Gastric Obstruction by Opium Packets: A Case Report.

Background: We reported a case of gastric obstruction in a body packer who swallowed a large number of opium packets. Case Report: A 36-year-old man opium addict visited the emergency department with epigastric pain for three days. He swallowed nearly 90 packets of opium for smuggling purposes four days earlier. He self-administered laxatives. In contrast, many times vomiting, he defecated only four packets and vomited one packet. The abdominal X-rays showed some amounts of fluid-air levels and multiple cylindrical opacities with the double-condom sign, corresponding to the distended stomach. Due to the worsening of his abdominal symptoms, he underwent an urgent laparotomy and 84 packets (4-6 cm in size and 8-10 g/ packet of opium) with a total weight of 870 g. They were wrapped in some layers of plastic and tied at the ends. He was discharged in stable condition. Conclusion: A large number of ingested drug packets can induce gastrointestinal obstruction.

Elucidated tumorigenic role of MAML1 and TWIST1 in gastric cancer is associated with Helicobacter pylori infection.

BACKGROUND: Epithelial-mesenchymal transition (EMT) has a fundamental role in tumor initiation, progression, and metastasis. Helicobacter pylori (HP) induces EMT and thus causes gastric cancer (GC) by deregulating multiple signaling pathways involved in EMT. TWIST1 and MAML1 have been confirmed to be critical inducers of EMT via diverse signaling pathways such as Notch signaling. This study aimed to investigate for the first time possible associations between TWIST1/MAML1 mRNA expression levels, HP infection, and clinicopathological characteristics in GC patients. METHOD: TWIST1 and MAML1 mRNA expression levels were evaluated in tumoral and adjacent normal tissues in 73 GC patients using the quantitative reverse transcription PCR (RT-qPCR) method. PCR technique was also applied to examine the infection with HP in GC samples. RESULTS: Upregulation of TWIST1 and MAML1 expression was observed in 35 (48%) and 34 (46.6%) of 73 tumor samples, respectively. Co-overexpression of these genes was found in 26 of 73 (35.6%) tumor samples; meanwhile, there was a significant positive correlation between MAML1 and TWIST1 mRNA expression levels (P < 0.001). MAML1 overexpression exhibited meaningful associations with advanced tumor stages (P = 0.006) and nodal metastases (P ˂ 0.001). 34 of 73 (46.6%) tumors tested positive for HP, and meanwhile, MAML1 expression was positively related with T (P = 0.05) and grade (P = 0.0001) in these HP-positive samples. Increased TWIST1 expression was correlated with patient sex (P = 0.035) and advanced tumor grade (P = 0.017) in HP-infected tumors. Furthermore, TWIST1 and MAML1 expression levels were inversely linked with histologic grade in HP-negative tumor samples (P = 0.021 and P = 0.048, respectively). CONCLUSION: We propose TWIST1 and MAML1 as potential biomarkers of advanced-stage GC that determine the characteristics and aggressiveness of the disease. Based on accumulating evidence and our findings, they can be introduced as promising therapeutic targets to modify functional abnormalities in cells that promote GC progression. Moreover, HP may enhance GC growth and metastasis by disrupting TWIS1/MAML1 expression patterns and related pathways.

Efficacy of Preoperative Albendazole on Protoscoleces Viability in Hydatid Cyst of the Liver.

Background: Optimal duration for medical therapy of liver hydatid cysts before surgery in not certainly defined yet. In this study, we aimed to evaluate the effectiveness of 2 weeks preoperative albendazole in decreasing viable cysts. Methods: Patients referring to Imam Reza Hospital, Mashhad, Iran with a diagnosis of hepatic hydatid cyst were randomly divided into intervention (44 patients) and control (46 patients) groups. The case group were treated with oral albendazole before surgery and the control group underwent surgery without albendazole therapy. Efficacy of albendazole on the reduction of prevalence and viability of the protoscoleces was finally evaluated. Results: A number of 90 patients were included in the final analysis. Protoscoleces were reported alive in 10 (22.7%) and 17 (36.9%) of patients in the case and control group, respectively. The decrease of live protoscoleces in case group was not statistically significant (P=0.14). Conclusion: Decrease in the viability of protoscoleces in hepatic hydatid cysts after 2 weeks administration of oral albendazole at a dose of 10 mg/kg/day preoperatively, is not significant. Optimal duration of medical treatment before surgery seems to be 4 weeks or more.

Concomitant empyema and peritonitis with Morganella morganii in an immunocompetent patient: A case report.

