Radiation and Cancer Research

Radiogenomics a New Marker on the Block Nagraj Gururaj Huilgol Journal of Radiation and Cancer Research 2018 9(4):131-131

Acute radiation syndrome: An update on biomarkers for radiation injury Vijay K Singh, Paola T Santiago, Madison Simas, Melissa Garcia, Oluseyi O Fatanmi, Stephen Y Wise, Thomas M Seed Journal of Radiation and Cancer Research 2018 9(4):132-146 The possible detonation of a radiological dispersal device or improvised nuclear device in a metropolitan city, or the accidental exposures to a radiation source, nuclear accidents, or the all-to-often threats of radiological/nuclear terrorism have led to the urgent need to develop essential analytic tools to assess such radiation exposures, especially radiation doses to exposed individuals. This exposure-assessing work using biological samples, and discipline, is known as biodosimetry. As of late, this field has progressed significantly as it has made use of the advances within newer areas of biologic analytics, namely omics (genomics, proteomics, metabolomics, and transcriptomics), lymphocyte kinetics, optically stimulated luminescence, and electron paramagnetic resonance technology in addition to conventional cytogenetic techniques. The use of automated high throughput platforms and the planning for laboratory surge capacity during the time of need are the latest developments in the field of biomarkers for biodosimetry. Such biomarkers are also needed for radiation exposure/dose conversion estimates that are essential for the development and application of radiation countermeasures, from animals to humans and that are currently being developed following the US Food and Drug Administration Animal Rule. Here, we present and discuss the current status of various biomarkers for assessing radiation dose after radiation exposure. It is anticipated that with the advent of improved biomarkers and associated biomarker platforms for the acute radiation syndrome, exposed victims can be more efficiently triaged and appropriately treated than is currently allowable. The latest advances in the field, and identify the areas where improvement is needed are also listed and discussed.

Intracellular reactive oxygen species determine cancer stem cell radiosensitivity related to predictive biomarker for radiotherapy Kaushala Prasad Mishra Journal of Radiation and Cancer Research 2018 9(4):147-154 Cancer cells display a higher level of reactive oxygen species (ROS) mainly due to increased metabolic activities resulting in altered redox balance. Imbalance in redox arises when the generation of ROS exceeds antioxidants defense system. ROS are generated in cells from multiple pathways, but mitochondria contribute significantly to cellular ROS pool by oxidative phosphorylation. Elevated levels of ROS are implicated in cell transformation, proliferation, and tumorigenesis. ROS-mediated signaling pathways activate pro-oncogenes which regulate cancer progression, angiogenesis, and survival. Normal cells maintain intracellular homeostasis by developing an array of enzymatic antioxidant systems such as catalase, superoxide dismutase, and glutathione peroxidase. Chemotherapy and radiotherapy exert their cytotoxic effects on tumor cells by the generation of excessive ROS. The failure of therapies is attributable to a small fraction of core cells in tumor mass called cancer stem cells (CSCs) which have self-renewal property and exhibit proliferation, differentiation, and resistance to treatments. Both normal and CSCs maintain low-ROS level ascribed to stemness. This review describes role and relevance of ROS in CSC with particular emphasis on developing predictive biomarker for outcome of cancer radiotherapy. It is pointed out that CSCs maintain lower ROS homeostasis and evade cell death by increased level of endogenous antioxidants capacity in cancer cells. Search for regulators of ROS and surface markers in CSC may render them sensitive to radiation offering new and effective strategy for cancer treatment.

Breast cancer stem cells, epigenetics, and radiation Garima Sinha, Alejandra Ferrer, Yahaira Naaldijk, Caitlyn A Moore, Qunfeng Wu, Henning Ulrich, Pranela Rameshwar Journal of Radiation and Cancer Research 2018 9(4):155-164 Breast cancer remains a clinical problem despite advancements in the field. Cancer stem cells (CSCs) within the breast cancer population are implicated in cancer relapse. The dormant CSCs generally resist available treatment, thus challenging the current treatment paradigm. Radiation is an aggressive form of treatment typically used to reduce tumor mass in breast cancer patients. Several clinical and research-based studies have shown that radiation treatment cannot target all cancer cells, leaving behind radioresistant cells. The radioresistant cells have the potential to acquire stem cell-like features that render them untargetable with respect to the current technology. This review elaborates on cancer cells acquiring stem cell phenotype. In addition, we discuss the phenotype and function of cancer cells that are derived from radioresistant cells as well as indirect changes as a consequence to bystander effect. In addition, the epigenetic profile of the radioresistant cells plays a crucial role in the acquisition of cycling quiescence and stem cell-like phenotype and is detailed in this review.

Biomarkers in chronic obstructive pulmonary disease patients for prediction of lung cancer development Murali M S Balla, Pooja K Melwani, Amit Kumar, Badri N Pandey Journal of Radiation and Cancer Research 2018 9(4):165-176 According to the World Health Organization (2016), chronic obstructive pulmonary disease (COPD) and lung cancer (along with trachea and bronchial cancers) are third and sixth among 10 top causes of death globally. The association between lung cancer and COPD has been widely established owing to their common endogenous and exogenous risk factors. Mechanistically, lung cancer and COPD are interlinked diseases in many ways such as oxidative stress-associated DNA damage, inflammation, and telomere shortening. An increase in lung cancer has been well correlated with smoking, which is likely to occur up to five folds higher in smokers with COPD than normal lung function subjects. In majority of cases, lung cancer development, especially in COPD patients, is asymptomatic and only diagnosed at advanced stages with poor prognosis. The development of biomarkers for early prediction of lung cancer in both high- and low-risk COPD patients will help clinicians for their better follow-up, early diagnosis, and improved therapeutic management.

Medical imaging: Contribution toward background radiation and human exposure Shangamithra Visweswaran, Karthik Kanagaraj, Santhosh Joseph, Venkatachalam Perumal Journal of Radiation and Cancer Research 2018 9(4):177-182 Annual public exposure from background radiation is about 2.8 mSv which comes from both natural and manmade sources. The medical applications of ionizing radiation contribute around 98% of the manmade sources of background radiation. The annual per caput dose rose from 0.35 to 0.62 mSv by the worldwide usage of radiation diagnostic examinations. Based on the published reports, the diagnostic examinations – computed tomography (CT) scan and cerebral angiography are high (7.4 mSv and 9.3 mSv, respectively) in the average effective dose. In our study, we measured the entrance surface dose at different anatomical locations using thermoluminescence dosimeter in patients who underwent CT examinations and neurointerventional radiology procedures. The measured dose values range between 0.70 and 518.12 mGy for CT and 0.99 and 777.31 mGy for interventional procedures. Thus, X-radiation based procedures delivered a considerable amount of radiation dose to the patients. To minimize the risks of developing any health effects, safety measures should be taken to reduce the dose without compromising the image quality.

Enhanced DNA double strand break repair triggered by microbeam irradiation induced cytoplasmic damage Teruaki Konishi, Alisa Kobayashi, Tengku Ahbrizal Farizal Tengku Ahmad, Jun Wang Journal of Radiation and Cancer Research 2018 9(4):183-189 Objective: Direct exposure of the nucleus to radiation, is the primary cause of various radiobiological effects. However, the cytoplasm is equally exposed to radiation during treatments that result in activation of intracellular response. Thus, the present study is aimed at investigating (1) whether cytoplasmic irradiation affects double-strand breaks (DSBs) repair when the cytoplasm (C) and nucleus (N) is irradiated sequentially, and (2) whether the cytoplasmic irradiation alone is sufficient to induce DNA DSBs in the nucleus. Materials and Methods: To distinguish the radiobiological effects between nuclear and cytoplasmic irradiation, all the experiments were conducted using the SPICE - National Institute of Radiological Sciences microbeam (SPICE) that can target precisely the N and/or C with desired number of 3.4 MeV protons. We examined the kinetics of DSB repair in WI-38 normal human fibroblast cells that were irradiated by microbeam targeted to the N, C, or N + C. Cells were fixed at various time points between 1 and 24 h postirradiation. Subsequently, they were immunostained with antibodies against γ-H2AX, a DSB marker, and imaged, to quantify the residual DSB in each nucleus. Results: Microbeam irradiation induced significant γ-H2AX, directly proportional to the number of protons delivered per N. In the C-targeted cells, γ-H2AX levels did not increase significantly, compared to controls, 1-h postirradiation. However, 4-h postirradiation, γ-H2AX levels were significantly increased in C-targeted cells, compared to nonirradiated controls, and the increase was proportional to the number of protons delivered. Cells irradiated with 500 protons per N, showed lowered residual γ-H2AX levels in N + C cells additionally irradiated with 500 or 1000 protons targeted to the C, 16 and 24 h postirradiation, respectively. Conclusion: Our results suggest that cytoplasmic damage triggers enhanced repair of DSBs that are induced on nucleus irradiation.

