gender was 7.35 compared to participants without cancer. This effect was observed only in chemotherapy treated patients: 17/73 seronegative (23.3%) vs. 3/215 (1.4%), p < 0.001; median IgG 1361 AU/mL vs. 4100, p < 0.001 but not in patients treated with non-chemotherapeutic drugs. Reduced immunogenicity to COVID-19 vaccine among chemotherapy-treated cancer patients, raises the need to continue exercising protective measures after vaccination in these patients.

Outcomes of Open Versus Arthroscopic Broström Surgery for Chronic Lateral Ankle Instability: A Systematic Review and Meta-analysis of Comparative Studies

Background:

Nearly 20% of acute ankle sprains progress to chronic lateral ankle instability that requires surgical intervention. In recent years, there has been a growing interest in arthroscopic Broström techniques as an alternative to open surgery.

Purpose:

To review the most up-to-date evidence comparing the outcomes of open and arthroscopic Broström procedures for chronic lateral ankle instability.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

This review was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Relevant comparative studies in English up to May 2020 were identified. The primary outcomes were (1) functional scores (Karlsson Ankle Function Score and American Orthopaedic Foot & Ankle Society [AOFAS] score) and (2) the 10-point visual analog scale (VAS) score for pain. The secondary outcomes were differences in (1) postoperative anterior drawer and talar tilt, (2) surgical time and complication rate, and (3) time to return to sports and weightbearing.

Results:

A total of 408 patients in 8 studies met the inclusion criteria. Of these, 193 (47.3%) patients underwent open surgery, while 215 (52.7%) patients underwent arthroscopic surgery. There were significant differences between the open and arthroscopic repair groups in mean 6-month AOFAS scores (82.4 vs 92.25, respectively; mean difference [MD], 11.36; 95% CI, 0.14-2.56; I² = 90%; P = .03), 1-year AOFAS scores (80.05 vs 88.6; MD, –11.96; 95% CI, –21.26 to –2.76; I² = 82%; P = .01), 6-month VAS scores (1.7 vs 1.4; MD, –0.38; 95% CI, –0.54 to –0.21; I² = 78%; P < .001), and 1-year VAS scores (2.05 vs 1.45; MD, 0.31; 95% CI, 0.09-0.54; I² = 0%; P < .001). The mean time to weightbearing was 14.25 and 9.0 weeks in the open and arthroscopic repair groups, respectively (MD, 1.89; 95% CI, 1.24-2.54; I² = 99%; P < .001). There were no statistically significant differences in the remaining outcomes evaluated.

Conclusion:

While technically more demanding, arthroscopic Broström was superior to open Broström-Gould surgery in postoperative AOFAS scores, VAS pain scores, and time to return to weightbearing. The operative time, complication rate, talar tilt, and anterior drawer tests were excellent and statistically comparable. Long-term clinical trials are required before recommending arthroscopic Broström as the new gold standard.

Chitosan functionalized AgNPs for efficient removal of Imidacloprid pesticide through a pressure-free design

Wide dissemination of pesticides for protecting plants against pests has resulted in high production of un-infected crops but higher environmental pollution. High percentages of pesticides are released to the environment and finally use water as the final destination. The current study is concerning by removal of Imidacloprid pesticide from water using pressure-free passage through polymeric membrane integrated design. Both of chitosan and chitosan functionalized silver nanoparticles (AgNPs @chitosan) membranes were prepared, characterized and applied as adsorbent matrix for Imidacloprid. SEM, TEM and PSA analysis revealed the biosynthesis of AgNPs in the range of 25-50 nm. However, SEM and FTIR analysis revealed the proper formation of chitosan membrane and its proper functionalization with silver nanoparticles. Both of chitosan and AgNPs @chitosan membranes succeeded to remove 40 and 85% of Imidacloprid at slightly acidic pH, respectively. Moreover, the amount of removed Imidacloprid was proportional with the amount of its initial concentration indicating the successful removal of Imidacloprid by AgNPs @chitosan membrane even at higher pesticide concentrations. The obtained results indicate the promising use of AgNPs @chitosan membranes for removal of Imidacloprid pesticide from contaminated water depending on the pressure-free design that lacks external energy support.

