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Chauhan H, Jiwa N, Nagarajan VR, Thiruchelvam P, Hogben K, Al-Mufti R, Hadjiminas D, Shousha S, Cutress R, Ashrafian H, Takats Z, Leff DR. Clinicopathological Predictors of Positive Resection Margins in Breast-Conserving Surgery. Ann Surg Oncol 2024; 31:3939-3947. [PMID: 38520579 PMCID: PMC11076377 DOI: 10.1245/s10434-024-15153-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 02/20/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Ductal carcinoma in situ (DCIS) is associated with risk of positive resection margins following breast-conserving surgery (BCS) and subsequent reoperation. Prior reports grossly underestimate the risk of margin positivity with IBC containing a DCIS component (IBC + DCIS) due to patient-level rather than margin-level analysis. OBJECTIVE The aim of this study was to delineate the relative risk of IBC + DCIS compared with pure IBC (without a DCIS component) on margin positivity through detailed margin-level interrogation. METHODS A single institution, retrospective, observational cohort study was conducted in which pathology databases were evaluated to identify patients who underwent BCS over 5 years (2014-2019). Margin-level interrogation included granular detail into the extent, pathological subtype and grade of disease at each resection margin. Predictors of a positive margin were computed using multivariate regression analysis. RESULTS Clinicopathological details were examined from 5454 margins from 909 women. The relative risk of a positive margin with IBC + DCIS versus pure IBC was 8.76 (95% confidence interval [CI] 6.64-11.56) applying UK Association of Breast Surgery guidelines, and 8.44 (95% CI 6.57-10.84) applying the Society of Surgical Oncology/American Society for Radiation Oncology guidelines. Independent predictors of margin positivity included younger patient age (0.033, 95% CI 0.006-0.060), lower specimen weight (0.045, 95% CI 0.020-0.069), multifocality (0.256, 95% CI 0.137-0.376), lymphovascular invasion (0.138, 95% CI 0.068-0.208) and comedonecrosis (0.113, 95% CI 0.040-0.185). CONCLUSIONS Compared with pure IBC, the relative risk of a positive margin with IBC + DCIS is approximately ninefold, significantly higher than prior estimates. This margin-level methodology is believed to represent the impact of DCIS more accurately on margin positivity in IBC.
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MESH Headings
- Humans
- Female
- Margins of Excision
- Mastectomy, Segmental/methods
- Retrospective Studies
- Middle Aged
- Breast Neoplasms/surgery
- Breast Neoplasms/pathology
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Aged
- Adult
- Follow-Up Studies
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Ductal, Breast/pathology
- Prognosis
- Aged, 80 and over
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Affiliation(s)
- Hemali Chauhan
- Department of Surgery and Cancer, Imperial College London, London, UK.
| | - Natasha Jiwa
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Paul Thiruchelvam
- Breast Unit, Charing Cross Hospital, Imperial College NHS Trust, London, UK
| | - Katy Hogben
- Breast Unit, Charing Cross Hospital, Imperial College NHS Trust, London, UK
| | - Ragheed Al-Mufti
- Breast Unit, Charing Cross Hospital, Imperial College NHS Trust, London, UK
| | - Dimitri Hadjiminas
- Breast Unit, Charing Cross Hospital, Imperial College NHS Trust, London, UK
| | - Sami Shousha
- Breast Unit, Charing Cross Hospital, Imperial College NHS Trust, London, UK
- North West London Pathology, Imperial College NHS Trust, London, UK
| | - Ramsey Cutress
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Hutan Ashrafian
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Zoltan Takats
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Daniel Richard Leff
- Department of Surgery and Cancer, Imperial College London, London, UK
- Breast Unit, Charing Cross Hospital, Imperial College NHS Trust, London, UK
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Almas T, Nagarajan VR, Ahmed D, Ullah M, Ashary MA, Oruk M, Khan A, Amin K, Malik U, Ramjohn J, Huang H, Rifai A, Alzahrani A, Alqallaf N, Alsairefi S, Hur YS, Bhullar A, Abdulkarim K, Alwheibi E, Kadom M, Alshabibi A, Shafi A, Murad F, Mansoor E. Recurrent appendicitis of vermiform appendix after a prior appendectomy: A case report and review of the literature. Ann Med Surg (Lond) 2022; 77:103603. [PMID: 35638013 PMCID: PMC9142391 DOI: 10.1016/j.amsu.2022.103603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Acute appendicitis is one of the leading causes of acute abdominal pain and surgical emergency. Stump appendicitis is a known complication of appendectomy whereby a retained appendiceal tip serves as a nidus for recurrent bouts of inflammation. Nevertheless, full-blown appendicitis of the vermiform appendix after a prior appendectomy remains a diagnostic conundrum. Case presentation A 45-year-old woman presented with a six-month history of right iliac fossa pain. Pertinently, she had undergone a prior open appendectomy twelve years ago. Further investigative workup revealed full-blown appendicitis, which was not attributable to a retained appendiceal stump. A subsequent laparoscopic appendectomy was performed, and the resultant specimen was sent for further evaluation, confirming the diagnosis of recurrent appendicitis. Clinical discussion Acute appendicitis is one of the