Oral Sciences

Confronting the menace of predatory publishers of health journals HA Mosadomi Saudi Journal of Oral Sciences 2019 6(1):1-2

Dentinal crack formation after different obturation techniques Hale Ari Aydinbelge, Nazife Tugba Azmaz, Mine Ozcelik Yilmaz Saudi Journal of Oral Sciences 2019 6(1):3-7 Introduction: The aim of this investigation was to compare the incidence of dentinal crack after different obturation techniques. Materials and Methods: Fifty-five mandibular teeth with mature apices and straight root canals (>5°) that had been extracted for periodontal reasons were selected and stored in distilled water until use. The teeth were randomly assigned to five groups of 15 teeth each. The groups were as follows; (Group 1) no canal preparation, (Group 2) canal preparation, (Group 3) canal preparation and obturation with cold lateral condensation technique, (Group 4) canal preparation and obturation with warm vertical condensation (WVC) technique, and (Group 5) canal preparation and obturation with single-cone (SC) technique. Afterward, the teeth were horizontally sectioned at 3, 6, and 9 mm from the apex with a low-speed saw under water cooling. All slices were then viewed through a stereomicroscope at ×25 magnification and pictures were taken. The presence of dentinal crack was noted and analyzed using the Chi-square test. Results: The Group 1 had no dentinal crack. All the other groups resulted in dentinal crack. Groups 3 and 4 produced significantly more dentinal crack than the other groups in the 6 and 9 mm sections (P < 0.05). The Groups 3 and 4 produced significantly more dentinal crack in the 6 and 9 mm sections than 3 mm sections (P < 0.05). Conclusion: Under the conditions of this study, after root canal filling with the cold lateral and WVC techniques determined more dentinal cracks than the only preparation and SC technique. The SC technique seems to be an appropriate obturation technique.

Micro-computed tomographic analysis of filling porosity of two different obturation techniques Amal A Almohaimede, Marwa M Almutairi, Haya M Alyousef, Ebtissam M Almadi Saudi Journal of Oral Sciences 2019 6(1):8-12 Introduction: The ideal root filling material should have inert properties, good adhesive ability, and result in void-free obturation along the root canals. The aim of this in vitro study was to compare the quality of two root canal obturation techniques; cold lateral (CL) condensation and continuous wave (CW) condensation, through measuring the volume of gaps and voids by using micro-computed tomography (micro-CT). Materials and Methods: Forty-extracted teeth with single canal were instrumented with profile rotary files, and divided into two groups as follows: CL condensation (n = 20), and CW obturation (n = 20). The teeth in each obturation group were scanned twice using micro-CT scan. The resultant images were rendered in proprietary software (NRecon version 1.6.9.4) to obtain three-dimensional (3D) pre- and post-obturation records of each specimen. The 3D images were imported into CT Analyser version 1.17.7.2 for volume measurement of voids and gaps in the apical third at 1 mm, 3 mm, and 5 mm. The analysis of variance test was used to compare the mean volume of voids and gaps between the two obturation groups in each level in the apical third (1 mm, 3 mm, and 5 mm). Furthermore, it was used to compare the mean volume of voids and gaps between the three different levels apically in each obturation technique. Results: CW obturation technique had more voids volume at the three different apical levels (1 mm: 0.19 ± 0.16, 3 mm: 0.76 ± 0.81, and 5 mm: 1.36 ± 1.44) compared to CL condensation technique at the same three levels (1 mm: 0.14 ± 0.21, 3 mm: 0.46 ± 0.46, and 5 mm: 1.10 ± 0.93) with no statistical significant difference between them (P < 0.05). Conclusions: None of the root canals filled teeth were voids-free, and there was no statistically significant difference between the two obturation techniques regarding the gaps volume apically.

In vitro assessment of human enamel surface composition bleached with two different bleaching agents Nazish Fatima Ahmed Saudi Journal of Oral Sciences 2019 6(1):13-17 Background: Varieties of methods are available for more obstinate tooth discoloration such as crowns, veneer, and micro and macro abrasion of enamel, but tooth bleaching gained high patient acceptance. The aim of the present research was to estimate changes in surface enamel composition after bleaching 16% carbamide peroxide (CP) (home-use bleaching) with 38% hydrogen peroxide (HP) (in office bleaching). Materials and Methods: A total of 90 enamel slabs from 45 sound human third molars were randomly divided into three groups. Of three groups, per group had thirty samples (n = 30), of which samples of Group 1 were placed in artificial saliva at 37°C in incubator (Memart, Germany) during complete experiment. Sample of Groups 2 and 3 was treated with power whitening gel (White Smile 2011, Germany) and tooth whitening pen (white Smile 2011, Germany), respectively. Later on, after bleaching treatment, discs were thoroughly washed and stored in artificial saliva at 37°C in incubator. Chemical analysis was done with energy dispersive spectroscopy (Edx) detector to detect changes in surface composition. Results: Energy dispersive X-ray spectroscopy (Edx) analysis showed no significant difference between all the three groups for Ca% mass (P > 0.99) and Ca% atomic (P > 0.99), C% mass (P = 0.78) and C% atomic (P = 0.76), and O% mass (P > 0.99) and O% atomic (P = 0.28). Similar results were shown for Na, Mg, P, and F. Conclusion: Statistically insignificant effect was observed on enamel composition with both bleaching agents (38% HP and 16% CP).

Oral health-related quality of life and associated factors of elderly population in Port Harcourt, Nigeria Omoigberai Bashiru Braimoh, Grace Onyenashia Alade Saudi Journal of Oral Sciences 2019 6(1):18-24 Aim: The objective of this study was to assess the impact of oral health on quality of life in a representative sample of elderly population in Port Harcourt, Nigeria, and to evaluate its associations with dental caries, periodontal disease, subjective oral measures, and sociodemographic factors. Subjects and Methods: The study was a cross-sectional observational research design. Participants were selected by systematic random sampling, and data were collected using a self-developed questionnaire and oral examination. Data analysis was done using SPSS version 20. Chi-square and logistic regression analysis was used to establish association between variables. Significance was determined at 95% confidence interval and statistical significance inferred at P < 0.05. Results: The prevalence of negative impact of oral health on quality of life was 38.1%. The mean Oral Health Impact Profile-14 score was 11.15 ± 8.36; the highest mean was recorded for physical pain (2.87 ± 1.17). Painful aching, 48.1%, was the highest impact on quality of life experienced by the participants. Female gender, younger elderly, poor self-perception of oral health, dental caries, and periodontitis produced a higher significant negative impact of oral disease on the quality of life. Conclusion: The prevalence of negative impact recorded in this study was comparable to that obtained in other similar studies. The study revealed that sociodemographic variables and subjective and clinical oral measures impact significantly on the oral health-related quality of life of the participants. The study suggests the need for these factors to be considered when planning oral health intervention program for the elderly.

Oral cancer awareness, knowledge, and practices among Saudi general dentists Zayed Ali Assiri, Abdulrahman Ahmed Alshehri, Alia Khalid Alfadhel Saudi Journal of Oral Sciences 2019 6(1):25-30 Objectives: The present study aimed to investigate oral cancer (OC) awareness, knowledge, and practices among Saudi general dentists. Materials and Methods: We included dentists who were recognized and licensed by the Saudi Commission for Health Specialties. They were e-mailed officially with a 28-item questionnaire and constructed to investigate the study objectives. Results: The final sample included 326 dentists. About 85.6% of the participants reported their awareness; this was confirmed when similar percentage (87.4%) stated that there are etiological factors other than tobacco and alcohol for OC. Only 34.7% of the participants had sufficient knowledge concerning the prevention and detection of OC. Concerning the referral, 53.4% referred their patients to oral medicine specialist. Conclusions: Our findings revealed that chances exist to improve the knowledge, increase awareness, and develop right practices toward OC. Furthermore, our results revealed that dentists believed their knowledge was insufficient to detect OCs, although most of them showed reasonable level of knowledge about some aspects of diagnosing OCs. All these emphasize general dentists' role in the prevention and diagnosis and the need to improve dentists' knowledge and practices toward OC.

Association of nutritional status and dental health among 3–6-year-old children of a South Indian population KL Girish Babu, Priya Subramaniam, KS Madhusudan Saudi Journal of Oral Sciences 2019 6(1):31-36 Background: Nutrition promotes healthy development and maintenance of oral health. Chronic malnutrition affects tooth exfoliation and renders the permanent teeth susceptible to caries.Aim: To assess the nutritional status and dental health in 3–6-year-old children.Materials and Methods: A cross-sectional epidemiological study was conducted on a representative sample of 1459 children, aged 3–6 years, and visiting the Integrated Child Development Centers (anganwadi) of T. Narasipura Taluk, Mysore, India. Nutritional status was evaluated by measuring body mass index (BMI) and mid-upper arm circumference (MUAC). Oral examination was carried out using a noninvasive technique with the child sitting in an upright position under good natural light. Dental caries, enamel hypoplasia, and oral mucosal status were recorded according to the WHO criteria. Results: Nutritional status according to BMI showed 41% of children to be underweight and according to MUAC only 0.82% of children were undernourished. A highest (41.7%) number of underweight children were seen in 3–4 years age group, with a higher number of females being affected. The prevalence of dental caries was 61.07% and was highest in 3–4 years age group. More number of females were affected with dental caries than males. The prevalence of enamel hypoplasia was 8.7%. Association of dental health status with BMI was significant with dental caries. Conclusions: Forty-one percent of children were underweight and the prevalence of underweight children increased with age. The prevalence of dental caries and enamel hypoplasia were 61% and 8.7%, respectively.

Root canal retreatment of permanent mandibular second molar with extruded foreign particles Yousef Hamad Al-Dahman, Abdullah Yousef Al-Hawwas, Asma Suliman Al-Jebaly Saudi Journal of Oral Sciences 2019 6(1):37-40 This article describes a successful management of permanent mandibular second molar presented with extruded foreign particles. Root canal foreign bodies in or beyond the root canal system may affect the treatment outcome. Attempts for removal of such materials are challenging and can jeopardize the tooth structure. Therefore, a proper diagnosis and treatment planning for such cases is critical to achieving adequate outcomes.