Value of separate tumor base biopsy in transurethral resection of bladder tumors

Introduction

The aim of our study was to evaluate whether a biopsy from the tumor base after transurethral resection of bladder tumor (TURBT) has an impact on subsequent management of patients with bladder tumors. While tumor base biopsy at the completion of TURBT is a common practice, there is no definition of its role within the major international professional guidelines.

Material and methods

We retrospectively reviewed the records of consecutive patients undergoing TURBT between 2015 and 2019 at our institution. We recorded demographic and tumor characteristics of initial TURBT, tumor base biopsy and restaging TURBT pathology outcomes. The pathologic outcomes were correlated to assess the additional value of a separate tumor base biopsy.

Results

A total of 532 patients underwent TURBT. A separate tumor base biopsy after completion of TURBT was performed in 154 patients. The mean patient's age was 72.8 ±11.7 years (range 48–94) and 119 (77.2%) were men. In 40 patients (25.9%) muscle was absent in the pathological specimen of the tumor resection. Muscle was present in all but 6 (3.9%) tumor base biopsies. Of the 33 patients who underwent repeated transurethral resection for pT1 tumors, 2 had residual low-grade pTa, 1 had residual high-grade pT1, and 3 patients were upstaged to pT2.

Conclusions

Although tumor base biopsy at the completion of TURBT is a common practice, our analysis fails to demonstrate any tangible benefit in the staging of bladder tumors. In our experience tumor base biopsy did not change the management in patients with superficial or muscle invasive disease.

Checkpoint Inhibitors in Gynecological Malignancies: Are we There Yet?

The emergence of immune checkpoint inhibitors (ICIs) has revolutionized the field of oncology. For many cancer types, treatment paradigms have changed, as immunotherapy is increasingly being integrated into frontline standard-of-care treatments and producing meaningful and prolonged responses. This has inspired an avalanche of clinical trials studying ICIs in all types of malignancies, including gynecological cancers. Ovarian and endometrial cancers are characterized by DNA damage repair defects, either via disruption of the homologous recombination DNA repair mechanism in the former or via defects in the mismatch repair (MMR) pathway in the latter, which lead to a high load of neoantigens in both. Cervical cancer is dependent on the expression of human papillomavirus (HPV) proteins, which induce an immune response. Regardless, clinical trials testing ICIs in gynecological malignancies have initially led to disappointing results. Despite durable responses in some patients, overall response rates have been dismal. Nevertheless, in recent years, with the development of better predictive tumor biomarkers, such as microsatellite instability for endometrial cancer and programmed death ligand 1 for cervical cancer, ICIs have found their way into routine treatments for patients with advanced-stage disease. ICI-based combinations, although adding toxicity, have further improved response rates, and new combinations are currently being tested in clinical trials, as are other immunotherapy modalities, such as adoptive cell transfer and HPV-based vaccines. This review summarizes current clinical evidence supporting the use of immunotherapy in gynecological malignancies and describes studies in progress, with a focus on ICIs and predictive response biomarkers.

Allele frequency comparative study between the two main Egyptian ethnic groups

The study of genetic correlation between ethnic groups, constituting one nation, is an important issue. This work aims to study the correlation between allele frequencies of nine Short Tandem Repeats (STRs) autosomal loci (D3S1358, VWA, FGA, THO1, TPOX, CSF1PO, D5S818, D13S317, and D7S820) for the main two Egyptian ethnic groups, Muslims and Christians, in order to test the hypothesis of a common ancestral for the whole Egyptian population. Each group is represented by a sample of 100 unrelated healthy individuals. The genetic correlation of the two ethnic groups is investigated using alleles' frequencies statistics, forensic efficiency parameters and populations' homogeneity charts. Graphical methods were used to check the harmony between the two ethnic groups. The results support that Egyptian Muslims and Egyptian Christians genetically originate from the same ancestors.

Peroneal tendon dislocation in talus fracture and diagnostic value of fleck sign

Introduction

Talus fractures are not uncommon and one of the serious fractures in the foot and ankle. Peroneal tendon dislocation is one of the commonly missed soft tissue injuries which may have significant impact on the outcomes including persistent pain and swelling. They have been reported to be associated with calcaneum as well as talus fractures.

Aim

To report the incidence of peroneal tendon dislocation in talus fracture and the significance of fleck sign in the diagnosis of peroneal tendon dislocation.

