Reassessing the role of surgery in the elderly or chronically sick with proximal extrahepatic cholangiocarcinoma

BackgroundMost data on postoperative outcomes among patients with proximal extrahepatic cholangiocarcinoma are reported by single institutions. The purpose of this study was to analyze postoperative outcomes stratified by age and comorbidities.MethodsPatients with proximal extrahepatic cholangiocarcinoma who underwent a resection were identified in the National Cancer Database. Pathologic, postoperative, and survival outcomes were compared based on age and Charlson-Deyo comorbidity index.ResultsAmong the 1,579 patients, the average age was 66 years, and 9.4% of patients were older than 80 years. Most patients had a Charlson-Deyo score of 0 (72.4%), with the minority having scores of 1 (20.5%) or ≥2 (7.1%). Patients ≥80 years had a higher 90-day mortality rate compared with patients 65 to 79 and <65 years (21.3% vs 12.0% vs 7.4%, P < .001). Patients with a Charlson-Deyo score ≥2 had longer duration of stay, greater likelihood of requiring an unplanned readmission, and a higher 90-day mortality rate compared with patients with a lower comorbidity index. Median survival of patients <65, 65 to 79, and ≥80 years was 31, 24, and 17 months, respectively. A similar trend was seen with increasing Charlson-Deyo score (0: 27 months, 1: 25 months, ≥2: 20 months). On multivariable analysis, age ≥80 years (hazard ratio = 1.52, P = .01) and Charlson-Deyo score ≥2 (hazard ratio = 1.45, P = .01) were associated with poor survival.ConclusionIn patients with proximal extrahepatic cholangiocarcinoma, age ≥80 years and greater comorbidity index are associated with increased risk of 90-day mortality and poor overall survival. This suggests that resections in high-risk patient populations should be approached with caution.     

T cell antigenicity and immunogenicity of allogeneic exosomes

Extracellular vesicles, including exosomes, are regularly released by allogeneic cells after transplantation. Recipient antigen-presenting cells (APCs) capture these vesicles and subsequently display donor MHC molecules on their surface. Recent evidence suggests that activation of alloreactive T cells by the so-called cross-dressed APCs plays an important role in initiating the alloresponse associated with allograft rejection. On the other hand, whether allogeneic exosomes can bind to T cells on their own and activate them remains unclear. In this study, we showed that allogeneic exosomes can bind to T cells but do not stimulate them in vitro unless they are cultured with APCs. On the other hand, allogeneic exosomes activate T cells in vivo and sensitize mice to alloantigens but only when delivered in an inflammatory environment.     

Bladder preservation versus radical cystectomy in transitional cell carcinoma and squamous cell carcinoma muscle invasive bladder cancer

Background:Randomizing patients to bladder preservation or radical cystectomy (RC) for the treatment of bladder cancer has not been practical, due to patient and physician preferences. Therefore, continually comparing the 2 treatment modalities is needed, in order to make the proper choice for each patient.Patients and methods:The records of T1–4N0M0 bladder cancer patients, who presented to the South Egypt Cancer Institute between 2007 and 2017 and were treated by either bladder preservation or RC were reviewed.Results:Out of the 166 included patients, 81 (48.8%) patients were treated by bladder preservation and 85 (51.2%) patients had RC. For the patients treated by bladder preservation and the patients treated by RC, the 5-year overall survival (OS) was 56% and 60% (p = 0.67), the 5-year local recurrence-free survival was 69% and 73% (p = 0.69), and the 5-year disease-free survival was 45% and 53% (p = 0.16), respectively. After propensity matching analysis, the mean 5-year OS was 58% for the bladder preservation patients and 61% for the RC patients (p = 0.51). It is notable that among the bladder preservation group, 8 patients (10%) had squamous cell carcinoma (SCC) pathology and refused RC. Their OS was 56% compared to 53% for the SCC patients treated by RC (p = 0.6).Conclusion:Bladder preservation is a safe alternative to cystectomy in transitional cell carcinoma stages T1–4aN0M0, and its use in SCC bladder cancer should be further studied, as it could be feasible to spare them from initial cystectomy.     

The Effect of Neonicotinoids Exposure on Oreochromis niloticus Histopathological Alterations and Genotoxicity

This study aimed to examine the side effects of selected neonicotinoids (Acetamiprid, Aceta, and Imidacloprid, Imid) on Oreochromis niloticus juveniles. The acute toxicity, Probit method, revealed an LC₅₀ of 195.81 and 150.76 ppm for Aceta/96 h and Imid/72 h respectively. The fish were divided into three groups that were exposed, for 21 days (n?=?5/replicate), to 1/10 of the LC₅₀ of either neonicotinoids, however, the third was an unexposed control group. Results of erythrocytic micronucleus (MN), and nuclear abnormalities (NA) showed that Aceta and Imid exposure caused a significant (p?<?0.05) increase in MN by?~?2.2 and?~?10 folds, respectively relative to control. NAs occurred at the order of kidney-shaped?>?budding?>?binucleated in Aceta, however, budding?>?binucleated?>?kidney-shaped was noticed in the Imid group. Histopathological changes in gills, liver, and muscles were observed significantly in both exposed groups with more severity in the Imid group. Collectively, Aceta and Imid have potential genotoxicity and histopathological alterations in O. niloticus.