Dental and craniofacial anomalies associated with Axenfeld–Rieger syndrome Amit Khatri, Prerna Beniwal, Namita Kalra, Rishi Tyagi Saudi Journal of Oral Sciences 2019 6(1):41-44 Axenfeld–Rieger syndrome (ARS) is a rare, autosomal dominant disorder with genetic and morphologic variability and characterized by ocular and nonocular clinical findings. Midface hypoplasia and maxillary hypodontia are classical presenting features of this syndrome. This case report describes a dental condition, immediate treatment required and a long-term treatment approach toward a patient 5-year-of-age with ARS, who presented with significant ocular and dental anomalies.

Clinical Ophthalmology

Live surgical broadcasts: Are there some lessons to be learned from the Johnson and Johnson's articular surface replacement hip implant case? Jatinder Bali, Renu T Bali Journal of Clinical Ophthalmology and Research 2019 7(1):1-3

Clinical study of efficacy of probing as a treatment for epiphora in adults CV Kavitha, Sahana R Manipur, Pavana Acharya, BR Lakshmi Journal of Clinical Ophthalmology and Research 2019 7(1):5-7 Background/Context: Probing is a simple operative procedure, can be performed easily in adults under local anesthesia, and is associated with minimal postoperative morbidity. The study aimed to determine the efficacy of probing in adults with epiphora due to common canalicular block (CCB) and nasolacrimal duct obstruction (NLDO). Materials and Methods: A prospective, interventional study was conducted on 44 patients with epiphora. Probing was done through upper and lower canaliculus under local anesthesia in all patients with epiphora due to CCB and NLDO. Probing was considered successful if the epiphora had been resolved or reduced to an acceptable level and if the lacrimal system was patent on lacrimal syringing for 6 months. Results: Patients comprised 36 women and eight men with the age group between 25 and 80 years who had epiphora for 3–24 months. Twenty-six patients had common CCB and 18 had complete NLDO. Complete patency was achieved in 12 and 5 and partial patency in 9 and 6 patients with CCB and NLDO, respectively. Treatment was successful in 72.72% of the patients. Ten patients underwent uneventful cataract surgery and 12 failed cases needed dacryocystectomy. Conclusion: Since probing is a simple, quick, cost-effective, and daycare procedure with low morbidity and obviates the need for further nasolacrimal surgery, probing can be recommended as an initial treatment in adults with epiphora.

Visual outcome of difficult cataract surgeries in a tertiary care center in India Ranjana Pande, Smita Mohod Harne, Namrata Bhuta Journal of Clinical Ophthalmology and Research 2019 7(1):9-11 Purpose: The purpose of this study is to determine the percentage of difficult cataracts out of total cataracts admitted in a tertiary care center, to study the intra- and postoperative complications in patients with difficult cataracts undergoing cataract surgery, and to determine their visual outcomes. Materials and Methods: This is a retrospective, noncomparative, single-institutional, observational study. The study was conducted on patients who were admitted over 2 years (January 2013–December 2014). Of these, patients with difficult cataracts (according to inclusion criteria) were screened and preoperatively evaluated. These patients underwent manual small incision cataract surgery and were followed up on the 1st, 7th, and 40th postoperative days. These cases were monitored for postoperative visual acuity (VA) and complications. The postoperative complications were graded according to the Oxford Cataract Treatment and Evaluation Team (OCTET) definitions and analyzed. Results: Of 5766 patients, 1858 (32.2%) patients presented with difficult cataracts. Hypermature and mature cataracts (24.9%), hard cataracts (20.02%), and pseudoexfoliation (33.04%) constituted as the major causes. Of these, 820 (44.1%) patients presented with no complications postoperatively. According to the OCTET grading, 44.9% of patients had Grade I, 9.5% had Grade II, and 1.83% had Grade III complications; the most common postoperative complication was corneal edema (39.2%). A total of 21.9% had VA <6/60 on postoperative day 1, which reduced to 5.27% on day 40 (P < 0.001). The patients with V/A >6/18 increased from 44.1% on day 1 to 61.8% on day 40 (P < 0.001). Conclusion: Visual morbidity remains high among patients with difficult cataracts, especially in patients with pseudoexfoliation and corneal pathology. Patients with hypermature cataract and Grade III–IV cataracts have a better visual outcome.

Choroidal thickness in type 2 diabetic patients with various stages of diabetic macular edema and retinopathy: A prospective study from central India Shilpi H Narnaware, Prashant K Bawankule, Dhananjay V Raje, Moumita Chakraborty Journal of Clinical Ophthalmology and Research 2019 7(1):12-17 Background: The objective of this study is to assess the changes in choroidal thickness in patients with type 2 diabetes with diabetic macular edema (DME) and diabetic retinopathy (DR), using enhanced-depth imaging (EDI) spectral domain optical coherence tomography (OCT). Materials and Methods: A total of 164 eyes from 104 patients were divided into no DR, DR without DME, and DR with DME. Eyes were also divided according to subtypes of DME. Subfoveal choroidal thickness (SFChT) and parafoveal choroidal thickness (PFChT) at 500 μm, 1000 μm and 1500 μm were measured using EDI-OCT and compared across groups. Results: A sample of 104 patients with diabetes consisted of 28 females and 76 males. The adjusted mean SFChT was 266.1 ± 42.40 μm in no DR eyes, 258.32 ± 39.52 μm in DR without DME eyes, and 246.11 ± 35.42 μm in DR with DME eyes (P = 0.028). The adjusted mean SFChT was 242.5 ± 33.04 μm in spongy edema eyes, 242.05 ± 39.73 μm in cystic edema eyes, and 247.9 ± 39.54 μm in serous retinal detachment eyes (P < 0.006). Conclusions: In eyes with DR, there is an overall thinning of the choroid on EDI-OCT. The subfoveal choroid was significantly thinner in eyes with DR and DME, specifically in cystic type of DME, as compared to those without DR. A decreased choroidal thickness may lead to tissue hypoxia and consequently increase the level of vascular endothelial growth factor, resulting in the breakdown of the blood-retinal barrier and development of macular edema.

Reduction in preexisting against the rule astigmatism in temporal manual small incision cataract surgery: Can curvilinear incision be a better choice? Karunanithy Palanisamy, P Amudha, R Amudhavalli, Ramalingam Munisamy, Arun Tipandjan Journal of Clinical Ophthalmology and Research 2019 7(1):18-21 Background: To address the issue of ATR astigmatism in patients who undergo temporal manual small incision cataract surgery (MSICS) surgery. Aim: The aim is to find out whether an incision that is made parallel to the limbus (curvilinear) while doing temporal MSICS can reduce the preexisting against-the-rule astigmatism (ATR). Settings and Design: The study was conducted on those patients who came for cataract surgery in a government general hospital. Materials and Methods: One hundred and five patients with cataract and ATR astigmatism of ≥1D were divided into three groups each with 35 patients. Group A patients underwent curvilinear incision temporal MSICS, Group B straight line incision temporal MSICS, and Group C limbal incision temporal phacoemulsification. The amount of change in ATR astigmatism in each group was calculated by comparing preoperative and postoperative keratometry readings. Statistical Analysis: All data were evaluated using SPSS version 19.0. To test the significant difference between pre- and post-operative astigmatism in each group, paired t-test was used. To test the significant difference in astigmatism between the three groups, ANOVA was used. Results: The reduction in the mean astigmatism in Group A was 0.89D, in Group B 0.62D, and in Group C 0.086D. The significant reduction of the ATR astigmatism in Group A and Group B could be due to the flattening of the horizontal curvature which is higher in patients with ATR astigmatism. Among these two groups, the curvilinear incision produced more flattening than the straight line incision. Conclusion: If a curvilinear (limbus parallel) is done while doing temporal MSICS in patients with higher ATR astigmatism, there can a significant reduction of ATR astigmatism giving a better uncorrected visual acuity.

Multiple retained intraocular glass foreign body with late-onset retinal detachment Prabhushanker Mahalingam, Tasneem Topiwalla, Geetha Ganesan Journal of Clinical Ophthalmology and Research 2019 7(1):22-24 Successful management of intraocular foreign body (IOFB) is deemed possible by the advent of superior surgical procedures, even in those patients who present late. We report a case of a 46-year-old male, who presented with sudden onset of defective vision in his right eye of 2 days duration and with a previous history of trauma following bulb blast at the age of 5 years. Examination revealed retinal detachment with multiple intraocular glass foreign body in his right eye. The primary management, in this case, was phaco-aspiration of lens through limbal tunnel, scleral buckling, 23G pars plana vitrectomy, IOFB removal through anterior segment, endolaser, and silicone oil injection. After 6 months, silicone oil was removed, and posterior chamber intraocular lens was implanted. This is a rare case wherein multiple glass IOFBs had remained quiescent in the eye for more than four decades resulting in retinal detachment at a later date and successful management with good visual outcome was possible.

