Prognostic tools for hypertrophic scar formation based on fundamental differences in systemic immunity

Unpredictable hypertrophic scarring (HS) occurs after approximately 35% of all surgical procedures and causes significant physical and psychological complaints. Parallel to the need to understanding the mechanisms underlying HS formation, a prognostic tool is needed. The objective was to determine whether (systemic) immunological differences exist between patients who develop HS and those who develop normotrophic scars (NS) and to assess whether those differences can be used to identify patients prone to developing HS. A prospective cohort study with NS and HS groups in which (a) cytokine release by peripheral blood mononuclear cells (PBMC) and (b) the irritation threshold (IT) after an irritant (sodium lauryl sulphate) patch test was evaluated. Univariate regression analysis of PBMC cytokine secretion showed that low MCP‐1, IL‐8, IL‐18 and IL‐23 levels have a strong correlation with HS (P < .010‐0.004; AUC = 0.790‐0.883). Notably, combinations of two or three cytokines (TNF‐a, MCP‐1 and IL‐23; AUC: 0.942, Nagelkerke R²: 0.727) showed an improved AUC indicating a better correlation with HS than single cytokine analysis. These combination models produce good prognostic results over a broad probability range (sensitivity: 93.8%, specificity 86.7%, accuracy 90,25% between probability 0.3 and 0.7). Furthermore, the HS group had a lower IT than the NS group and an accuracy of 68%. In conclusion, very fundamental immunological differences exist between individuals who develop HS and those who do not, whereas the cytokine assay forms the basis of a predictive prognostic test for HS formation, the less invasive, easily performed irritant skin patch test is more accessible for daily practice.     

CASE OF FASCIOLIASIS: EXTRACTION WITH ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY

Fascioliasis is a worldwide zoonotic infection with fasciola hepatica and fasciola gigantica. The zoonoses are particularly endemic in sheep‐raising countries and are also endemic in Turkey. Clinical features of fascioliasis relate to the stage and intensity of infection. Fasciola hepatica infection comprises two stages: hepatic and biliary, with different signs and symptoms. Cholestatic symptoms may be sudden, but, in some cases, they may be preceded by a long period of fever, eosinophilia and vague gastrointestinal symptoms. We reported a case with fever and upper‐quadrant abdominal pain since 3 months that comes from an area endemic for fasciola hepatica, with suspected imaging about fasciola hepatica in common bile duct on ultrasonography. After that, fasciola hepatica was extracted with endoscopic retrograde cholangiography.     

Treatment of malignant dysphagia with nitinol stents

Self-expanding nitinol stents were used in 22 patients for palliative treatment of malignant esophagogastric strictures. All patients but 5 were men (age range 47–75 years). The strictures were caused by squamous cell carcinoma (n = 12), adenocarcinoma (n = 8), and recurrent anastomotic carcinoma (n = 2). No technical failure or procedural complications occurred. After the procedure, the severity of dysphagia decreased at least one grade in all patients. Tumor ingrowth into the stent was seen in 7 patients of 22 (32%). Four of these patients were treated with additional stents, and in 3 patients, due to refusal, only balloon dilations were performed, which caused temporary relief. Tumor ingrowth into the stent was noted from 10 days to 7 months (mean 3 months). This seems to be a disadvantage of nitinol stents. At the end of the study 10 patients had died dead with a mean survival of 3 months (range 1 week to 6 months) and 12 patients were still alive with a mean follow-up of 4 months (range 1–8 months). It is concluded that nitinol stents provide satisfactory palliation in patients with malignant dysphagia with neglectable procedural morbidity and mortality rates.     

The evaluation of acute kidney injury due to ischemia by urinary neutrophil gelatinase-induced lipocalin (uNGAL) measurement in patients who underwent partial nephrectomy

International Urology and Nephrology - To investigate the role of urinary neutrophil gelatinase-induced lipocalin (uNGAL) measurement in the early diagnosis of acute kidney injury that may occur...     