BACKGROUND: Peritoneal infection following pleural empyema is not a common occurrence. Concomitant pleural empyema and peritonitis have been described in the literature mostly in immunocompromised patients with different pathogenic mechanisms and a wide array of microorganisms. Here we report a case of concomitant pleural empyema and peritonitis with an unusual microorganism in an immunocompetent host. CASE PRESENTATION: The patient is a 42-year-old man with a history of 2 weeks epigastric pain who had been referred for surgical consult after failure of outpatient medical therapy. Physical examination at emergency ward revealed generalized abdominal guarding, tenderness and rebound tenderness. On emergent laparotomy, the peritoneal cavity was full of malodor pus. All abdominal viscera were intact but there was a 2x2 centimeter defect in the top of left hemi-diaphragm. Pus originated from the left thoracic cavity and then drained to the peritoneal cavity. Morganella morganii grew in the culture of aspirated pleural fluid. After abdominal lavage and chest tube drainage and receiving 14 days course of parenteral antibiotics, the patient experienced marked clinical improvement. Punctual history taking revealed a history of pneumonia before the beginning of abdominal symptoms. CONCLUSION: In concomitant empyema and peritonitis in an immunocompetent patient, one should keep in mind the possibility of diaphragmatic defect and infection by unusual organisms like M. m organii.

Induction of T cell-mediated immune response by dendritic cells pulsed with mRNA of sphere-forming cells isolated from patients with gastric cancer.

Gastric cancer (GC) as the third most common cause of cancer-associated mortality worldwide is one of the cancers with very high heterogeneity. Cancer stem cells (CSCs) as a small subset of cancer cells in solid tumors with the self-renewal, differentiation and tumorigenic ability are responsible for tumor initiation, progression, recurrence, metastasis, and resistance to current treatments. Therefore, eradication of CSCs is very vital to cure cancer. Here, we first isolated and identified sphere-forming cells in tumor tissue from four GC patients and then analyzed T cell responses induced by monocyte-derived dendritic cells (DCs) loaded with total mRNA of sphere-forming cells in terms of interferon-gamma (IFN-γ) gene expression and specific cytotoxicity. Spheroid colonies were formed in serum-free media. Sphere-forming cells dissociated from tumorspheres heterogeneously expressed CD44, CD54, and epithelial cell adhesion molecule (EpCAM) markers and generated one tumor in nude mice. These results demonstrated that gastric CSCs were enriched in tumorspheres. Cytokine-matured DCs loaded with mRNA of sphere-forming cells were able to induce IFN-γ gene expression in T-lymphocytes after a 12-day co-culture. mRNA level of IFN-γ gene in these lymphocytes was more highly expressed compared to stimulated T-lymphocytes by DCs transfected with normal tissue (6.4-9.39 folds). Cytotoxic activity of primed T-lymphocytes with antigens of sphere-forming cells was significantly higher than normal tissue antigens and mock DCs (P ≤ 0.0001). Taken together, DCs loaded with mRNA of sphere-forming cells that elicit effectively specific T cell-mediated immune responses in vitro, may be considered as a promising therapeutic vaccination in GC patients in future.

Serum Procalcitonin and Lactoferrin in Detection of Acute Appendicitis; a Diagnostic Accuracy Study.

INTRODUCTION: Finding an accurate diagnostic test can reduce the rate of unnecessary abdominal surgery in cases of suspected acute appendicitis (AA). This study aimed to evaluate the diagnostic value of serum lactoferrin (LF) and procalcitonin (PCT) in detection of patients with acute appendicitis. METHODS: In this diagnostic accuracy study, screening performance characteristics of PCT and LF were calculated in patients suspected with acute appendicitis and healthy volunteers as control group. RESULTS: 131 cases participated (61 as case and 70 as control). The mean serum level of LF (0.9±0.14 vs 0.2±0.13 µg/ml; p 0.0001) and PCT (0.15±0.21 vs 0.11±0.02 ng/dl; p = 0.02) were significantly higher in patients suspected with AA. The AUC of PCT and LF were 0.46 (95% CI: 0.31-0.61) and 0.61 (95%CI: 0.47 - 0.76), respectively. At a 0.90 µg/ml cut-off value, LF had 77% (95 % CI: 63 - 91) sensitivity and 43% (95 % CI: 31 - 55) specificity. Also, at a 0.11 ng/dl cut-off value, PCT had 41% (95 % CI: 26 - 56) sensitivity and 69% (95 % CI: 53 - 85) specificity. CONCLUSION: Based on the main finding of present study, the overall accuracy of serum PCT and LF in detection of patients with acute appendicitis are in poor to failed range and it seems that they could not be considered as good screening tools for this purpose.

Molecular Landscape in Alveolar Soft Part Sarcoma: Implications for Molecular Targeted Therapy.