Keratoactinomycosis: A rare case report Pradnya Krishnakant Bhole, Dipali P Parmar Journal of Clinical Ophthalmology and Research 2019 7(1):24-26 A 50-year-old female farmer, with a history of vegetative trauma, presented to a tertiary eye care center, with right eye ulcerative keratitis, initially treated elsewhere as fungal keratitis, refractory to conventional antifungal therapy. A corneal scraping was done and it revealed Gram-positive filamentous Actinomyces bacteria. Treatment with topical penicillin (100,000 U/ml) showed a complete resolution of the corneal infection, within 2 weeks of therapy. Actinomyces keratitis is a rare clinical condition. A history of ocular vegetative trauma, with a clinical picture similar to fungal keratitis, leads to delay in the diagnosis of such rare presentations of posttraumatic keratoactinomycosis, which otherwise shows a good response to topical penicillin therapy. A corneal scraping done helps in timely diagnosis and effective treatment.

Malingering versus dissociative disorder: A clinical dilemma!! Shobha G Pai, Madhurima Nayak, Jayanthi Kalary, SS Krithishree Journal of Clinical Ophthalmology and Research 2019 7(1):27-29 Malingering and dissociation coincide with the mode of presentation. Dissociation and attention-deficit hyperactivity disorder (ADHD) can coexist due to their similar etiology. We report a case of dissociative disorder in a boy with ADHD presenting with sudden visual diminution. To our knowledge, though common, such case has not been reported in the literature. A 9-year-old boy, a case of ADHD on atomoxetine (25 mg) and risperidone (0.25 mg), was brought by his apprehensive mother, with sudden diminution of vision in his right eye for 1 week. On examination, his visual acuity was 20/120 in the right eye and 20/20 in the left eye, even on repeating with various charts. His anterior segment, fundus, and cycloplegic retinoscopy were normal. Visually evoked potential was normal in both the eyes. With a suspicion of malingering, +20D in front of the left eye. The test was positive for malingering, and the mother was reassured. The kid was sent to the psychiatry department for further counseling. They diagnosed it as a dissociative disorder. Simple tests for malingering still have an important role in ophthalmology. Children cannot be underestimated in their ability to malinger, but at the same time, dissociative disorder should be borne in mind before labeling a patient as a case of malingering. Because once the label of malingering is given, then it is a human tendency to form a prejudice idea about that patient and later that the patient would not get proper medical assistance.

Smartphone-based monochromatic green filter fundus imaging Ashish A Ahuja, Olukorede O Adenuga Journal of Clinical Ophthalmology and Research 2019 7(1):30-30

Incidence of various causes of infectious keratitis in the part of rural central India and its visual morbidity: Prospective hospital-based observational study Pratik Narendra Mohod, Archana Sunil Nikose, Pradnya Mukesh Laddha, Shadwala Bharti Journal of Clinical Ophthalmology and Research 2019 7(1):31-34 Introduction: Infectious keratitis is potential causes for vision loss in India. Early recognition with prompt diagnosis and rapid institution of appropriate therapy will significantly improve visual prognosis. Aim: The aim of this study was to evaluate the incidence of various causes of infectious keratitis in this part of rural central India, predisposing factor and visual morbidity. Materials and Methods: This was a prospective observational hospital-based study conducted at the Department of Ophthalmology, at a tertiary care hospital, in the part of rural central India. Data related to socioeconomic status, predisposing factor, and course of disease was collected. Results were analyzed on the basis of history, slit lamp examination, and appropriate laboratory investigation. Results: During the period of January 2015 to February 2017 total 680 patients were examined in cornea specialty clinic, of which 88 were diagnosed with infective keratitis and were included in the study. Majority of patients of infectious keratitis were in between 41 and 60 (41%) age group followed by 21–40 (23%) and incidence in male was higher (61%) as compared to female. Prevalence of Fungal keratitis (59.09%) was higher than bacterial (19.31%) and viral (17.04%) in this part of India. Ocular trauma and occupational accidents were the most common (42%) among farmer. Majority of corneal ulcer (68%) healed, 11% had no change in ulcer status, 4% was progressed, and 10% perforated. About 53% had stable best-corrected visual acuity (BCVA) as compared to BCVA at the time of presentation and in 34% BCVA improved. Conclusion: Incidence of fungal corneal ulcer is higher among various causes of infectious keratitis in this part of rural central India. Agricultural injuries are the main predisposing factor for infectious keratitis in this region. Prompt diagnosis and early appropriate treatment on the basis of laboratory investigation can helps the community to reduce the burden of corneal blindness.

Chest Diseases and Tuberculosis

Dilemma of community-acquired pneumonia Lamia H Shaaban The Egyptian Journal of Chest Diseases and Tuberculosis 2019 68(1):1-4 The lungs are particularly susceptible to infection, owing to continuous direct interaction with the external atmosphere in the process of gas exchange, and many anatomical facts, such as the presence of the pharynx, which constitutes a common pathway for both of the lung and stomach. With the process of development of many new generations of antibiotics, pneumonia still continues to be an important unsolved problem worldwide. Community-acquired pneumonia is still considered a problem and is associated with significant morbidity and mortality with cost load, especially with the emergent pathogens that presented with aggressive pictures of community-acquired pneumonia.

Prognostic values of neutrophilic count and neutrophil–lymphocyte ratio among chronic obstructive pulmonary disease patients admitted with acute exacerbation Ibrahim Dwedar, Mohamed Ali, Hossam M Abdel-Hamid The Egyptian Journal of Chest Diseases and Tuberculosis 2019 68(1):5-8 Introduction Chronic obstructive pulmonary disease (COPD) is characterized by chronic inflammatory pathway with neutrophils and lymphocytes representing the main cells of inflammation. Patients and methods A prospective study was designed to assess the neutrophilic count as well as neutrophil–lymphocyte ratio (NLR) as predictors of mortality among patients admitted in the hospital with acute exacerbation COPD. Fifty COPD patients were admitted to Ain Shams Hospital complaining of acute exacerbation. They were followed up during their course inside the hospital with routine blood tests assessment. Results From the 50 patients admitted, eight patients died along their in-hospital course. No differences regarding their ages and sex. Total leucocytic count (TLC), neutrophilic count, lymphocytes, and NLR were found to be significantly higher in the nonsurvival versus the survival groups. Mean C-reactive protein values showed no significant difference between both the subgroups. The nonsurvival group tend to stay more days in the respiratory care unit in comparison to the survival group. Conclusion The neutrophilic count and the NLR were strongly valuable inflammatory markers with reported higher sensitivity and specificity in predicting the mortality among COPD patients admitted for acute exacerbation.

Does vitamin D deficiency worsen the hospital outcome in patients with acute exacerbation of chronic obstructive pulmonary disease? Mohamed F Abdel Ghany, Hoda A Makhlouf, Aliae A.R.M Hussein, Amal A Mahmoud The Egyptian Journal of Chest Diseases and Tuberculosis 2019 68(1):9-13 Background There are limited data about the hospital outcome in hospitalized patients diagnosed as chronic obstructive pulmonary disease (COPD) with concomitant deficiency of vitamin D. Objectives To assess the level of serum 25-hydroxyvitamin D in patients with severe exacerbation of COPD and to find if there is any correlations between vitamin D and clinical, functional parameters, as well as survival, days of hospital stay, and need for ICU admission. Patients and methods In this case–control study, 60 patients with acute exacerbation COPD requiring hospital admission were recruited and 24 healthy controls. Chest radiography, spirometry, arterial blood gases, 6 min walking distance, modified Medical Research Council dyspnea scale, and St George Respiratory Questionnaire were assessed. Serum 25-hydroxyvitamin D level was measured by enzyme-linked immunosorbent assay. Results About 90% COPD patients had vitamin D deficiency. Serum vitamin D levels were statistically significantly lower in COPD with and without comorbidities when compared with normal controls (P<0.001) but COPD with or without comorbidities did not differ statistically (P>0.05). No significant correlation was found between serum 25-hydroxyvitamin D and survival; days of hospital stay or need for mechanical ventilation. As well, no significant correlation between vitamin D and forced expiratory volume in the 1 s %, 6 min walking distance, modified Medical Research Council, or St George Respiratory Questionnaire scores was found. Conclusion Vitamin D deficiency is found in most COPD patients. However, in patients suffering from severe exacerbation, the presence of low vitamin D levels did not have any effect on survival, days of hospital stay, or need for mechanical ventilation.

Assessment of prevalence of active pulmonary tuberculosis among patients with ocular tuberculosis Heba A Eshmawey, Eiman M Abd El Latif, Hadir A.S Okasha The Egyptian Journal of Chest Diseases and Tuberculosis 2019 68(1):14-23 Background Tuberculosis (TB) is considered a multisystemic disease showing many extrapulmonary presentations. TB uveitis is one of the common forms of extrapulmonary TB. The lung is still the first organ to be attacked by TB, and pulmonary TB is the only infectious form of the disease. Aim The aim of the study was to detect the prevalence of active pulmonary TB among patients with TB uveitis. Patients and methods The present study included 37 patients with diagnosis of ocular TB on the basis of previous history, ocular examination, and exclusion of other suspected causes of uveitis. In addition, positive tuberculin skin test, or positive interferon-gamma release assays were carried out. All included patients were subjected to sputum examination for acid-fast bacilli and plain radiography of chest P-A view, and certain cases had a bronchoalveolar lavage. Patients with active pulmonary TB were detected. Both groups (patients with active pulmonary TB and patients with free chest) were compared with regard to all the previously mentioned studied parameters. Results The mean age of the studied patients was 34.8±12.5 years. All the studied patients showed positive tuberculin test with a mean of 18.5±3.4 mm. With regard to the Quantiferon Gold test, 34 patients (91.9%) had positive results. Concerning radiography, only 10 (27%) patients had normal radiograph, the rest of the patients showed various radiological lesions. Thirty (81.1%) patients were diagnosed to have active pulmonary TB. Sputum examination for acid-fast bacilli revealed that 22 (59.5%) patients had positive results; an additional eight patients (who had negative results on sputum examination) showed positive results when they underwent a bronchoalveolar lavage. There was no statistically significant difference with regard to all the previously mentioned parameters between patients with active pulmonary TB and patients with a free chest. Conclusion The present study revealed that a considerable percentage of the patients with TB uveitis had active pulmonary TB.

