To the Editor,
We thank Thakur and Bhatia for their insightful letter, “Home-based Pulmonary Rehabilitation in COPD: Bridging Evidence and Practice for Comprehensive Patient-centered Care,” and for their gracious recognition of our study, “From Breathless-ness to Better Living: Transforming COPD Care with Home-based Pulmonary Rehabilitation.”
The evolving landscape of metastatic prostate cancer (mPCa) necessitates a redefinition of the urologist’s role, extending beyond diagnosis to active participation in therapeutic and surgical management. This review outlines evidence-based approaches to biopsy and surgical interventions across the disease spectrum. Prostate biopsy remains fundamental for diagnosis, treatment stratification, and molecular profiling, with targeted and metastatic lesion sampling improving precision oncology. For symptom relief, surgical management of bladder outlet obstruction through transurethral resection of the prostate and holmium laser enucleation of the prostate remains essential, with emerging data suggesting possible oncologic benefits when combined with systemic therapy. GreenLight photoselective vaporization may represent an alternative option, though evidence remains limited. Cytoreductive radical prostatectomy in carefully selected patients with metastatic hormone-sensitive disease may provide improved local control and delayed progression, supported by growing biological rationale but constrained by the retrospective nature of current evidence. Collectively, these findings underscore the expanding multidisciplinary role of the urologist in mPCa care, emphasizing the need for prospective studies to validate the integration of surgical approaches within systemic treatment frameworks.
Background: Ampullary neuroendocrine tumors (NETs) are extremely rare, representing 0.3%–1% of gastrointestinal NETs and less than 2% of periampullary cancers. Due to their rarity, there is limited data on their natural history, management, and outcomes. Current European Neuroendocrine Tumor Society guidelines (2023) recommend pancreaticoduodenectomy (PD) as the standard treatment. However, this approach is invasive and associated with high morbidity and mortality. Emerging evidence suggests that endoscopic papillectomy (EP) could be a viable alternative in selected cases. This retrospective multicenter study aimed to evaluate the feasibility and outcomes of endoscopic resection for ampullary NETs.
Methods: This retrospective case series included 14 patients who underwent EP for ampullary NETs between 2011 and 2022 across three Italian tertiary centers. Pre-procedural evaluation was performed following European Society of Gastrointestinal Endoscopy guidelines. Endoscopic papillectomy was performed under monitored sedation, using standard snares for en bloc resection. Follow-up endoscopy was conducted at a median of 3 months. Primary outcomes included complete resection (R0) and recurrence rates; secondary outcomes focused on adverse events.
Results: Fourteen patients (median age: 62.5 years; 50% male) were included. Median tumor size was 18 mm. In 12 out of 14 cases, ampullary NETs were diagnosed only after endoscopic resection. Post-resection histology identified 8 G1 NETs (Ki-67 1%) and 6 G2 NETs (Ki-67 5%). Complete resection was achieved in 11 cases (78.6%). Among 3 incomplete resections, 2 were managed surgically, while 1 was followed up without recurrence. Residual disease was detected in 3 patients: 2 were managed endoscopically, and 1 required surgery. No recurrences occurred during a median follow-up of 14.5 months. Adverse events occurred in 42.9% of patients, including 5 cases of bleeding and 1 case of mild pancreatitis, all resolved without major sequelae. Median hospital stay was 2.5 days.
Conclusions: Our findings suggest that EP offers a promising alternative to surgery in selected patients with ampullary NETs. Endoscopic resection was associated with high rates of R0 and favorable short-term outcomes, with effective endoscopic management of residual disease and procedure-related adverse events. Consistent post-procedural surveillance remains essential to detect residual or recurrent disease. Larger prospective studies are warranted to refine patient selection criteria, optimize protocols, and establish the long-term efficacy.
Immunotherapy using immune checkpoint inhibitor (ICI) has been increasingly used in the oncology treatment field. Although ICIs could help suppress cancer and improve survival rates, it could also lead to certain adverse events, including immune-mediated liver injury caused by ICIs (ILICI). The manifestation of ILICI ranged greatly from asymptomatic disease to liver failure and even death. In this review article, we will discuss the pathogenesis, manifestation, and clinical approach of ILICI.
To the Editor,
We thank Dr Vijayasimha and colleagues for their thoughtful analysis of our work and their proposal for prospective validation of the Padua × D-dimer (PaDd) score. Their roadmap provides a rigorous framework that addresses critical gaps in our single-center retrospective design. We welcome this opportunity to clarify key methodological considerations and invite the global research community to collaborate on next-generation studies.
We address the critical diagnostic challenge of IgG4-related mastitis (IgG4-RM), a rare tumor-like condition that may represent an isolated breast involvement or be the initial manifestation of systemic IgG4-related disease. IgG4-RM presents a significant diagnostic pitfall in the context of core needle biopsies (CNBs) because it frequently mimics malignancy, clinically presenting as a firm mass with skin changes or lymphadenopathy. Accurate diagnosis is often hindered by several factors: the nonspecific nature of the histopathology (fibrosis and lymphoplasmacytic infiltrate), significant overlap with inflammatory entities like Granulomatous Lobular Mastitis, limited tissue yield from CNBs, and the under-utilization of definitive IgG4 immunohistochemical staining. Furthermore, the lack of in-house IgG4 immunohistochemistry at many facilities restricts its use. Given that IgG4-RM is a medically managed condition, primarily treated with systemic corticosteroids, the underdiagnosis of this entity leads to unnecessary, costly, and morbid surgical excisions. We advocate for pathologists to maintain a high index of suspicion and routinely employ supplementary IgG4 staining in suspicious CNB cases to ensure correct non-surgical patient management.