most common life-threatening abdominal surgical emergencies worldwide, with 300000 appendectomies performed annually in the United States alone. Stump and chronic appendicitis are two separate and exceedingly rare clinical entities that may present simultaneously and develop serious complications unless promptly recognized and appropriately managed. The present paper prompts the clinicians to distinguish amongst the two at the initial surgery in order to thwart further exacerbations. Conclusion While stump appendicitis is a rare but well-characterized complication of a prior appendectomy, full-blown appendicitis of vermiform appendix remains elusive. It is therefore imperative to distinguish between a duplicated and a recurrent appendix at the initial operative procedure to facilitate optimal patient management.
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Affiliation(s)
- Talal Almas
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Corresponding author. Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin, Ireland.
| | | | - Danyal Ahmed
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Muneeb Ullah
- Department of Surgery, Maroof International Hospital, Islamabad, Pakistan
| | | | - Mert Oruk
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Arsalan Khan
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Kiran Amin
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Uzair Malik
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Helen Huang
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Ali Rifai
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Ahlam Alzahrani
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Nagi Alqallaf
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Sood Alsairefi
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Anhad Bhullar
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Eissa Alwheibi
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Mhmod Kadom
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Aaisha Alshabibi
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Adil Shafi
- Department of Surgery, Maroof International Hospital, Islamabad, Pakistan
| | - Faisal Murad
- Department of Surgery, Maroof International Hospital, Islamabad, Pakistan
| | - Emad Mansoor
- Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
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Ali S, Almas T, Zaidi U, Ahmed F, Shaikh S, Shaikh F, Tafveez R, Arsalan M, Antony I, Antony M, Tahir B, Aborode AT, Ali M, Nagarajan VR, Samy A, Alrawashdeh MM, Alkhattab M, Ramjohn J, Ramjohn J, Huang H, Nawaz QS, Khan KA, Khullar S. A novel case of lupus nephritis and mixed connective tissue disorder in a COVID-19 patient. Ann Med Surg (Lond) 2022; 78:103653. [PMID: 35495962 PMCID: PMC9034828 DOI: 10.1016/j.amsu.2022.103653] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/15/2022] [Accepted: 04/17/2022] [Indexed: 12/23/2022] Open
Abstract
Introduction Mixed connective tissue disease (MCTD) is a rare autoimmune condition characterized by Scleroderma, Polymyositis, and Systemic Lupus Erythematous (SLE). Though a possible relationship between COVID-19 and autoimmune diseases has been recently reported, its pathophysiological mechanism behind flares in Lupus Nephritis (LN), a complication of SLE, remains unknown. Case presentation A 22-year-old COVID-19 positive female presented with anemia, bilateral pitting edema, periorbital swelling, and posterior cervical lymphadenitis. Further inspection revealed lower abdominal striae, hepatosplenomegaly, and hyperpigmented skin nodules. Complete blood counts showed elevated inflammatory markers and excessively high protein creatinine ratio. Antinuclear antibody titers were elevated (anti-smith and U1 small nuclear ribonucleoprotein) and Rheumatoid Factor was positive. She was diagnosed with MCTD associated with a flare of LN. To control her lupus flare, a lower dose of steroids was initially administered, in addition to oral hydroxychloroquine and intravenous cyclophosphamide. Her condition steadily improved and was discharged on oral steroid maintenance medication. Discussion We present a rare phenomenon of newly diagnosed LN, a complication of SLE, with MCTD in a PCR-confirmed COVID-19 patient. The diagnostic conundrum and treatment hurdles should be carefully addressed when patients present with lupus and COVID-19 pneumonia, with further exploration of the immuno-pathophysiology of COVID-19 infection in multi-systemic organ dysfunction in autoimmune disorders. Conclusion In COVID-19 patients with LN and acute renal injury, it is critical to promptly and cautiously treat symptomatic flares associated with autoimmune disorders such as SLE and MCTD that may have gone unnoticed to prevent morbidity from an additional respiratory infection. SLE disease has been associated with COVID-19. However, there is a lack of data on LN in conjunction with MCTD in COVID-19 positive patients. A possible relationship between Coronavirus disease 2019 (COVID-19) and autoimmune disease has been documented in many case reports. Because of the overlapping clinical manifestations and laboratory findings between lupus and COVID-19 pneumonia, the diagnostic problems and treatment hurdles should be carefully addressed. In COVID-19 patients with LN flare and acute renal injury, it is critical to resolve any reversible causes of the kidney injury and manage the COVID-19 before treating the LN.