Treatment outcomes of patients on non-Revised National Tuberculosis Control Programme (private) anti-tuberculosis regimen from a tertiary-care centre in Kerala, India Akhilesh Kunoor, Rakesh Purushothama Bhat Suseela, Mithula Raj, Rajesh Chemmarissery Thankappan, Ponneduthamkuzhi Thomas James The Egyptian Journal of Chest Diseases and Tuberculosis 2019 68(1):24-27 Introduction Although standardised tuberculosis (TB) treatment in India is delivered by the public sector through the Revised National TB Control Programme (RNTCP), majority of patients in the country are treated with private anti-TB drugs. The objective of the study was to assess the treatment outcome of patients initiated on non-RNTCP regimen from a private tertiary-care centre from January to June 2016. Patients and methods A nonconcurrent cohort study was done which followed up the patients who have been initiated on private anti-TB regimen from a private tertiary-care centre in Kerala, India, during the first and second quarter of 2016. Details of further visits were sought from the hospital health management information system. A phone call interview was done with all patients, 9–12 months after treatment initiation. Results There were 81 patients who were initiated on private anti-TB regimen. Of them, 26 were of pulmonary TB and 55 were of extrapulmonary tuberculosis (EPTB). Among pulmonary TB, 17 (65.38%) cases and in EPTB, 41 (74.54%) cases had successful treatment outcome. The overall success of the non-RNTCP regimen was 71.6%. In pulmonary TB, six (23.1%) cases and in EPTB 11 (20%) cases came under lost to follow-up category. Conclusion The results calls for urgent actions to have a system in place for tracking patients initiated on private anti-TB drugs so as to ensure the standards of TB care. The national programme may further strengthen monitoring of treatment adherence in private sector with established ICT-based treatment support models.

Raised dsDNA autoantibodies in tuberculosis patients Faheem Shahzad, Atia Ali, Abid Mushtaq, Khursheed Javaid, Afzaal Nazir, Amna Pervez, Mohammad Kashif, Noman Bashir, Afia Abbas, Romeeza Tahir, Shah Jahan, Nadeem Afzal The Egyptian Journal of Chest Diseases and Tuberculosis 2019 68(1):28-31 Background Tuberculosis (TB) is caused by Mycobacterium tuberculosis. M. tuberculosis can become dormant, resist the hostile environment of the phagosome, and trigger a delayed-type hypersensitivity reaction leading to chronic infection and granuloma formation. In granulomas, destruction of tissues results in the release of intracellular self-antigens that may provoke the development of autoantibodies. Therefore, the present cross-sectional study was conducted to detect anti-dsDNA antibodies in local TB patients. Patients and methods In all, 160 patients were recruited for this comparative study. Anti-dsDNA antibodies were detected by enzyme-linked immunosorbent assay. Independent Student’s t test was used to compare mean anti-dsDNA values between TB patients and healthy individuals. A p value less than or equal to 0.05 was considered as statistically significant. Results Anti-dsDNA antibodies were high in TB patients as compared with healthy controls and the difference between the two groups was statistically significant (P<0.0001). No significant association of dsDNA autoantibody between TB patients and healthy controls was obtained. Similarly, no significant association of dsDNA autoantibodies was obtained in drug resistance TB patients and TB patients without drug resistance. Conclusion Increased level of dsDNA autoantibody was detected in TB patients and its level was clinically significant in TB patients, but no association of this autoantibody was established with TB.

Hurdle in the eradication of tuberculosis: delay in diagnosis Jayasri H Gali, Harsha V Varma, Aruna K Badam The Egyptian Journal of Chest Diseases and Tuberculosis 2019 68(1):32-38 Objective Identifying the factors responsible for the delay in the diagnosis of tuberculosis (TB). Patients and methods In this retrospective study, data on pulmonary and extrapulmonary forms of TB, registered for the treatment at the directly observed treatment, short course, centre were analysed. Results Of 163 patients, 34 (20.86%) were diagnosed at the first visit. The delay in seeking medical care ranged from 0 to 25 days from the diagnosis. A total of 110 (67%) patients started on the same day or the day after diagnosis, less than 1 month in 33 (20.25%) and 1–3 months in 83 (51%). Delay from patient and health services (both combined) ranged from half a month to 48 months; the mean±SD diagnostic delay was 4.09±4.19 days (range: 0–24 days), whereas the mean±SD treatment delay (n=162) was 2.19±3.89 days. of the 124 patients who received medical help, 90% of them did so within six months of onset of Symptoms. There was a statistically significant difference in patients’ delay in receiving the treatment/medical care by sex. Mean±SD delay for pulmonary and extrapulmonary TB was 48±24 and 240±386 days, respectively. Conclusion Delay in diagnosis is a preventable factor. Patient delay is longer compared with healthcare delays. Active surveillance, even in the urban areas by healthworkers, may help in reducing this delay.

Role of echocardiographic tissue Doppler imaging in the assessment of myocardial diastolic dysfunction in children with diffuse lung diseases Waleed Mohamed Elguindy, Maryam Ali Abdelkader The Egyptian Journal of Chest Diseases and Tuberculosis 2019 68(1):39-43 Background Pulmonary arterial hypertension (PAH) is a common complication of prolonged diffuse lung diseases in children. It is considered a crucial factor of morbidity, mortality, and severity of the disease in these children. Conventional echocardiography is an indirect tool to assess pulmonary hypertension (PH) with a limited sensitivity compared with right heart catheterization and requires well-trained physicians. So, the aim of the current study was to determine the role of echocardiographic tissue Doppler imaging in the assessment of the effect of pulmonary hypertension on right ventricular functions in children with prolonged, diffuse lung diseases and if it can have a predictive role of the secondary right ventricular (RV) dysfunction in these children. Patients and methods This is a case–control study in which 40 children with diffuse lung diseases were recruited from the chest clinic, Ain Shams University Hospitals. The patients were classified into PH and non-PH groups according to the echocardiographic measurement of mean PAP greater than 25 mmHg. Results Patients with PAH had significantly higher RV stroke volume as well as indexed RV systolic and diastolic areas. Furthermore, these patients had significantly higher RV myocardial performance index and E/E′ ratio suggesting diastolic dysfunction as well as decreased compliance. Conclusion Although conventional echocardiography could detect changes in RV dimensions and stroke volume, tissue Doppler imaging could further highlight changes in RV diastolic functions as well as compliance secondary to PAH.

Functional evaluation of patients with progressive systemic sclerosis-associated diffuse parenchymal lung disease Ahmed A.A Hussieny, Yosri M.K Akl, Reem I Elkorashy, Amira I Mostafa, Doaa H Attia, Mohamed Faheem, Fatma E.-Z Ahmed The Egyptian Journal of Chest Diseases and Tuberculosis 2019 68(1):44-49 Background Interstitial lung diseases are common features in scleroderma that seem to add to the morbidity and mortality of the disease. Other complications that may occur with scleroderma are pulmonary hypertension. Aim to evaluate the functional status of patients with progressive systemic sclerosis-associated diffuse parenchymal lung disease. Methodology A total of 44 adult patients with a confirmed diagnosis of scleroderma were included. The disease severity was assumed by using the grading of the inter-incisor distance and finger-to-palm distance. Assessment of the chest high-resolution computed tomography (HRCT) was performed, and then functional assessment in the form of arterial blood gas, spirometry, 6-min walk distance, and echocardiography was performed. Results There were no significant differences between the scleroderma with diffuse parenchymal lung disease and those with normal HRCT regarding the measured and calculated parameters, except for the pulmonary artery systolic pressure, which was significantly higher in the normal HRCT group than those with interstitial lung disease.

Idiopathic pulmonary fibrosis and subclinical hypothyroidism: an underestimated comorbidity Heba H AboElNaga, Alyaa A ElSherbeny, Emad A AbdelHady The Egyptian Journal of Chest Diseases and Tuberculosis 2019 68(1):50-56 Background Idiopathic pulmonary fibrosis (IPF) is the most damaging and mysterious form of lung fibrogenesis, with worldwide growing prevalence and mortality. Subclinical hypothyroidism (SCH) is evidenced that its prevalence is still higher in patients with IPF. Objectives To study the incidence of SCH in patients with IPF in comparison with the controls with a focus on the different clinical characteristics and spirometry measurements. Patients and methods The research involved 50 patients who were diagnosed as IPF and 30 healthy participants, enrolled from the outpatient clinic departments of pulmonary medicine of October 6 University Hospital. The patients performed spirometry tests, high-resolution computed tomography chest, and thyroid function test. Results There were significant differences in spirometry data and thyroid-stimulating hormone level between the IPF and the control group, indicating more prevalence of SCH in IPF patients. IPF patients diagnosed with SCH have a significant decline in some spirometry measurements than those with IPF only. Conclusion The prevalence and clinical outcomes of SCH in patients with IPF certainly require advanced research, since the thyroid function tests were not done regularly for most patients with IPF. This study intensely proposes that in future encouraging management should be further studied to enhance the prognosis of IPF patients.