The effect of renal artery-only or renal artery–vein clamping during partial nephrectomy on short and long-term functional results: Is clamping technique important?

Purpose

To evaluate the effect of artery-only (AO) and artery–vein (AV) clamping during partial nephrectomy (PN) on short- and long-term renal function outcome.

Methods

Medical records of 154 patients in the AO group and 192 patients in the AV group who underwent open and minimally invasive (laparoscopic/robotic) PN between January 2011 and January 2018 were retrospectively assessed. Preoperative patient and tumor-specific characteristics in addition to perioperative factors and renal function outcomes were compared. The change in the estimated glomerular filtration rate (eGFR) from postoperative 1–3 days, 12 and 24 months after surgery was calculated. Acute kidney injury (AKI) was defined a as a?>?25% reduction in eGFR.

Results

There were no statistically significant differences between the clamping techniques in terms of postoperative 1–3 days, 12 and 24 months eGFR change percentage and risk of progression to chronic kidney disease (CKD). No significant difference in short- and long-term renal functions was found between the minimally invasive or open AO and AV clamping subgroups at any time point. In multivariate analysis, the R.E.N.A.L score (AO group p?=?0.026, AV group p?<?0.001) and preoperative eGFR (AO group p?<?0.001, AV group p?=?0.010) were strong predictors of the acute kidney injury in both groups. Older age (AO group p?=?0.045, AV group p?=?0.010) and preoperative eGFR (AO group p?=?0.008, AV group p?=?0.002) were significantly associated with CKD progression at 2-year follow-up in both groups.

Conclusion

AV clamping does not adversely affect postoperative renal function compared to AO clamping. Preoperative patient- and tumor-related factors are more important for renal function regardless of the clamping technique.

     

Is ‘Omega Sign’ anatomical endoscopic enucleation of the prostate technique reproducible?

We aimed to evaluate the learning curve of the surgically standardised ‘Omega Sign’ anatomical endoscopic enucleation (AEEP) of the prostate surgery technique for junior surgeons. This study is a retrospective comparison of cases that underwent AEEP by a mentor surgeon and three junior surgeons who have completed their learning curve. A video-based laser enucleation of the prostate assessment tool (LEAT) composed of 8 steps of the technique was used to assess a senior surgeon and junior surgeons’ surgical compatibility and consistency. The surgeon who defined Omega Sign technique was determined as group 1, and cases by three junior surgeons were identified as group 2. The end points were to assess the reproducibility and repeatability and operative post-operative outcomes of the technique. 55 patients’ videos were rated by five experienced endourologists. There was no significant difference in LEAT scores between the groups among all steps. The most symmetry was found in the 1st and 3rd steps. Inter-rater consistency was also high for each step, with no statistically significant difference between the evaluators. The standardised anatomical ‘Omega Sign’ technique is reproducible for the junior surgeons. The operative steps can be performed with high consistency, and the functional and perioperative outcomes are comparable with the senior surgeon.     

Bilateral median nerve compression at the level of Struthers' ligament. Case report

Struthers' ligament syndrome is a rare cause of median nerve entrapment. Bilateral compression of the median nerve is even more rare. It presents with pain, sensory disturbance, and/or motor function loss at the median nerve's dermatomal area. The authors present the case of a 21-year-old woman with bilateral median nerve compression caused by Struthers' ligament. She underwent surgical decompression of the nerve on both sides. To the authors' knowledge, this case is the first reported bilateral compression of the median nerve caused by Struthers' ligament. The presentation and symptomatology of Struthers' ligament syndrome must be differentiated from median nerve compression arising from other causes.     