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Affiliation(s)
- Sajjad Ali
- Department of Medicine, Ziauddin Medical University, Karachi, Pakistan
- Corresponding author. Department of Medicine, Ziauddin Medical University, Karachi, Pakistan.
| | - Talal Almas
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Ujala Zaidi
- Department of Medicine, Karachi Medical and Dental College, Karachi, Pakistan
| | - Farea Ahmed
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | | | | | - Rida Tafveez
- Department of Medicine, Ziauddin Medical University, Karachi, Pakistan
| | - Maaz Arsalan
- Department of Medicine, Ziauddin Medical University, Karachi, Pakistan
| | - Ishan Antony
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Burhanuddin Tahir
- Department of Medicine, Ziauddin Medical University, Karachi, Pakistan
| | | | - Murtaza Ali
- Department of Medicine, Dr. Ruth K.M. Pfau, Civil Hospital Karachi, Pakistan
| | | | - Arjun Samy
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Maha Alkhattab
- Department of Surgery, Galway University Hospital, Galway, Ireland
| | | | | | - Helen Huang
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | | | | | - Shane Khullar
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
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Khan MA, Almas T, Ullah M, Alkhattab M, Shaikh F, Shaikh S, Bagwe I, Antony M, Khedro T, Nagarajan VR, Ramjohn J, Alsufyani R, Almubarak D, Al-Awaid AH, Alsufyani M, Nagarajan DR, Khan MO, Huang H, Oruk M, Samy A, Alqallaf N, Shafi A, Adeel A, Khan MK. Candida glabrata infection of a pancreatic pseudocyst in a COVID-19 patient: A case report and review of the literature. Ann Med Surg (Lond) 2022; 77:103648. [PMID: 35638027 PMCID: PMC9142617 DOI: 10.1016/j.amsu.2022.103648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/15/2022] [Accepted: 04/15/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Pancreatic pseudocysts remain a feared complication of acute or chronic pancreatitis and are often characterized by collections of fluids due to underlying damage to the pancreatic ducts, culminating in a walled-off region bereft of an epithelial layer but surrounded by granulation tissue. While fungal infections of pancreatic pseudocysts are rarely encountered, candida albicans remains the most frequently implicated organism. Case presentation A 55-year-old male presented with pain in the left-hypochondriac region, accompanied by non-bilious emesis and nausea. Interestingly, the patient also tested positive for a COVID-19 infection. Investigative workup divulged enhancing pancreatic walls with a radiologic impression consistent with a pancreatic pseudocyst. An ultrasound-guided external drainage was performed; the drainage was conducted unremarkably, with the resultant fluid collection revealing the presence of Candida Glabrata. The patient was commenced on antifungal therapy and continues to do well to date. Discussion Infectious ailments of pancreatic pseudocysts remain a widely known complication of acute pancreatitis. While it is rare, fungal infection is a crucial consideration for patients with pancreatic pseudocysts, especially in the context of a lack of an adequate response to antibiotics, deterioration, comorbidities, and immunocompromised states. Conclusion Rapid identification of the microbe responsible for pancreatic pseudocyst infection is vital for time-sensitive treatment and a more rapid recovery, curbing associated morbidity and mortality. Fungal infections of pancreatic pseudocysts remain a rare but well-characterized complication, culminating in significant morbidity and mortality. Telltale signs include unresponsiveness to antibiotics and worsening clinical symptoms. Rapid identification of the responsible microbe is vital for time-sensitive treatment and a more rapid recovery.