Surgery

Surgical strategies to reduce recurrence in Crohn's disease Charlotte Austin, Randolph M Steinhagen World Journal of Colorectal Surgery 2019 8(1):1-3 Almost from the time of initial description of Crohn's disease 85 years ago, it has been known that surgical resection is not curative. The disease invariably recurs. Over this period of time, numerous strategies have been proposed in an attempt to reduce the recurrence rate, or delay the development of recurrent disease. The purpose of this review is to examine a number of strategies and to evaluate their effectiveness. It also aims to look at what might lie ahead in the future. This review consists of an English language literature search to identify previous studies that have proposed various surgical strategies to reduce the recurrence rate following surgery for Crohn's disease. A number of surgical strategies have been proposed including widening the resection margins, changing the type of anastomosis, use of laparoscopy, and most recently, resecting wide mesenteric margins. To date, none of these strategies has proven to be effective in reducing recurrence rates. Although a surgical strategy to reduce recurrence in Crohn's disease has not been identified, there are currently investigators looking at other possibilities that may be shown to be effective in the future.

Evaluating the efficacy of biofeedback for chronic constipation using the constipation severity instrument and constipation-related quality of life measure Yuan-Tzu Lan, Lillian G Jahan, Madhulika G Varma World Journal of Colorectal Surgery 2019 8(1):4-9 Background: Many studies have described using biofeedback to treat chronic constipation, but few reports have addressed its impact on quality of life (QOL). Objective: The aim was to evaluate the effect of biofeedback with a validated Constipation Severity Instrument (CSI) and Constipation-Related QOL (CRQOL) measure. Design: Prospectively collected data with retrospective analysis. Setting: Tertiary care academic center. Patients and Methods: Patients referred to the Center for Pelvic Physiology with chronic constipation and objective signs of pelvic floor dyssynergia, who received a complete course of biofeedback therapy and returned all of their questionnaires, were enrolled in the study. Questionnaires were given upon initial evaluation, immediately after the complete course of biofeedback, and 6 months later. Main Outcome Measures: Improvement of dyssynergia symptom and QOL by CSI and CRQOL. Sample Size: A total of 25 patients (20 females and 5 males) were included. Results: Overall, 75% of patients reported satisfactory symptom and QOL improvement. CSI total scores decreased after treatment (35.0 vs. 31.0, P = 0.06) and at 6-month follow-up (35.0 vs. 30.0, P = 0.05). Only the obstructive defecation (OD) subscale of CSI improved significantly after treatment (median 21.0 vs. 16.5, P < 0.01) and sustained to 6 months after therapy (median 21.0 vs. 18.5, P = 0.03). Statistically significant improvement was seen in the distress subscale of the CRQOL immediately after biofeedback (24.0 vs. 18.0, P = 0.02). Conclusions: This study demonstrated that the active effects of biofeedback in constipated patients were specific to OD symptoms and the distress subscale for QOL. CSI and CRQOL are both useful tools to evaluate the specific response of constipated patients after biofeedback therapy. Limitations: The study limitation was the small sample size due to difficulty in obtaining complete information in the enrolled patients.

Outcomes in cecal volvulus: Does age affect outcomes in patients who undergo surgery? Ashley M Tameron, Amy E Murphy, Lala R Hussain, David Lee, Hamza Guend World Journal of Colorectal Surgery 2019 8(1):10-13 Background: Colonic volvulus is a rare cause of bowel obstruction with an incidence of 2%–10%. Cecal volvulus accounts for 10%–40% of cases, with a mean age of 53 years. There is a paucity of literature reporting how older patients with cecal volvulus fair relative to their younger counterparts. Objective: The goal of our study is to evaluate the outcomes after surgical resection in patients ≥50 years old with cecal volvulus. Design: The design of the study was to collect the National Surgical Quality Improvement Program (NSQIP) data and analyze primary outcomes. Settings: These data were collected from NSQIP database focusing on patients with cecal volvulus. Materials and Methods: We utilized the NSQIP database. We identified volvulus by ICD-9 code 560.2. We selected patients with cecal volvulus who underwent surgical resection by specifying the CPT codes for open and laparoscopic right hemicolectomy. Main Outcome Measures: The primary outcomes were mortality and major and minor postoperative complications. Student's t-test was used to compare continuous variables. Chi-square and Fisher's exact tests were used to compare categorical variables. Sample Size: Analyzing the NSQIP database from 2010 to 2015, 1220 patients were identified. Results: 21.8% of patients were <50 years old and 78.2% were ≥50 years old. Patients aged ≥50 years had higher rates of comorbid conditions. There was no significant difference in mortality between the two groups or major and minor complications. Patients aged ≥50 years had a longer length of total hospital stay, i.e., days from operation to discharge. Conclusion: Cecal volvulus is an uncommon reason for bowel obstruction with unclear outcomes in elderly patients in the literature. Our study demonstrates no differences in outcomes after surgical intervention for cecal volvulus. Limitations: Limitations of this study include large database collection and selection bias. As we specifically included right hemicolectomy, this excludes patients who underwent nonresection intervention.

Right versus left Colon cancer: Is there a difference in outcomes? Aris Plastiras, Evangelia Iosif, Georgia Georgiou, Amyn Haji, Asif Haq, Savvas Papagrigoriadis, Joseph W Nunoo-Mensah World Journal of Colorectal Surgery 2019 8(1):14-21 Background: Colorectal cancer is a major healthcare problem due to its high prevalence and mortality rates. Objective: The objective of the study is to delineate the relationship between the location of the colon cancer and the outcomes. Design: This is a retrospective, single-center study including patients diagnosed with right and left colon cancer from January 2010 to December 2015. Setting: Patients with no rectal or synchronous metastatic disease were included in the study. Diagnosis was confirmed following a computed tomography and colonoscopy. Patients and Methods: Four hundred and seventy-five patients with colon cancer were included; 226 right-sided tumors (RCC) and 249 with left-sided colon cancer (LCC) underwent surgery. Main Outcome Measures: We compared right- and left-sided tumors in terms of epidemiological, histological, clinical, and perioperative characteristics, and we also attempted to determine whether there is a difference in the overall and per stage survival. Sample Size: Four hundred and seventy-five patients with colon cancer. Results: Patients with colon cancer were analyzed, 226 (47.5%) with RCC and 249 (52.4%) with LCC underwent surgery. Patients with RCC were more likely to be women, older, and with more comorbidities. Furthermore, RCC were more likely to be poorly differentiated (29.65%, P < 0.001) and more locally advanced at the time of diagnosis (P < 0.001). Controlling the differentiation for each stage, there was no statistical significant difference between left and right survival and recurrence (P > 0.05). When stratified according to tumor stage, Stage II LCC had better overall survival (odds ratio [OR], 1.694, 95% confidence interval [CI], 1.015, 2.827) and Stage III LCC had a better overall survival (OR, 1.403, 95% CI, 1.007, 2.143), disease-free survival (OR, 1.293, 95% CI, 1.011, 1.714), and less cancer-related deaths (OR, 0.282, 95% CI, 0.080, 1.000). Conclusions: Comparing similar stages, patients with LCC appear to have better oncological outcomes irrespective of tumor differentiation. Limitations: Single-center, retrospective study without excluding patients with hereditary cancers. Oncological biomarkers were not available in all patients, and further analysis was not performed.

The hanging pouch Daniel J Wong, Michael Q Tran, Vitaliy Y Poylin World Journal of Colorectal Surgery 2019 8(1):22-23 Ileoanal pouch reconstruction can be complicated intraoperatively by the inability for the pouch to reach the anus in a tension-free manner. Here, a case is presented where standard “mesentery lengthening” procedures did not allow the pouch to reach the anus and thus the pouch was left hanging in situ resulting in pouch lengthening over several months and a successful anastomosis at a later date.

Leiomyoma of the sigmoid mesocolon associated to hemorrhagic infarct and high count of mast cells Carlo Lozano-Burgos, Claudio Etcheverry-Pizarro, Wilfredo Alejandro González-Arriagada, Paola Ochova-Gallardo World Journal of Colorectal Surgery 2019 8(1):24-26 Leiomyoma is a soft-tissue benign tumor and its occurrence in the mesocolon is extremely rare. We present a particular case of a leiomyoma of the sigmoid mesocolon of a 58-year-old man, associated to a hemorrhagic infarction treated surgically and without recurrences after 1 year of follow-up. The macroscopic, histopathologic, and immunohistochemical features are presented and discussed. The high mast cell count associated with a low rate of cell proliferation is a sign of the benign biological behavior in this entity and may be helpful hallmarks for the differential diagnosis with other gastroenterological neoplasia.

Rare complication of a common disease: Coccygeal osteomyelitis following Pilonidal sinus Mugdha Kowli, Pranav Mandovra, Gautam Zaveri, Roy Patankar World Journal of Colorectal Surgery 2019 8(1):27-29 Pilonidal sinuses commonly arise in the sacrococcygeal region. The common complications are local cellulitis, abscess formation which is related to the infectious process, and recurrence after surgery. They rarely evolve with osteomyelitis, meningitis, or malignant transformation. Coccygeal osteomyelitis as a direct complication of sacrococcygeal pilonidal sinus disease (PSD) is extremely rare with limited data. We report a case of complicated sacrococcygeal PSD with coccygeal osteomyelitis. It was managed with: wide local excision of the pilonidal sinus, coccygectomy, perineal musculature reconstruction, and defect closure by Limberg rhomboid flap.