Alveolar soft part sarcoma (ASPS) is a highly aggressive rare soft tissue sarcoma (STS) with poor prognosis especially in the metastatic form. ASPS is resistant to standard chemotherapy. Although, early diagnosis and surgical resection of operable tumor could lead to improved patient survival but novel treatment options are needed for advanced (metastatic) ASPS. This malignancy exhibits highly angiogenic behavior which reflects hyper-activation and over expression of angiogenic factors. Understanding the molecular events in this type of sarcoma is important in finding novel molecular based targeted therapies. We aim to review molecular aspects of ASPS growth and treatment.

Evaluation of the diagnostic value of serum level of total bilirubin in patients with suspected acute appendicitis.

INTRODUCTION: Clinical diagnosis of acute appendicitis still remains a problem. Delays in diagnosis of acute appendicitis may cause perforation and septic peritonitis which result in increasing morbidity and mortality. The aim of this study was to determine the sensitivity, specificity and the diagnostic value of total serum bilirubin levels as a predictor of acute appendicitis. METHODS: In this cross-sectional study, patients who underwent appendectomy with the diagnosis of acute appendicitis from April 2012 to March 2013 at Emam Reza Hospital in Mashhad (Iran) were enrolled. Serum bilirubin-Total and Direct-, were measured. Then based on the final pathologic reports, patients were categorized into five groups of normal appendix, chronic inflammatory changes, acute appendicitis, gangrenous and/or necrotic changes, and perforated appendicitis. Independent sample t-test, ANOVA, and Chi-square test were used for data analysis by SPSS version 16. RESULTS: There were 174 patients studied, (117 male, 57 female) with a mean age of 27.15±0.7 years. All of the patients had rebound tenderness; 75.3% had nausea, 58.6% had anorexia and 21.3% had fever. The histological reports of all patients showed 76.4% acute appendicitis. Analyzing p-values for SGPT, SGOT, WBC was (p=0.903) and differential count was (p=0.959). The study showed no significant difference between the pathological groups. However, there were no significant differences in serum total bilirubin levels between the pathological groups. Total bilirubin showed sensitivity of 48% and specificity of 61% in the diagnosis of acute appendicitis. Total serum bilirubin more than 0.85 mg/dl was the cut-off value with the best performance for diagnosis of appendicitis. CONCLUSION: Bilirubin levels are reliable, sensitive and specific to diagnosis and a prediction of complicated appendicitis.

Chronic Anal Fissure: A Comparative Study of Medical Treatment Versus Surgical Sphincterotomy.

To determine whether the medical Treatment of anal fissure can be an effective alternative for surgery Methods: Retrospectively, we randomly selected 190 Patients being treated for anal fissure between the years 2005-2010 in 3 equal groups: group A: Patients who received medical treatment with topical nitroglycerin, group B: Patient treated with topical diltiazem, and group C: Patients underwent surgery. The results were then correlated with the statistical program SPSS using chi-square test. Main complaints of the patients were first anal pain and then bleeding. The response to treatments for relieving pain was: 77% in A, 83% in B, and 98% in group C. Response of treatments for fissure healing, in order of groups A, B and C was: 74%, 83%, and 94%. Despite good response to medical treatment, surgical treatment was more effective and medical treatment of choice in patients who are willing to have surgery.

Concomitant splenic and hepatic hydatidosis: report of two cases and review of the literature.

Hydatid disease has a worldwide spreading. The most common site of the disease is the liver, lungs, kidney, bones, and brain. Splenic hydatid disease has been reported to constitute 2% to 6% of patients with abdominal hydatid disease. Because of the rarity of splenic hydatid disease, the probable concomitance of the liver and splenic hydatid cysts should be taken into consideration by clinicians, especially in nonendemic areas. In this report, we present two patients with concomitant splenic and liver hydatid cysts that underwent splenectomy and cystostomy-capitonage.

Assessment of surgical site infection risk factors at Imam Reza hospital, Mashhad, Iran between 2006 and 2011.

BACKGROUND: The present study was conducted to establish the patterns and risk factors of surgical site infections in our institution between 2006 and 2011. METHODS: This was a retrospective cross-sectional study. The surgical site infection (SSI) was identified based on the presence of ICD-10-CM diagnostic code in hospital discharge records. By using a standardized data collection form predictor variables including patient characteristics, preoperative, intra-operative and postoperative data were obtained. RESULTS: Ninety five patients fulfilled the inclusion criteria. The patients were admitted for various procedures including both elective (62.1%) and emergency (37.9%) operations. Colectomy (13.7%) was the leading procedure followed by umbilical herniation (12.6) and appendix perforation (12.6%). The mean age was 47.13 years with standard deviation of 19.60 years. Twenty percent were addicted to opium. Midline incision above and below the umbilicus (40%) had the highest prevalence of infection. Most patients (46.3%) had cleancontaminated wounds and 30.5% had contaminated one. The quantitative variables which were also measured include duration of surgery, pre-operative and post-operative hospital stay with the mean of 2.9±1.45 hours, 1.02±1.42 and 7.75±6.75 days respectively. The most antibiotics prescribed post-operatively were the combination of ceftriaxone and metronidazole (51.6%). CONCLUSION: The contaminated and clean-contaminated wounds are associated with higher rate of SSIs. Also, there was a converse relation between length of surgical incision and rate of SSIs. In overall, we found type of surgery as the main risk factor in developing the SSIs.