     

Female Genital Cutting and Deinfibulation: Applying the Theory of Planned Behavior to Research and Practice

At least 200 million girls and women across the world have experienced female genital cutting (FGC). International migration has grown substantially in recent decades, leading to a need for health care providers in regions of the world that do not practice FGC to become knowledgeable and skilled in their care of women who have undergone the procedure. There are four commonly recognized types of FGC (Types I, II, III, and IV). To adhere to recommendations advanced by the World Health Organization (WHO) and numerous professional organizations, providers should discuss and offer deinfibulation to female patients who have undergone infibulation (Type III FGC), particularly before intercourse and childbirth. Infibulation involves narrowing the vaginal orifice through cutting and appositioning the labia minora and/or labia majora, and creating a covering seal over the vagina with appositioned tissue. The WHO has published a handbook for health care providers that includes guidance in counseling patients about deinfibulation and performing the procedure. Providers may benefit from additional guidance in how to discuss FGC and deinfibulation in a manner that is sensitive to each patient’s culture, community, and values. Little research is available to describe decision-making about deinfibulation among women. This article introduces a theoretically informed conceptual model to guide future research and clinical conversations about FGC and deinfibulation with women who have undergone FGC, as well as their partners and families. This conceptual model, based on the Theory of Planned Behavior, may facilitate conversations that lead to shared decision-making between providers and patients.

     

Optimization of uretero-intestinal anastomosis in urinary diversion: an experimental study in dogs

Summary A new antireflux uretero-ileal reimplantation technique suitable for use with bladder substitutes is presented. This procedure entails creation of a serouslined extramural tunnel. Following detubularization of the bowel segment, the adjacent flaps are approximated by continuous 4/0 non-absorbable sutures 1.5 cm from the cut edges. The ureters are laid in the trough thus fashioned. Button-holes are created in the bowel flaps and a mucosa-to-mucosa uretero-ileal anastomosis is carried out. The mucosal edges of the flaps are then approximated by one layer of continuous 4/0 (PGA) suture resulting in closure of this artificial tunnel. The feasibility and functional outcome of this technique were experimentally investigated in 8 dogs. Follow-up was carried out up to 30 weeks. Assessment by intravenous urography and ascending studies showed that the procedure is an efficient method of providing an unobstructed unidirectional flow of urine.     

Role of cytomegalovirus in inducing congenital anomalies

Sixty eight infants and newborns were included in the present study being consisted of 55 cases with congenital anomalies and 13 cases of apparently healthy infants acting as controls. Three types of congenital anomaly cases were studied; 17 cases of microcephaly, 17 cases of cerebral palsy and 21 cases with jaundice. All serum samples were tested for cytomegalovirus IgM antibodies (CMV IgM) by microassay ELISA technique to explore the role of CMV infection in inducing congenital anomalies. Six out of the 68 serum samples were found to be positive for CMV IgM. Four of them were detected among the congenital cases (5 our to 55; 7.3%), while 2 cases were among the controls (2 out of 13; 15.4%). The microcephalic group showed 5.9% positivity (one out of 17). The jaundiced infants showed 14.3% positivity (3 out of 21), while all the cerebral palsy cases were negative for CMV IgM. Such a high percentage of CMV IgM in the control group may be attributed to asymptomatic infection, with liability for long term sequelae, particularly hearing loss or ocular abnormalities by 2 years of age. So, continuous follow-up of such asymptomatic cases is essential to control any possible congenital abnormality as early as possible.     

Categorical analysis of factors affecting needs and demands for removable dentures among Alexandria Dental Research Center clientele

An accurate assessment of dental needs is important to public health planners. With this information, it is possible to assess future treatment needs and demands for services including those for removable dentures. The present work aimed to estimate the magnitude and types of needs, and demands for partial or complete removable dentures, to study some factors that may affect the identified needs and demands for removable dentures, in addition to studying the factors that may affect satisfaction with the dentures. The present study was conducted in "Alexandria Dental Research Center". Data were collected by means of interview questionnaire, followed by dental examination of all patients attending the center for the sake of removable dental restorations for a period of 6 months. A further follow up over a period of three months was undertaken to the 330 cases recorded. About one third of the cases demanded partial and/or complete dentures and were above 60 years old. The first purpose for construction of new dentures was mastication, followed by cosmetics. Only one quarter of cases decided to have delayed immediate dentures. Diabetics and those having chronic diseases showed more demand for complete dentures. The most discriminating variable between the demand for different dentures was the missing in the lower anterior teeth followed by missing in the upper both anterior and posterior and then missing in the upper anterior teeth. Satisfaction score increased with advance of age, among males, among those for complete dentures, and those who had had previous dentures. Stepwise logistic regression revealed that the best predictor for overall satisfaction was the history of having previous dentures. Results of the present study, suggest that early screening and treatment of diabetic patients, gathering detailed information by means of a questionnaire before new dentures fabrication may be an important tool for the dentist in predicting and consequently enhancing patient satisfaction with the dentures. Health education should stress on the value of restoring missing teeth and all available options around this.