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Affiliation(s)
| | - Talal Almas
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Muneeb Ullah
- Department of Surgery, Maroof International Hospital, Islamabad, Pakistan
| | - Maha Alkhattab
- Department of Surgery, Galway University Hospital, Galway, Ireland
| | | | | | - Isha Bagwe
- Mercy University Hospital, Cork, Ireland
| | | | - Tarek Khedro
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | | | | | - Reema Alsufyani
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Dana Almubarak
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Majid Alsufyani
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | | | | | - Helen Huang
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Mert Oruk
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Arjun Samy
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Nagi Alqallaf
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Adil Shafi
- Department of Surgery, Maroof International Hospital, Islamabad, Pakistan
| | - Aqsa Adeel
- Department of Surgery, Maroof International Hospital, Islamabad, Pakistan
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Almas T, Ehtesham M, Malik U, Nagarajan VR, Sukaina M, Alshareef N, Alzahrani A, Abuhaimed S, Irani YP, Alzadjali E, Alwheibi ES, Kadom M, Khalid S, Shehryar M, Al Shumrani KM. It's not always Occam's razor: The pivotal role of telemedicine in stroke patients amidst the COVID-19 pandemic. Ann Med Surg (Lond) 2022; 76:103528. [PMID: 35371470 PMCID: PMC8959656 DOI: 10.1016/j.amsu.2022.103528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/10/2022] [Accepted: 03/26/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Talal Almas
- Royal College of Surgeons in Ireland, Dublin, Ireland
- Corresponding author. Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin, Ireland.
| | | | - Uzair Malik
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | | | | | | | - Suliman Abuhaimed
- Imam Abdulrahman Bin Faisal University— College of Medicine, Saudi Arabia
| | | | | | | | - Mhmod Kadom
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Saif Khalid
- Royal College of Surgeons in Ireland, Dublin, Ireland
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Song D, Almas T, Abdelghffar M, Jain S, Geetha HS, Shah V, Nagarajan VR, Alshareef N, Gunasaegaram V, Ravintharan K, Tan ST, John A. A rare case of delayed anaplasma phagocytophilum-induced pancytopenia: A diagnostic conundrum. Ann Med Surg (Lond) 2022; 75:103366. [PMID: 35198193 PMCID: PMC8851287 DOI: 10.1016/j.amsu.2022.103366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 02/05/2022] [Accepted: 02/10/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction Human granulocytic anaplasmosis (HGA) is a potentially fatal tick-borne disease caused by the obligate intracellular bacterium Anaplasma phagocytophilum. It is most commonly found in the Northeastern and Midwestern parts of the United States especially during spring and summer months. The clinical picture of anaplasmosis is varied ranging from common symptoms such as fever, headache and myalgia to rarer presentations such as pancytopenia. Case presentation We present a case of a 62 year old male who presented with watery diarrhea, fever, and pancytopenia. Although there is a broad differential for pancytopenia, a thorough history provides clues regarding the diagnosis. In our patient, a recent history of camping in Upstate New York was suggestive of an infectious etiology from a tick borne illness. Clinical discussion A tick-borne panel guided us to identify the diagnosis of HGA. Although the exact underlying pathogenesis of tick-borne illnesses leading to pancytopenia is still unknown, the pancytopenia is postulated to be due to a multi-nodal mechanism involving immune and non immune platelet destruction, global bone marrow suppression, hemophagocytic lymphohistiocytosis and myelosuppressive chemokines release. Conclusion We hope that this case report elucidates the importance of obtaining a meticulous history in guiding clinicians towards prompt diagnosis, even in instances where there may be an evolving clinical picture. Human granulocytic anaplasmosis (HGA) is a potentially fatal tick-borne disease caused by the obligate intracellular bacterium Anaplasma phagocytophilum. A prompt diagnosis and management will facilitate an early recovery and prevent any fatal complications such as pancytopenia. HGA causing pancytopenia is likely due to a multi-modal mechanism involving immune and non-immune platelet destruction, global bone marrow suppression, hemophagocytic lymphohistiocytosis, and myelosuppressive chemokines release.