Methods

We retrospectively reviewed 93 consecutive talus fractures in the period between 1/1/2011 to 1/11/2018. Inclusion criteria were: The patient underwent open reduction and internal fixation, had pre-operative CT scan that is available for review and three view ankle plain radiographs. Two independent authors review the radiographs for peroneal tendon dislocation, fleck sign and fracture classification, if any. Any dispute was resolved by the senior author.Patient records were reviewed for laterality, age, sex,mode of injury, associated injuries and operative interventions. 50 ankles met the inclusion criteria. 49 were males, mean age was 32.5 year and the predominant mode of injury was a fall from height.

Results

Peroneal tendon dislocation was found in ten patients out of 50 (20%). Risk of dislocation increased with severity of the fracture and neck fractures. Most of the dislocations were missed by surgeons and radiologist, and no additional procedures were done to address such an injury. The Fleck sign had a statistically significant correlation with peroneal tendons dislocations (p=.005)

Conclusion

Peroneal tendons dislocation is associated with as high as 20% of talus fractures. The authors recommend carefully reviewing CT scans by surgeons and radiologists alike to avoid missing such injury and allow for appropriate surgical approach utilization. The Fleck sign is a highly specific radiographic sign that has a statistically significant correlation with PT dislocation and hence we recommend intra-operative assessment of peroneal tendons in patients with the fleck sign.

Pain Control after Laparoscopic Radical Prostatectomy: Comparison between Unilateral Transversus Abdominis Plane Block and Wound Infiltration

BACKGROUND AND OBJECTIVES

To determine the efficacy of unilateral transversus abdominis plane (TAP) block versus wound local infiltration for postoperative pain following laparoscopic radical prostatectomy (LRP).

METHODS

Data of consecutive patients who underwent extraperitoneal LRP and received either wound infiltration or unilateral TAP block for analgesia were retrospectively analyzed. The patients were divided into 2 groups based on the technique used. We compared pain intensity scores and on-demand analgesic use both during the hospital stay and post-discharge between the 2 groups.

RESULTS

A total of 48 patients were included, 27 received unilateral TAP blocks (group 1) and 21 were managed with wound infiltration (group 2). The unilateral TAP block group showed lower median pain scores on postoperative days (POD) 1 with pain scores being 0.2 (0-4) and 0.8 (0-4), respectively (p < 0.05). On POD2, the median pain intensity was 0.9 (0-5) and 1.6 (0-6) in groups 1 and 2, respectively (p < 0.05). The median number of on-demand analgesic doses during the POD1 was 0.2 (0-2) and 0.4 (0-2) in groups 1 and 2, respectively (p = 0.19). On POD2, the patients received 0.5 (0-2) and 1.1 (0-3) on-demand doses in groups 1 and 2, respectively (p < 0.05).

CONCLUSION

Unilateral TAP block might improve pain control more pronounced after LRP than wound infiltration.

A new reconstructive technique for select patients with long upper ureteral obliteration

Ureteral reconstructions pose a challenge for urologists. We describe a novel reconstructive technique for long upper ureteral obliteration with an intrarenal pelvis. The obliterated ureteral segment was excised and the healthy segment of the ureter was spatulated and anastomosed end-to-side to the intrarenal lower calyx (ureterocalycostomy). The procedure was successfully performed without any complication. To date, the patient's clinical state, renal function and radiographic imaging are stable without any evidence of deterioration. The described technique is a useful surgical option for select patients with long upper ureteral obliteration and intrarenal pelvis.

Cannabis Impacts Tumor Response Rate to Nivolumab in Patients with Advanced Malignancies

BACKGROUND

There has been a significant increase in the use of immunotherapy and cannabis recently, two modalities that have immunomodulatory effects and may have possible interaction. We evaluated the influence of cannabis use during immunotherapy treatment on response rate (RR), progression-free survival (PFS), and overall survival (OS).

SUBJECTS, MATERIALS, AND METHODS

In this retrospective, observational study, data were collected from the files of patients treated with nivolumab in the years 2015-2016 at our hospital, and cannabis from six cannabis-supplying companies. Included were 140 patients (89 nivolumab alone, 51 nivolumab plus cannabis) with advanced melanoma, non-small cell lung cancer, and renal clear cell carcinoma. The groups were homogenous regarding demographic and disease characteristics. A comparison between the two arms was made.