Right hemicolectomy in a patient with heterotaxy syndrome Maxime Dewulf, Roel Beckers, Pieter Pletinckx World Journal of Colorectal Surgery 2019 8(1):30-33 In this communication, we present a first description of right hemicolectomy in a patient with heterotaxy syndrome (HS). A 78-year-old male was admitted to the outpatient clinic with complaints of dysphagia. Diagnostic workup revealed the presence of an esophageal web. On subsequent colonoscopy, a tumoral lesion was found in the ascending colon. Computed tomography scan illustrated abdominal situs ambiguous with right-sided polysplenia, right-sided stomach, and intestinal nonrotation. Furthermore, a preduodenal portal vein, azygos continuation of the inferior vena cava, and hemiazygos continuation of the left renal vein were observed. After careful assessment of the anatomy, a right hemicolectomy with radical lymphadenectomy was performed. HS consists of a rare and complex situs anomaly, with an abnormal arrangement of the thoracic and/or abdominal organs along the left–right axis. To our knowledge, right hemicolectomy has not been described in patients with HS.

Minimal Access Surgery

Is laparoscopic approach for wandering spleen in children an option? Gratiana Oana Alqadi, Amulya K Saxena Journal of Minimal Access Surgery 2019 15(2):93-97 Aim: Wandering spleen present generally as an acute abdomen after twisting of the splenic vascular pedicle. This study aimed to review the literature with regard to the management and outcomes of the laparoscopy in children with wandering spleen. Methods: The literature was reviewed for articles on PubMed with regard to the following search terms 'laparoscopy', 'wandering', 'spleen' and 'children'. The inclusion criteria included article only in the paediatric age group of 0–16. Articles that did not meet the inclusion criteria were excluded from the study. Results: The PubMed search from 1998 to 2016 identified 15 articles. There were 20 children with an age range from 2 to 16 years who underwent the laparoscopic procedure for wandering spleen. The median age was 8 years. Associated conditions were present in 45% of patients: gastric volvulus (n = 3), torsion of the distal pancreas (n = 3), splenic cyst (n = 2), mental retardation and myotonic dystrophy (n = 1). In two cases, the spleen was twisted around the pedicle and was non-viable, and therefore, a splenectomy was performed. Other 18 cases were managed by splenopexy using a 3–5-port technique. An extraperitoneal pocket was created using a balloon device in five patients. Fixation of the spleen was performed using a mesh in 10 cases and omentum in three cases. In one case, additional support was created by plicating the phrenicocolic ligament. Simultaneous gastropexy was performed in four patients. There were no post-operative complications. Conclusions: Wandering spleen is a rare entity and in the paediatric age group 10% cannot be salvaged for which splenectomy is the only option. Of the 90% that can be pexied, the literature has favoured the application of meshes followed by the extraperitoneal pockets and omental pouch. Laparoscopic splenopexy is feasible, with no reported conversions or complications.

The surgical outcome of minimally invasive pharyngo-laryngo-oesophagectomy in prone position Mariko Ogino, Yuma Ebihara, Akihiro Homma, Kimitaka Tanaka, Yoshitsugu Nakanishi, Toshimichi Asano, Takehiro Noji, Yo Kurashima, Soichi Murakami, Toru Nakamura, Takahiro Tsuchikawa, Keisuke Okamura, Toshiaki Shichinohe, Satoshi Hirano Journal of Minimal Access Surgery 2019 15(2):98-102 Purpose: Pharyngo-laryngo-oesophagectomy (PLE) which is mainly indicated for cervical oesophageal cancer or synchronous double cancer of the thoracic oesophagus and the pharynx or larynx, is extremely invasive. Since minimally invasive oesophagectomy (MIE) using video-assisted thoracic surgery has become popular recently, the procedure can be adopted to PLE. Moreover, the use of the prone position (PP) in MIEs has been increasing recently because technical advantages and fewer post-operative complications were reported. To assess the validity of PP, this study compared surgical outcomes of minimally invasive PLE (MIPLE) in PP with that in the left lateral decubitus position (LLDP). Patients and Methods: This study enrolled consecutive 15 patients that underwent MIPLE with LLDP (n = 7) or PP (n = 8) between January 1996 and October 2016. The patients' background characteristics, operative findings and post-operative complications were examined. Results: Eligible diseases are 5 cases of cervical oesophageal cancer, 9 cases of synchronous double cancer of the thoracic oesophagus and head and neck and 1 case of cervical oesophageal recurrence of the head-and-neck cancer. The patients' background characteristics were not significantly different. During surgery, thoracic blood loss was significantly lower in PP than in LLDP (P = 0.0487). Other operative findings and post-operative complications were not significantly different between the two groups. Conclusions: In MIPLE, the PP could reduce blood loss due to the two-lung ventilation under artificial pneumothorax and was associated with lower surgical stress than LLDP.

Laparoscopic ureterolithotomy: Experience of 60 cases from a developing world hospital Mudassir Maqbool Wani, Abdul Munnan Durrani Journal of Minimal Access Surgery 2019 15(2):103-108 Objective: Laparoscopic ureterolithotomy, which has been quoted to have a success rate equivalent to open ureterolithotomy for uretric stones, can be performed transperitoneally and retroperitoneally. The aim of the present study is to report our experience with laparoscopic retroperitoneal ureterolithotomy, its results and advantages in the current era of minimally invasive surgery in a developing country. Patients and Methods: It was a prospective study carried from May 2010 to December 2012. 60 patients diagnosed with upper and middle uretric calculi, with sizes more than 1 cm and with value of more than 1500 hu on CT Urography ,underwent laparoscopic retroperitoneal ureterolithotomy. Results: All patients underwent retroperitoneal laparoscopic ureterolithotomy successfully. The mean operative time was 64.53 min. The mean blood loss was 39.83 ml. 3 patients had minor intra-operative complications which were tackled on table. Post-operative complications developed in 3 patients, all minor. There were no major complications. The removal of drain was at (2.7 days). Mean hospital stay was of 3.3 days. Patients reported to their routine activities in 1.78 weeks. During follow-up 3 months later, CT urography revealed normal ureter in all cases. Conclusion: Laparoscopic retroperitoneal ureterolithotomy has low rate of conversion to open surgery and an acceptable overall complication rates. In selected patients with impacted, hard, large ureteral stones, which are likely to cause diffi-culty in endo-urological procedures, laparoscopic ureterolithotomy is a reason-able treatment option.

Short-term outcomes of minimally invasive surgery for patients presenting with suspected gallbladder cancer: Report of 8 cases Gerald Zeng, Nan Zun Teo, Brian K. P. Goh Journal of Minimal Access Surgery 2019 15(2):109-114 Introduction: Minimally invasive surgery (MIS) for gallbladder cancer (GBCa) has traditionally been discouraged, with limited studies reporting on its outcomes. The aim of this study was to evaluate the short-term outcomes of MIS for patients with GBCa or suspected GBCa. Methods: A retrospective study of 8 consecutive patients who underwent MIS for GBCa by a single surgeon over a 22-month period between 2015 and 2017. Results: Three patients underwent robotic surgery, while five underwent conventional laparoscopic surgery. Four patients presented with histologically proven GbCa detected incidentally after cholecystectomy. All 4 patients underwent resection of Segment 4b/5. Of these, 3 underwent hilar lymphadenectomy and 1 underwent hilar lymph node sampling. Four patients presenting with suspected GBCa underwent upfront extended cholecystectomy. Two patients who had malignancy on frozen section underwent hilar lymphadenectomy. The median operation time was 242.5 (range, 165–530) min, and the median blood loss was 175 (range, 50–700) ml. The median post-operative hospital stay was 3.5 (range, 2–8) days. There were no open conversion, post-operative morbidities and mortalities. Six had histologically proven GBCa. Five were T3 and one had T2 cancers. Conclusions: The results of the present study confirm the short-term safety and feasibility of MIS for patients with GBCa, as all eight patients underwent successful MIS with no major morbidity or mortality. Further studies with larger patient cohorts with long-term follow-up are needed to determine the oncologic outcomes and the definitive role of MIS in treating GBCa.

Changes of serum and peritoneal inflammatory mediators in laparoscopic radical resection for right colon carcinoma Pengcheng Zhu, Wenzhong Miao, Feng Gu, Chungen Xing Journal of Minimal Access Surgery 2019 15(2):115-118 Objective: The objective of this study is to investigate the effects of laparoscopic and open operation on serum and peritoneal inflammatory mediators in patients with right colon carcinoma. Patients and Methods: A total of 100 patients were randomly divided into laparoscopic group (n = 50) and open group (n = 50). The age, sex, operation time, operation blood loss, post-operative Dukes stage, time to first passage of flatus and post-operative hospital stay were recorded. The levels of hypersensitive C reactive protein (hsCRP) and tumour necrosis factor-α (TNF-α) in serum and abdominal exudate were measured by ELISA at the time of pre-operative 2 h and post-operative 6 h and 24 h. Results: There was no significant difference in age, sex, Dukes stage and pre-operative inflammatory mediators between the two groups (P > 0.05). The operation time, intraoperative blood loss, time to first passage of flatus and post-operative hospital stay were significantly better in laparoscopic group than those in open operation group. At 6 h and 24 h after operation, the levels of hsCRP and TNF-α in serum and abdominal exudate in laparoscopic group were significantly lower than those in open operation group. Conclusions: Laparoscopic surgery for the treatment of right colon carcinoma has the advantages of fewer traumas, less systemic and local inflammatory response, rapider post-operative recovery and shorter hospital stay. It is worthy of clinical application.