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Almas T, Ehtesham M, Basit J, Khedro T, Malik U, Nagarajan VR, Hur J, Alshareef N, Fathima A, Virk HUH, Hameed A, Li J. Prasugrel versus ticagrelor for acute coronary syndrome patients undergoing percutaneous coronary intervention: A critical appraisal of randomized controlled trials. Ann Med Surg (Lond) 2022; 74:103330. [PMID: 35198169 PMCID: PMC8844802 DOI: 10.1016/j.amsu.2022.103330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/30/2022] [Indexed: 11/28/2022] Open
Affiliation(s)
- Talal Almas
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Corresponding author. RCSI University of Medicine and Health Sciences, 123 St. Stephen's Green, Dublin, Ireland.
| | - Maryam Ehtesham
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Janita Basit
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Tarek Khedro
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Uzair Malik
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Jung Hur
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Norah Alshareef
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Areen Fathima
- University Hospital, National University of Ireland Galway, Galway, Ireland
| | | | - Aamir Hameed
- Tissue Engineering Research Group, Department of Anatomy and Regenerative Medicine, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Jun Li
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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Almas T, Murad MF, Mansour E, Khan MK, Ullah M, Nadeem F, Shafi A, Khedro T, Almuhaileej M, Abdulhadi A, Alshamlan A, Nagarajan VR, Mansoor E. Look, but to the left: A rare case of gallbladder sinistroposition and comprehensive literature review. Ann Med Surg (Lond) 2021; 71:103016. [PMID: 34840764 PMCID: PMC8606894 DOI: 10.1016/j.amsu.2021.103016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 10/31/2021] [Accepted: 10/31/2021] [Indexed: 11/29/2022] Open
Abstract
Left-sided gallbladder (LSGB) is a rare anatomic variation that, while benign in the context of its transposition, is of significant intraoperative importance. Due to its association with other anatomic anomalies involving key structures in the hepatobiliary system, discovering it intraoperatively as opposed to preoperatively suddenly increases the difficulty of a gallbladder procedure. Left-sided gallbladder (LSGB) is a rare anatomic variation that, while benign in the context of its transposition, is of significant intraoperative importance. Although laparoscopic cholecystectomy of a LSGB is safe, it is associated with higher risk of complications such as common bile duct injury. Most cases of a LSGB are diagnosed intraoperatively, and this sudden discovery during the procedure can increase the difficulty, duration, and stress of the procedure due to the other potential anatomic anomalies that LSGB is associated with in the hepatobiliary system.
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Affiliation(s)
- Talal Almas
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Eyad Mansour
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Muneeb Ullah
- Department of Surgery, Maroof International Hospital, Islamabad, Pakistan
| | - Faisal Nadeem
- Department of Surgery, Maroof International Hospital, Islamabad, Pakistan
| | - Adil Shafi
- Department of Surgery, Maroof International Hospital, Islamabad, Pakistan
| | - Tarek Khedro
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | | | | | | | - Emad Mansoor
- Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
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Almas T, Farooqi M, Nagarajan VR, Niaz MA, Akbar A, Irani YP, Hur J, Finsterer J. The Kardashian index of cardiologists: Do more social media followers mean more citations or merely celebrity status in academia? Ann Med Surg (Lond) 2021; 71:102981. [PMID: 34840745 PMCID: PMC8606697 DOI: 10.1016/j.amsu.2021.102981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 10/15/2021] [Accepted: 10/28/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Talal Almas
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | | | | | | | | | | | - Jung Hur
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Josef Finsterer
- Klinik Landstrasse, Messerli Institute, Postfach 20, 1180 Vienna, Austria, Postfach 20, 1180, Vienna, Austria
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Song D, Geetha HS, Kim A, Seen T, Almas T, Nagarajan VR, Alsaeed N, Cheng JH, Lieber J. Transformation of acute cholecystitis to acute choledocholithiasis in COVID-19 patient. Ann Med Surg (Lond) 2021; 71:102946. [PMID: 34664016 PMCID: PMC8514612 DOI: 10.1016/j.amsu.2021.102946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/11/2021] [Accepted: 10/13/2021] [Indexed: 01/08/2023] Open
Abstract