RESULTS

In a multivariate model, cannabis was the only significant factor that reduced RR to immunotherapy (37.5% RR in nivolumab alone compared with 15.9% in the nivolumab-cannabis group (p = .016, odds ratio = 3.13, 95% confidence interval 1.24-8.1). Cannabis use was not a significant factor for PFS or OS. Factors affecting PFS and OS were smoking (adjusted hazard ratio [HR] = 2.41 and 2.41, respectively (and brain metastases (adjusted HR = 2.04 and 2.83, respectively). Low performance status (adjusted HR = 2.83) affected OS alone. Tetrahydrocannabinol and cannabidiol percentages did not affect RR in any group (p = .393 and .116, respectively).

CONCLUSION

In this retrospective analysis, the use of cannabis during immunotherapy treatment decreased RR, without affecting PFS or OS and without relation to cannabis composition. Considering the limitations of the study, further prospective clinical study is needed to investigate possible interaction.

IMPLICATIONS FOR PRACTICE

Although the data are retrospective and a relation to cannabis composition was not detected, this information can be critical for cannabis users and indicates that caution is required when starting immunotherapy.

Delayed Soft Tissue Necrosis in an Atypical Closed Calcaneal Fracture: A Case Report

INTRODUCTION

Calcaneal fracture is the most common foot fracture. It occurs due to an axial load and is associated with high morbidity, especially when the articular surface is involved. There are two types of calcaneal fractures: Joint depression type and tongue type. The latter has a high risk of skin necrosis and should be operated on promptly.

CASE REPORT

This is a 37-year-old Bangladeshi man who sustained a comminuted calcaneal fracture and a Lisfranc fracture of the left foot. Initial radiograph showed a joint depression-type fracture, excluding a surgical emergency. Nevertheless, the patient developed skin necrosis over the posterior aspect of the heal that improved after open reduction and internal fixation of the calcaneus. Pre-operative computed tomography (CT) scan demonstrated a bony fragment that was displaced posteriorly causing the skin necrosis.

CONCLUSION

X-ray imaging is not sufficient to exclude surgical emergencies with calcaneal fractures. Highly comminuted fractures should be assessed more thoroughly with urgent CT scan.

Delayed Soft Tissue Necrosis in an Atypical Closed Calcaneal Fracture: A Case Report

INTRODUCTION

Calcaneal fracture is the most common foot fracture. It occurs due to an axial load and is associated with high morbidity, especially when the articular surface is involved. There are two types of calcaneal fractures: Joint depression type and tongue type. The latter has a high risk of skin necrosis and should be operated on promptly.

CASE REPORT

This is a 37-year-old Bangladeshi man who sustained a comminuted calcaneal fracture and a Lisfranc fracture of the left foot. Initial radiograph showed a joint depression-type fracture, excluding a surgical emergency. Nevertheless, the patient developed skin necrosis over the posterior aspect of the heal that improved after open reduction and internal fixation of the calcaneus. Pre-operative computed tomography (CT) scan demonstrated a bony fragment that was displaced posteriorly causing the skin necrosis.

CONCLUSION

X-ray imaging is not sufficient to exclude surgical emergencies with calcaneal fractures. Highly comminuted fractures should be assessed more thoroughly with urgent CT scan.

Peroneal tendon dislocation in Talus fracture and diagnostic value of fleck sign

Category:

Trauma

Introduction/Purpose:

INTRODUCTION: Talus fractures are not uncommon and one of the serious fractures in foot and ankle. Peroneal tendon dislocation is one of the commonly missed soft tissue injuries which may have significant impact on the outcomes including persistent pain and swelling. AIM: To report the incidence of peroneal tendon dislocation in talus fracture and the significance of fleck sign in the diagnosis of peroneal tendon dislocation.

Methods:

We retrospectively reviewed 100 consecutive talus fractures in the period between 1/1/2011 to 1/7/2017. Inclusion criteria were: The patient underwent open reduction and internal fixation, had pre-operative CT scan that is available for review and 3 views ankle plain radiographs. 2 independent authors review the radiographs for peroneal tendon dislocation, fleck sign and fracture classification if any. Any dispute was resolved by the senior author. Patient records were reviewed for laterality, age, sex, mode of injury, associated injuries and operative interventions. 43 ankles met inclusion criteria. 42 were males, mean age was 31 year and the predominant modes of injury were fall from height or unknown.