Spontaneous rupture of the spleen secondary to amyloidosis.

Spontaneous splenic rupture (SSR) is a rare condition. It may be an idiopathic event or may occur secondary to a pathological condition of the spleen. Systemic amyloidosis is characterized by the extracellular deposition of amyloid proteins in one or more organs. The spleen can be affected in 41% of patients. Amyloidosis and consequently, splenic rupture may occur as a complication of amyloid infiltration. We present the case of a 61-year-old male with abdominal pain and hypotension. There were peritoneal signs during physical examination and falling hematocrit was reported in the laboratory tests. The patient was suspected of having an aortic dissection. Thoraco-abdominal computed tomography (CT) angiogram was negative and ultrasonography revealed splenic rupture and free fluid in the abdominal cavity. The patient underwent laparotomy when found hemoperitoneum as a consequence of splenic rupture. The subsequent histopathological report of the spleen revealed amyloidosis. Thus, in patients with abdominal pain and hypotension, we should suspect the possibility of a spontaneous splenic rupture, even without trauma or infection history.

Large omental cyst: a case report and review of the literature.

Omental cysts occur rarely. Patients with omental cysts usually present with abdominal distention and a painless abdominal mass. In children it may present as an acute abdomen due to intestinal obstruction. The most common physical finding of an omental cyst is a freely movable abdominal mass, which should be considered in differential diagnosis of these cases. The diagnostic procedures include ultrasonography and computed tomography (CT) scans. Complete excision of the cyst is considered as the treatment of choice. Recurrence and malignant deterioration of omental cysts are rare. We describe a 32- year-old female who presented with complaints of vague abdominal pain and distension. The patient underwent laparotomy with preoperative diagnosis of the ovarian cyst. The diagnosis of omental cyst was established by intraoperative findings. Thus, complete excision of the cyst was performed. The diagnosis was confirmed by pathological examination.

Primary localization of a hydatid cyst in the latissimus dorsi muscle: an unusual location.

BACKGROUND: Hydatid disease is a parasitic infection that is endemic in Iran. It infests humans and herbivorous animals and reflects infection by Echinococcus granulosus. Although it can develop anywhere in the body, the liver and lungs are the most common sites of involvement. Primary muscular hydatidosis with no involvement of thoracoabdominal organs is a rare event. METHODS: Case report and review of relevant literature. RESULTS: We treated a 27-year old male patient with a swelling on his right shoulder that turned out to be a hydatid cyst by magnetic resonance imaging scan. The treatment included surgical excision combined with post-operative anthelminthic administration. Of the total reported cases of hydatidosis, 0.7-3% were described as musculoskeletal cysts. CONCLUSIONS: Especially in endemic areas, to avoid fine-needle biopsy and the risk of spillage of cyst contents irrespective of their location, hydatid disease should be considered in the differential diagnosis of muscular masses, and the diagnosis should be made by imaging and serology insofar as possible.

Study of the Radical vs. Conservative Surgical Treatment of the Hepatic Hydatid Cyst: A 10-Year Experience.

The hepatic hydatid cyst is a major health problem in endemic areas. Surgery is still the best choice for the treatment of hydatid cyst of the liver. There is controversy regarding efficacy of radical versus conservative surgical approaches. In this study, we aimed to evaluate the two surgical methods in patients treated for the hepatic hydatid cyst. This is a retrospective review of the medical records of 135 patients who underwent surgery for the hepatic hydatid cyst from 1993 to 2003. Surgery comprised conservative methods (evacuation of the cyst content and excision of the inner cyst layers) and radical methods (total excision of the cyst and removal of its outer layer). One hundred thirty five patients underwent liver surgery. Conservative surgery was performed for 71 (53%), whereas, the remaining 64 patients (47%) underwent radical surgery. Local recurrence rate of the cysts was lower in the radical versus conservative surgery group and the mean length of hospital stay was shorter in the radical surgery group. Radical surgery of the hepatic hydatid cyst may be the preferred treatment because of its low rate of local recurrence, as well as short hospital stay.