The global pandemic of Coronavirus 2019 (COVID-19) or SARS-CoV-2 has numerous manifestations in different organ systems. It is known that SARS-CoV-2 infects the hepatobiliary system leading to presentations such as acute cholecystitis, choledocholithiasis and hepatitis. Although the exact mechanism of the underlying pathology is unknown, it is likely attributed by the tropism of the virus to the ACE2 receptors in the hepatocytes and bile duct cells resulting in a cytokine storm that precipitates as systemic symptoms from acute COVID-19 infection. In this case report we present a case of a 47-year-old male who presented with signs consistent with acute cholecystitis. It was confirmed on ultrasound and he was incidentally found to be positive for COVID-19 on routine surveillance testing. He was asymptomatic and was being prepped for cholecystectomy, but developed an acute elevation of liver enzymes suggesting choledocholithiasis. After endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy the patient experienced a rapid normalization of liver enzymes and improvement of his abdominal symptoms. SARS-CoV-2 can infiltrate gallbladder wall cells, mimicking acute cholecystitis and choledocholithiasis. Exact mechanism is unknown, but it is likely attributed by the tropism of the virus to the ACE2 receptors in the hepatocytes and bile duct cells resulting in a cytokine storm that precipitates as systemic symptoms from acute COVID-19 infection. Patients with acute cholecystitis and COVID-19 require close monitoring to prevent the progression into cholidocolithasis and cholangitis.
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Affiliation(s)
- David Song
- Icahn School of Medicine at Mount Sinai - Elmhurst Hospital Center, Elmhurst, NY, USA
| | | | - Andrew Kim
- New York Institute of Technology College of Osteopathic Medicine, Westbury, NY, USA
| | - Tasur Seen
- Icahn School of Medicine at Mount Sinai - Elmhurst Hospital Center, Elmhurst, NY, USA
| | - Talal Almas
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Noor Alsaeed
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Jui Hsin Cheng
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Joseph Lieber
- Icahn School of Medicine at Mount Sinai - Elmhurst Hospital Center, Elmhurst, NY, USA
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Khalid SN, Khan ZA, Ali MH, Almas T, Khedro T, Raj Nagarajan V. A blistering new era for bullous pemphigoid: A scoping review of current therapies, ongoing clinical trials, and future directions. Ann Med Surg (Lond) 2021; 70:102799. [PMID: 34540212 PMCID: PMC8435812 DOI: 10.1016/j.amsu.2021.102799] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 08/24/2021] [Accepted: 09/02/2021] [Indexed: 01/12/2023] Open
Abstract
Bullous pemphigoid (BP) is a severe autoimmune blistering skin disorder that primarily causes disease in the older population and is the most prevalent subepidermal variant of the pemphigoid diseases. It manifests as exquisitely pruritic vesiculobullous eruptions and is associated with significant morbidity and mortality. Studies are reporting an increase in prevalence, and, among the elderly, BP is no longer considered to be as rare as previously thought. The pathogenesis involves autoantibodies directed against proteinaceous components of hemidesmosomes, with consequent autoimmune destruction of the dermal-epidermal junction. In recent times, more complex elements of the underlying inflammatory orchestra have been elucidated and are being used to develop targeted immunotherapies. The primary treatment modalities of BP include the use of topical and systemic corticosteroids, certain non-immunosuppressive agents (tetracyclines, nicotinamide, and sulfone), and immunosuppressants (methotrexate, azathioprine, cyclophosphamide, and Mycophenolate). However, in the long term, most of these agents are associated with substantial toxicities while recurrence rates remain high. Such egregious prospects led to significant efforts being directed towards developing newer targeted therapies which work by attenuating specific newly discovered pillars of the inflammatory pathway, and these efforts have garnered hope in providing safer alternatives. Our review focuses on presenting the various therapeutic options that are currently in trial since December 2019, as well as on summarizing presently established treatment guidelines to provide readers with the latest exciting updates. Bullous pemphigoid (BP) is a severe autoimmune blistering skin disorder that primarily causes disease in the older population and is the most prevalent subepidermal variant of the pemphigoid diseases. In recent times, more complex elements of the underlying inflammatory orchestra have been elucidated and are being used to develop targeted immunotherapies. The present review focuses on presenting the various therapeutic options that are currently in trial since December 2019, as well as on summarizing presently established treatment guidelines to provide readers with the latest exciting updates.