Results:

Peroneal tendon dislocation was found in 9 patients out of 43. (20%). All dislocations were found in talar neck fractures, and up to 67% of Hawkins type III and IV Talar neck fractures were associated with peroneal tendon dislocation. Risk of dislocation increased with severity of the fracture. 5 cases of peroneal tendon dislocation out of 9 were associated with lateral or bimalleolar fractures. Most of the dislocations were missed and no additional procedures were done to address such injury. Fleck sign sensitivity was 44.4% while specificity was 88%. The Negative Predictive Value (PPV) was 86%.

Conclusion:

Peroneal tendons dislocation is associated with 20% of talus fractures. The incidence of dislocation increases with neck fracture and severity of these fractures. Fleck sign is highly specific radiographic sign and hence we recommend intra-operative assessment of peroneal tendons in patients with fleck sign.

A survey on inspecting structures using robotic systems

Advancements in robotics and autonomous systems are being deployed nowadays in many application domains such as search and rescue, industrial automation, domestic services and healthcare. These systems are developed to tackle tasks in some of the most challenging, labour intensive and dangerous environments. Inspecting structures (e.g. bridges, buildings, ships, wind turbines and aircrafts) is considered a hard task for humans to perform and of critical importance since missing any details could affect the structure’s performance and integrity. Additionally, structure inspection is time and resource intensive and should be performed as efficiently and accurately as possible. Inspecting various structures has been reported in the literature using different robotic platforms to: inspect difficult to reach areas and detect various types of faults and anomalies. Typically, inspection missions involve performing three main tasks: coverage path planning, shape, model or surface reconstruction and the actual inspection of the structure. Coverage path planning ensures the generation of an optimized path that guarantees the complete coverage of the structure of interest in order to gather highly accurate information to be used for shape/model reconstruction. This article aims to provide an overview of the recent work and breakthroughs in the field of coverage path planning and model reconstruction, with focus on 3D reconstruction, for the purpose of robotic inspection.

Enhancing ex vivo expansion of cord blood-derived unrestricted somatic stem cells for clinical applications

OBJECTIVES

To study effects of serum-containing medium (SCM) versus serum-free medium (SFM) and influence of seeding density, on rate of expansion of cord blood (CB) unrestricted somatic stem cells (USSCs), as a prerequisite for evaluating their therapeutic potential in ongoing clinical trials.

MATERIAL AND METHODS

Isolation, propagation and characterization of USSCs from CB samples were performed and followed by their passage 3 culture in SCM and SFM, at cell densities of 5, 50, 500 and 5000 cells/cm(2) .

RESULTS

The cells were CD44(+) , CD90(+) , CD73(+) , CD105(+) , CD34(-) , CD45(-) , and HLA-DR, with Oct4 & Sox2 gene expression; they were differentiated into osteoblasts and adipocytes. USSCs cultured in SCM had significantly higher population doubling levels (P < 0.01) than those cultured in SFM. Those cultured in SCM at 5 cells/cm(2) and those cultured in SFM at 50 cells/cm(2) had significantly higher population doubling (P < 0.01) levels than those cultured at higher cell densities.

CONCLUSIONS

For scaling up of USSCs from 106 (?) to 1012 (?) in 6 weeks, culturing of CB-derived cells of early passage (≤P3) in SCM at low cell seeding density (5 cells/cm(2) ) is suggested for increasing cell count with lower passaging frequency, followed by culture of expanded USSCs at 50 cells/cm(2) in SFM, to avoid undesirable effects of bovine serum in clinical applications.

Age and competition level on injuries in female ice hockey

The objective of this study was to describe the number, types and locations of known injuries occurring across different age categories and levels of competition in female ice hockey within the Ontario Women's Hockey Association from 2004/05 to 2007/08. We further examined under which aforementioned factors and combination of factors an unusually high or low number of injuries was recorded. Secondary analysis of anonymized injury data was conducted. The most common known injury type was strain/sprain, followed by concussion while the most frequent injury location was head/face/mouth. Analysis of deviance indicated that a significantly higher than expected number of sprain/strain, concussion and laceration injuries were recorded compared to all other injury types. In addition, there were a higher number of injuries recorded at the AA level compared to all other levels of competition. Finally, the age categories of Peewee, Midget and Intermediate within the AA level of competition, as well as Senior/Adult within the Houseleague level of competition also recorded a significantly higher number of injuries compared to other combinations of descriptive factors. Further research with female youth is needed to better understand the high number of injuries, including concussions, reported overall.