The Talmud describes several illnesses attributed to Rabbi Judah ha-Nasi, one of the foremost leaders of the Jewish people after the destruction of the Second Temple, and the compiler of the canonical Mishnah. Among these conditions, Tzafedina of the oral cavity is mentioned, characterized by severe and persistent pain lasting for seven years. Although many modern scholars tend to identify this condition with scurvy, the Talmudic accounts of Rabbi Judah’s diet and lifestyle do not support a state of nutritional deficiency. Moreover, scurvy is not typically associated with oral pain. Instead, it is more plausible that the term Tzafedina functioned as an umbrella designation for a spectrum of oral disorders, potentially involving the teeth or gingiva. When applied to Rabbi Judah ha-Nasi, the Talmudic narrative appears to emphasize the psychological and symbolic dimensions of suffering. Thus, in addition to the possibility of organic oral pathologies with psychosomatic components that may manifest in the gingiva, the account may also correspond to chronic oral pain syndromes recognized in contemporary oral medicine.
Introduction: Polypharmacy carries the potential for increased risk and severity of adverse reactions. Deprescribing may reduce adverse events and possibly hospitalizations, although evidence on hard outcomes such as mortality is mixed. As the medication experts responsible for the close monitoring of their patient, doctors, nurses, and pharmacists play a crucial role in the process of medication deprescribing. They are involved in the therapeutic process and contribute to the appropriate use of medications and the proper discontinuation of those that no longer benefit the patient or are harmful. This role is particularly important for vulnerable groups, such as older people, who often take chronic medication.
Objective: This study aims to review the literature on polypharmacy and the importance of suspending unnecessary or harmful medications in older people, emphasizing the role of healthcare professionals in the process.
Methods: A narrative review of recent publications (articles from 2023 to 2025) in Web of Science, PubMed, and Scopus databases, addressing polypharmacy and deprescribing in older adults was conducted.
Conclusions: A multidisciplinary team including doctors, nurses, and pharmacists plays a pivotal role in this process by reviewing patients’ therapeutic regimens, identifying inappropriate medications, and monitoring the withdrawal process. Their intervention can support more appropriate medication use, may improve patients’ quality of life, and has the potential to reduce healthcare costs.
While individual Jewish plastic surgeons have been recognized in the literature for their groundbreaking achievements, a comprehensive review of their collective contributions to plastic surgery is lacking. The goal of this review is to document and highlight the major advancements made by Jewish physicians whose work significantly impacted plastic and reconstructive surgery from its inception as a discipline to the present day. A comprehensive literature search was conducted to identify key developments in the history of plastic surgery, which were then narrowed to those made by Jewish practitioners. The Jewish identity of these practitioners, along with the significance of their work, was verified through historical records, newspaper archives, and peer-reviewed publications. Contributions were then organized chronologically to construct a cohesive historical narrative. Beginning in the 1800s and accelerating through the 20th century, Jewish plastic surgeons have been instrumental in shaping the field. Their innovations include advancements in the treatment of facial deformities, the development of the lumpectomy with adjunctive radiation therapy as a less invasive alternative to radical mastectomy, and the founding of key institutions such as the American Society of Plastic Surgeons and the International College of Surgeons. Additional breakthroughs include the use of albumin in burn management, foundational work in angiogenesis physiology, and numerous innovations in cosmetic surgery. The history of plastic and reconstructive surgery is a rich tapestry of discovery and evolution. Fully understanding its development is not possible without acknowledging the enduring and transformative contributions of Jewish surgeons and researchers.
Objectives: This study explored the relationship between visual perceptual skills and participation performance in 4–6-year-old children diagnosed with autism spectrum disorder (ASD).
Methods: A cross-sectional design was employed for children diagnosed with ASD. Visual perceptual abilities were assessed using the Motor-Free Visual Perception Test–Fourth Edition (MVPT-4), and participation levels were measured using the Children Participation Questionnaire (CPQ). Statistical analysis was done using SPSS version 26, employing one-sample t-tests and Pearson correlation analysis.
Results: A total of 48 participants were included in the study: mean age, 4.98±0.82 years; 66.7% were male; 79.2% attended regular schools. One-sample t-tests indicated significant deficits across all CPQ dimensions (P<0.001). Visual perception was negatively correlated with autism severity (r=-0.429, P=0.002) and positively correlated with participation diversity (r=0.404, P=0.004). In the activities of daily living (ADL) and instrumental ADL (IADL) occupations, visual perception was significantly associated with all CPQ elements. Conversely, play and leisure occupations showed mostly negative correlations with the CPQ occupations, while social participation and education showed mixed results. Visual perception was positively correlated with most elements but negatively associated with enjoyment (r=-0.428; P=0.002).
Conclusions: Preschool children with ASD demonstrate significant participation restrictions. Visual perception emerged as a critical determinant of participation, particularly in ADL and educational contexts. Early interventions targeting visual perception skills may enhance independence and functional engagement, though interventions should also address the enjoyment and emotional experience occupations to ensure holistic participation outcomes.