Hepatitis C virus reactivation in cancer patients in the era of targeted therapies

The purpose of this review is to summarize the evidence of hepatitis C reactivation in cancer patients in the era of targeted therapies.Targeted therapies are novel therapeutics frequently used in cancer patients.During treatment with targeted therapies,viral replication is one of the major problems that can occur.The PubMed database,ASCO,and ASCO Gastrointestinal Cancer Symposium abstracts were searched up until September 15,2013 using the following search keywords:"targeted therapies,rituximab,alemtuzumab,brentuximab,hepatitis,hepatitis C reactivation,tyrosine kinase inhibitors,imatinib,mammalian target of rapamycin(mTOR)inhibitors,everolimus,anti-HER therapies,trastuzumab,pertuzumab,lapatinib,antiepidermal growth factor receptor therapies,cetuximab,panitumumab,and ipilimumab".Papers considered relevant for the aim of this review were selected by the authors.The data about rituximab-induced hepatic flare in hepatitis C virus(HCV)positive patients is controver-sial.However,there is the possibility of life-threatening hepatic flare that can develop after HCV ribonucleic acid(HCV-RNA)viral load increases.Routine followup of liver function tests should be advised.Especially in high-risk patients,such as those with baseline chronic active hepatitis and cirrhosis,and where there are plans to administer rituximab concomitantly with corticosteroids,it is advised to have close follow-up of HCV viral load.The data is insufficient to make accurate statements about the association of alemtuzumab therapy and HCV reactivation.However,alemtuzumab may cause deep immunosuppression.Due to this,it is better to follow up with liver function tests and HCV RNA levels during alemtuzumab therapy.Brentuximab has effects on antibody dependent cellular toxicity and may decrease humoral immunity.Thus,we believe that during brentuximab treatment of HCV infected patients,clinicians may encounter hepatitis C reactivation.There have been no reported cases of hepatitis C reactivation with imatinib therapy.However,there are many reports of hepatitis B reactivation with imatinib treatment.Based on the evidence of hepatitis B reactivation with imatinib and the effects of imatinib on immune system functions,we suggest that imatinib therapy might be a risk factor for HCV reactivation.Anti-human epidermal growth factor receptor 2 therapies are not associated with hepatic flare in HCV infected patients.Post-transplant studies reported that mTOR was safely administered to patients with active hepatitis C without causing hepatic flare.Cetuximab and panitumumab have not been associated with HCV reactivation.Two cases of HCV infected melanoma were safely treated with ipilimumab without any HCV reactivation or hepatic flare.Targeted therapies are a new and emerging area of oncology treatment modalities.While treating HCV infected cancer patients,clinicians should be mindful of the immunosuppressive properties of targeted therapies.Further randomized trials are needed to establish algorithms for this issue.     

Transcervical Tongue Base Reduction with Hyoepiglottoplasty: Long-Term Results

Aims To evaluate the long term results of tongue base reduction with hyoepiglottoplasty as a surgical option in the treatment of severe obstructive sleep apnea. Material and Method Severe obstructive sleep apnea patients diagnosed as upper airway narrowing at the tongue base level were treated with transcervical tongue base reduction with hyoepiglottoplasty. Seven years after single stage multilevel surgery, the patients were reevaluated clinically, radiologically and polysomnographic records were taken. Preoperative, early postoperative and long-term postoperative parameters were compared to determine the success rate of the surgical technique. Results In the postoperative long-term follow-up Epworth sleepiness scale (ESS) scores were reduced to 4 and 6 respectively 2 months after surgery despite the initial values of 17 and 15. BMI were decreased from 29.7 and 27.9 kg/m² respectively to 26 and 24 kg/m². The apnea/hypopnea index (AHI) were reduced to 14.1 and 16.2 respectively from 68.6 and 83.83. O₂ nadir was 55 and 66% respectively and improved to 86 and 89%. Flexible nasopharyngoscopy revealed competent airway in both retropalatal and retroglossal level. Bed partners scored snoring as 2/10 and 4/10 corresponding to very mild and moderate. Daytime somnolence and witnessed apneic periods were completely disappeared in both patients. Conclusion Open tongue base resection with hyoepiglottoplasty is effective among all other surgical corrections of sleep apnea even after 7 years postoperatively.