Golgi alkaline ceramidase regulates cell proliferation and survival by controlling levels of sphingosine and S1P

Sphingosine-1-phosphate (S1P), a sphingolipid metabolite, promotes cell proliferation and survival whereas its precursor, sphingosine, has the opposite effects. However, much remains unknown about their regulation. Here we identify a novel human ceramidase (haCER2) that regulates the levels of both sphingosine and S1P by controlling the hydrolysis of ceramides. haCER2 is localized to the Golgi complex and is highly expressed in the placenta. High ectopic expression of haCER2 caused fragmentation of the Golgi complex and growth arrest in HeLa cells due to sphingosine accumulation. Low ectopic expression of haCER2 increased S1P without sphingosine accumulation, promoting cell proliferation in serum-free medium. This proliferative effect was suppressed by dimethylsphingosine, an inhibitor of the S1P formation, or by the RNA interference (RNAi) -mediated inhibition of S1P(1,) a G-protein-coupled receptor for S1P. The RNAi-mediated down-regulation of haCER2 enhanced the serum deprivation-induced growth arrest and apoptosis of HeLa cells, which was inhibited by addition of exogenous S1P. Serum deprivation up-regulated both haCER2 mRNA and activity in HeLa cells. haCER2 mRNA is also up-regulated in some tumors. Taken together, these results suggest that haCER2 is important for the generation of S1P and S1P-mediated cell proliferation and survival, but that its overexpression may cause cell growth arrest due to an accumulation of sphingosine.

Acid Ceramidase but Not Acid Sphingomyelinase Is Required for Tumor Necrosis Factor-α-induced PGE2 Production

Sphingolipids are well established effectors of signal transduction downstream of the tumor necrosis factor (TNF) receptor. In a previous study, we showed that the sphingosine kinase/sphingosine 1-phosphate (S1P) pathway couples TNF receptor to induction of the cyclooxygenase 2 gene and prostaglandin synthesis (Pettus, B. J., Bielawski, J., Porcelli, A. M., Reames, D. L., Johnson, K. R., Morrow, J., Chalfant, C. E., Obeid, L. M., and Hannun, Y. A. (2003) FASEB J. 17, 1411-1421). In this study, the requirement for acid sphingomyelinase and sphingomyelin metabolites in the TNFalpha/prostaglandin E(2) (PGE(2)) pathway was investigated. The amphiphilic compound desipramine, a frequently employed inhibitor of acid sphingomyelinase (ASMase), blocked PGE(2) production. However, the action of desipramine was independent of its action on ASMase, since neither genetic loss of ASMase (Niemann-Pick fibroblasts) nor knockdown of ASMase using RNA interference affected TNFalpha-induced PGE(2) synthesis. Further investigations revealed that desipramine down-regulated acid ceramidase (AC), but not sphingosine kinase, at the protein level. This resulted in a time-dependent drop in sphingosine and S1P levels. Moreover, exogenous administration of either sphingosine or S1P rescued PGE(2) biosynthesis after desipramine treatment. Interestingly, knockdown of endogenous AC by RNA interference attenuated cyclooxygenase 2 induction by TNFalpha and subsequent PGE(2) biosynthesis. Taken together, these results define a novel role for AC in the TNFalpha/PGE(2) pathway. In addition, the results of this study warrant careful reconsideration of desipramine as a specific inhibitor for ASMase.

Using an improved 1D boundary layer model with CFD for flux prediction in gas-sparged tubular membrane ultrafiltration

Tubular membrane ultrafiltration and microfiltration are important industrial separation and concentration processes. Process optimisation requires reduction of membrane build-up. Gas slug introduction has been shown to be a useful approach for flux enhancement. However, process quantification is required for design and optimisation. In this work we employ a non-porous wall CFD model to quantify hydrodynamics in the two-phase slug flow process. Mass transfer is subsequently quantified from wall shear stress, which was determined from the CFD. The mass transfer model is an improved one-dimensional boundary layer model, which empirically incorporates effects of wall suction and analytically includes edge effects for circular conduits. Predicted shear stress profiles are in agreement with experimental results and flux estimates prove more reliable than that from previous models. Previous models ignored suction effects and employed less rigorous fluid property inclusion, which ultimately led to under-predictive flux estimates. The presented model offers reliable process design and optimisation criteria for gas-sparged tubular membrane ultrafiltration.