Applicability of transoral endoscopic parathyroidectomy through vestibular route for primary sporadic hyperparathyroidism: A South Indian experience P R K Bhargav, M Sabaretnam, V Amar, N Vimala Devi Journal of Minimal Access Surgery 2019 15(2):119-123 Introduction: Primary hyperparathyroidism is one of the most common endocrine disorders requiring surgical parathyroidectomy for its definitive treatment. Surgical exploration is traditionally performed through conventional open neck approach. A wide range of minimal access and minimally invasive endoscopic techniques (gas less and with gas) have been attempted in the past two decades. In this context, we evaluated the feasibility and safety of an innovative transoral endoscopic parathyroidectomy (EP) technique, which represents a paradigm shift in transluminal endocrine surgery. Materials and Methods: This is a prospective study conducted at a tertiary care Endocrine Surgery Department in South India between May 2016 and August 2017. We employed a novel transoral, lower vestibular route for EP. All the clinical, investigative, operative, pathological and post-operative data were collected from our prospectively filled database. Statistical analysis was performed with SPSS 20.0 version. Operative Technique: Under inhalational general anaesthesia, access to the neck was obtained with 3 ports (central frenulotomy and two lateral port sites), dissected in subplatysmal plane and insufflated with 6 mm Hg CO2 for working space. Rest of surgical steps is similar to conventional open parathyroidectomy. Results: Out of the 38 hyperparathyroidism cases operated during the study, 12 (32%) were operated by this technique. Mean operative time was 112 ± 15 min (95–160). The post-operative course was uneventful with no major morbidity, hypocalcemia or recurrent laryngeal nerve palsy. Cure and diagnosis were confirmed by >50% fall in intraoperative parathyroid hormone levels and histopathology (all were benign solitary adenomas). Conclusions: Through this study, we opine that this novel transoral vestibular route parathyroidectomy is a feasibly applicable approach for primary sporadic hyperparathyroidism, especially with solitary benign adenomas.

Who profits from three-dimensional optics in endoscopic surgery? Analysis of manual tasks under two-dimensional/three-dimensional optic vision using a pelvic trainer model Cornelius Jacobs, Frank Alexander Schildberg, Dieter Christian Wirtz, Philip Peter Roessler Journal of Minimal Access Surgery 2019 15(2):124-129 Background: In endoscopic operations, direct binocular view, tissue sensation and depth perception get lost. It is still unclear whether the novel three-dimensional (3D) high-definition (HD) cameras are able to compensate the limited senses and how this affects the skill set of users with different endoscopic experience. This study aimed first to evaluate if the 3D technology improves depth perception, precision and space orientation as compared to conventional two-dimensional (2D) HD technology. The second aim was to determine the 3D influence on participants with different endoscopic experience. Methods: A total of 24 participants of different experience levels performed three different tasks on a pelvic trainer using the same thoracoscopic unit in 2D and 3D modes. Results were statistically analysed using Student's t-test and Pearson's product–moment correlation. Results: Across all the participants, we found that 3D optic vision significantly reduced the needed time to perform a defined difficult task in comparison to 2D. This difference was less pronounced in participants with higher experience level. Participants with eyeglasses performed slower in both 2D and 3D in comparison to participants with normal vision. Only participants with normal vision could significantly improve their completion times with 3D optic vision. Conclusions: By testing the novel generation of 3D HD cameras, we could demonstrate that the 3D optic of these systems improves depth perception and space orientation for novices and experienced users and especially inexperienced users benefit from 3D optic.

Diagnostic laparoscopy or selective non-operative management for stable patients with penetrating abdominal trauma: What to choose? Oleh Yevhenovych Matsevych, Modise Zacharia Koto, Moses Balabyeki, Lehlogonolo David Mashego, Colleen Aldous Journal of Minimal Access Surgery 2019 15(2):130-136 Background: Selective non-operative management (NOM) and diagnostic laparoscopy (DL) are well-accepted approaches in the management of stable patients with penetrating abdominal trauma (PAT). The aim of this pilot study was to investigate the advantages and disadvantages of early DL in stable asymptomatic or minimally symptomatic patients with PAT as opposed to NOM, a standard of care in this scenario. The secondary aim was to suggest possible indications for DL. Methods: Patients managed with DL or NOM over a 12-month period were included in this study. The age, gender, mechanism and location of injuries, trauma scores, haemodynamic and metabolic parameters, intraoperative findings and length of hospital stay (LOS) were recorded and correlated with outcomes. Results: Thirty-six patients were in the NOM group and 35 in the DL group. Stab wounds were more common. The most common location of injury was the anterior abdominal wall in the NOM group and the lower chest in the DL group. Computed tomography (CT) scan was performed more often in the NOM group (75% vs. 17.1%). The injury severity score (ISS), New ISS and PAT Index were higher in the DL group. Nearly 23 (66%) patients in the DL group had a penetration of the peritoneum, but no significant abdominal injuries. LOS in the NOM group was 2 days versus 3.1 days in the DL group. There were no missed injuries, complications or mortality. Conclusion: NOM is a preferred modality for minimally symptomatic stable patients. However, there is a risk of missed injuries and delayed treatment. DL accurately visualizes injuries, decreases unnecessary CT scans and avoids nontherapeutic laparotomies.

End-stage renal disease is a risk factor for complex laparoscopic cholecystectomy in patients waiting for renal transplantation Sara Colozzi, Samuele Iesari, Giovanni Cianca, Quirino Lai, Luigi Bonanni, Francesco Pisani, Gianfranco Amicucci Journal of Minimal Access Surgery 2019 15(2):137-141 Introduction: To date, there are no studies investigating whether laparoscopic cholecystectomy (LC) is technically more complex in patients waiting for kidney transplant. The aim of this study is to create a user-friendly score to identify high-risk cases for complex LC integrating end-stage renal disease (ESRD). Materials and Methods: We retrospectively analysed 321 patients undergoing LC during the period 2014–2016. Two groups were compared: ESRD group (n = 25) versus control group (n = 296). Concerning statistical analysis, continuous variables were compared using Kruskal–Wallis' test, dummy variables with Chi-square test or Fisher's exact test when appropriate. A multivariable logistic regression analysis was performed to identify risk factors for complex LC. A backward conditional method was used to design the final model. Results: Seventy out of 321 (21.8%) cases were considered as complex, with a higher prevalence in the ESRD group (32.0 vs. 20.9%; P = 0.2). Using a multivariable logistic regression analysis, we formulated a score based on the independent risk factors for complex LC: 4×(previous cholecystitis) +5 × (previous ESRD) +1 × (age per decade) +2 × (previous open abdominal surgery). High-risk cases (score ≥ 10) were more commonly reported in the ESRD group (72.0 vs. 24.7%; P < 0.0001). Conclusion: Although several scores investigating the risk for complex LC have been proposed, none of them has focused on ESRD. This is the first series demonstrating that ESRD is an independent risk factor for technical complexity in LC. We developed a score to offer surgeons an extra tool for pre-operative evaluation of patients requiring LC.

Gastrointestinal stromal tumours of stomach: Robot-assisted excision with the da Vinci Surgical System regardless of size and location site Niccolò Furbetta, Matteo Palmeri, Simone Guadagni, Gregorio Di Franco, Desirée Gianardi, Saverio Latteri, Emanuele Marciano, Andrea Moglia, Alfred Cuschieri, Giulio Di Candio, Franco Mosca, Luca Morelli Journal of Minimal Access Surgery 2019 15(2):142-147 Aims: The role of minimally invasive surgery of gastrointestinal stromal tumours (GISTs) of the stomach remains uncertain especially for large and/or difficult located tumours. We are hereby presenting a single-centre series of robot-assisted resections using the da Vinci Surgical System (Si or Xi). Subjects and Methods: Data of patients undergoing robot-assisted treatment of gastric GIST were retrieved from the prospectively collected institutional database and a retrospective analysis was performed. Patients were stratified according to size and location of the tumour. Difficult cases (DCs) were considered for size if tumour was >50 mm and/or for location if the tumour was Type II, III or IV sec. Privette/Al-Thani classification. Results: Between May 2010 and February 2017, 12 consecutive patients underwent robot-assisted treatment of GIST at our institution. DCs were 10/12 cases (83.3%), of which 6/10 (50%) for location, 2/10 (25%) for size and 2/10 (25%) for both. The da Vinci Si was used in 8 patients, of which 6 (75%) were DC, and the da Vinci Xi in 4, all of which (100%) were DC. In all patients, excision was by wedge resection. All lesions had microscopically negative resection margins. There was no conversion to open surgery, no tumour ruptures or spillage and no intraoperative complications. Conclusion: Our experience suggests a positive role of the robot da Vinci in getting gastric GIST removal with a conservative approach, regardless of size and location site. Comparative studies with a greater number of patients are necessary for a more robust assessment.