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Affiliation(s)
- Subaina Naeem Khalid
- Shifa College of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Zeest Ali Khan
- Shifa College of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Muhammad Hamza Ali
- Shifa College of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Talal Almas
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Tarek Khedro
- Royal College of Surgeons in Ireland, Dublin, Ireland
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Khalid SN, Rizwan N, Khan ZA, Najam A, Khan AM, Almas T, Khedro T, Nagarajan VR, Alshamlan A, Gronfula A, Alshehri R. Fungal burn wound infection caused by Fusarium dimerum: A case series on a rare etiology. Ann Med Surg (Lond) 2021; 70:102848. [PMID: 34540224 PMCID: PMC8435921 DOI: 10.1016/j.amsu.2021.102848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/07/2021] [Accepted: 09/08/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction Fusarium dimerum is a filamentous mold associated with poor outcomes in immunocompromised hosts and burn victims. It can be acquired via inhalation or through skin dehiscence. Methods Our work presents a Case series of 8 patients from ages 3–57 years who were admitted with multiple burn wounds over the past 6 months. After initial stabilization measures, they all underwent debridement for the lesions after negative initial fungal cultures. The 44-year-old male was the first patient to develop punched-out eruptions on burn areas 7 days after admission; all the other patients experienced similar lesions during the next 6 days. Tissue cultures of the lesions exhibited Fusarium dimerum growth. The patients were managed accordingly with amphotericin B or voriconazoles. All the patients recovered except the 11-year-old boy, who expired on day 9 due to ARDS and sepsis complications. Outcomes Infection with Fusarium dimerum carries a high risk of dissemination in burn infections. Hence, appropriate screening should be carried out via histologic and mycologic diagnostics early in the disease course. Conclusion Considering the sparse literature that is available regarding Fusarium infection in burn victims, this study aims to improve the knowledge surrounding different facets of this disease including its epidemiology, diagnosis, management, and the need to maintain high suspicion of this fungal disease in burn patients. Fusarium dimerum is a filamentous mold associated with poor outcomes in immunocompromised hosts and burn victims. It can be acquired via inhalation or through skin dehiscence. Our work presents a Case series of 8 patients from ages 3–57 years who were admitted with multiple burn wounds over the past 6 months. After initial stabilization measures, they all underwent debridement for the lesions after negative initial fungal cultures. Infection with Fusarium dimerum carries a high risk of dissemination in burn infections. Hence, appropriate screening should be carried out via histologic and mycologic diagnostics early in the disease course.
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Affiliation(s)
- Subaina Naeem Khalid
- Shifa College of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | | | - Zeest Ali Khan
- Shifa College of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Ali Najam
- Shifa College of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Amin Moazzam Khan
- Shifa College of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Talal Almas
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Tarek Khedro
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | | | - Amin Gronfula
- Royal College of Surgeons in Ireland, Dublin, Ireland
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Farooqi M, Ullah I, Irfan M, Taseer AR, Almas T, Hasan MM, Asad Khan FM, Alshamlan A, Abdulhadi A, Nagarajan VR. The revival of telemedicine in the age of COVID-19: Benefits and impediments for Pakistan. Ann Med Surg (Lond) 2021; 69:102740. [PMID: 34457264 PMCID: PMC8379814 DOI: 10.1016/j.amsu.2021.102740] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 08/14/2021] [Accepted: 08/15/2021] [Indexed: 11/01/2022] Open
Affiliation(s)
- Maheera Farooqi
- Department of Internal Medicine, Dow University of Health Science, Karachi, Pakistan
| | - Irfan Ullah
- Kabir Medical College, Gandhara University, Peshawar, Pakistan
| | | | | | - Talal Almas
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mohammad Mehedi Hasan
- Department of Biochemistry and Molecular Biology, Faculty of Life Science, Mawlana Bhashani Science and Technology University, Tangail, 1902, Bangladesh
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