Introduction: Malrotation is considered a newborn disease. This case report sheds light on the rare, but possible late presentation of malrotation in adulthood, which if missed, can leave the patient in a detrimental state. Presentation of case: 28-year-old female presented in critical state with acute abdomen. Computed tomography abdomen/pelvis showed midgut volvulus, requiring urgent laparotomy. The patient’s bowels were discolored, yet they normalized upon detorsion, except for a small portion, which was equivocal and left for observation. Ladd’s bands were excised, and the abdomen was closed with Bogota bag for re-exploration. The patient underwent two more laparotomies to observe the intestinal segment until it was back to normal. Ladd procedure was then completed, and an absorbable mesh was applied. Follow-up of 20 months has been uneventful, except for a small, asymptomatic, incisional hernia. Discussion: Malrotation in adults is often missed due to its subacute, nonspecific presentation. It is often diagnosed by CT abdomen, which shows inversion or vertical positioning of the superior mesenteric vessels. Symptomatic, but stable patients, can undergo laparoscopic Ladd procedure, which carries the benefit of less length of stay. While an incidental malrotation can be prophylactically operated on, correcting asymptomatic malrotation beyond age of 20 is ineffective and possibly harmful. Conclusion: Intestinal malrotation presenting in an adult should be on the differential diagnosis when dealing with abdominal pain, especially in the context of small bowel obstruction in a virgin abdomen. It is vital to consider a patient’s age prior to prophylactically operate on malrotation discovered incidentally. Highlights:

Background: The reliability of sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NACT) in patients with initially node-positive breast cancer is still controversial. This meta-analysis is conducted to investigate the feasibility and accuracy of SLNB after NACT in patients with initially positive axillary nodes. Methods: We conducted a literature search using Medline, PubMed, Embase, Central, and SCOPUS up until April 2021 for studies on the performance of SLNB following NACT. We included prospective studies including breast cancer patients with positive lymph nodes at diagnosis and received NACT before undergoing SLNB irrespective of their molecular subtypes or stage. Our main outcomes of interest were the identification rate (IR) and the false negative rate (FNR) of SLNB. Results: We included an aggregate of 33 studies in this meta-analysis enrolling 4624 patients. The reported IR ranged from a minimum of 77.6% to a maximum of 100% and resulted in a pooled IR of 88% (95% confidence interval [CI]: 86–90, I ²: 80.9%). The FNR reported in the studies ranged from a minimum of 5.1% to a maximum of 43% and showed a pooled FNR of 13% (95% CI: 11–15, I ²: 72.31%). The subgroup analysis demonstrated that the usage of dual mapping technique could decrease the FNR and increase the IR. Moreover, the number of lymph nodes retrieved inversely correlated with FNR (P < 0.01). Conclusions: Our findings support the feasibility and accuracy of SLNB after NACT in initially node-positive breast cancer patients, that converted to clinically node-negative when performed in properly selected cases. SLNB offers a less invasive approach in selected patients sparing them the morbidity associated with ALND. This approach aligns with efforts to de-escalate surgical management in breast cancer and reinforces that SLNB post-NACT should be incorporated into clinical practice, provided that stringent patient selection and procedural standards are maintained.

Introduction. Advances in genomic techniques have been valuable in guiding decisions regarding the treatment of early breast cancer (EBC) patients. These multigene assays include Oncotype DX, Prosigna, and Endopredict. There has generally been a tendency to overtreat or undertreat patients, and having reliable prognostic factors could significantly improve rates of appropriate treatment administration. In this study, we showcase the impact of genomic tests on adjuvant treatment decisions in EBC patients. Materials and Methods. This is a retrospective study that includes EBC patients treated between December 2016 and February 2018. The physicians choice of treatment was recorded before and after obtaining the results of the genomics tests. Baseline demographics and pathological data were collected from medical records. Results. A total of 75 patients were included. Fifty patients underwent Oncotype DX genomic analysis, 11 patients underwent Prosigna analysis, and 14 patients underwent Endopredict analysis. A total of 21 physicians plans (28) were initially undecided and then carried out after obtaining genomic test results. 13 patients were planned to undergo endocrine therapy alone, while 8 were planned to undergo both endocrine therapy and chemotherapy. Treatment was changed in 26 patients (34.67). The decision to deescalate therapy was taken in 19 patients (25.33). The decision to escalate treatment was made in 7 patients (9.33). Conclusion. Our study demonstrates the importance of genomics testing, as it assisted physicians in avoiding unnecessary adjuvant chemotherapy in 25.33 of patients, thus reducing side effects of chemotherapy and the financial burden on patients.

Developing countries have a significantly higher incidence of breast cancer in patients younger than 40 years as compared to developed countries. This study aimed to examine if young age at diagnosis is an independent prognostic factor for worse survival outcomes in breast cancer as well as the effect of age on Disease-free survival (DFS) and local recurrence free survival (LRFS) after adjusting for various tumor characteristics, local and systemic treatments. This is a secondary analysis of prospective cohort of patients from two existing databases. We identified patients with breast cancer aged 40 years or less and we matched them to those older than 40 years. We also matched based on stage and molecular subtypes. In cohort 1, we matched at a ratio of 1:1, while in cohort 2 we matched at a ratio of 1:3. In cohort 1, Disease-free survival (DFS) at 5 years was significantly shorter for those younger than 40 years (75.6% and 92.7% respectively; p < 0.03). On multivariate analysis, only chemotherapy was found to be significant, while age was not found to be an independent predictor of prognosis. Local recurrence free survival at 5 years was similar between both age categories. Only hormonal therapy is a significant predictor for LRFS at 5 years. In the second cohort, DFS and LRFS at 3 years were similar between those younger and those older than 40 years. On multivariate analysis, no factor including age was found to be an independent predictor of prognosis. Data in the literature is controversial on the effect of young age on breast cancer prognosis. Our findings could not demonstrate that age is an independent prognostic factor in our population. There is a need for outcomes from larger, prospective series that have longer follow-ups and more data from our region.

Background: Anal fissure is a common complication of the anorectal region and one of the most reported causes of anal pain. Acute anal fissure can be cured by surgery or medical treatment. There is an increase in the use of topical therapy for the treatment of anal fissures. A common topical drug used is Diltiazem (DTZ), a calcium-channel blocker, which relaxes the anal sphincter and thus promotes healing of the anal fissure. Moist exposed burn ointment (MEBO) is an ointment that is effective for the treatment of burns and wound healing and is becoming popular in the treatment of anal fissures. Methods: This is a 1:1:1 randomized, controlled, parallel design, with endpoint measures of change in pain score, wound healing, defecation strain score and patient’s global impression of improvement. The study will be conducted at AUBMC over a 10-week period. Patients will be randomized to three treatment arms: MEBO, Diltiazem, and a combination of MEBO and Diltiazem ointments. Discussion: The results of this study will allow physicians to assess the efficacy and safety of MEBO in the treatment of acute anal fissure, and also in comparison to Diltiazem. This trial will generate evidence-based conclusions regarding the use of a herbal/natural-based product (MEBO ointment) for the treatment of anal fissures. Trial registration: ClinicalTrials.gov Identifier NCT04153032. Clinical Trial Registration Date: 06-NOVEMBER-2019.