Functional and Aesthetic Outcomes of No-Dissection Nasal Dorsum Using Subdorsal Septal Excision in Preservation Rhinoplasty.

BACKGROUND: Dorsal preservation (DP) caused privilege change in the concept of rhinoplasty and a promising superior functional and aesthetic transformation in rhinoplasty surgery. Avoiding dissection of the dorsal nasal bone and cartilage will leave the soft-tissue envelope intact, leading to a fine and smooth appearance, faster operation with less subsequent edema, and overall preservation of the dorsal aesthetic line. METHODS: This prospective study included 113 patients who underwent DP rhinoplasty for nasal hump treatment with minimum dissection of nasal dorsum soft-tissue envelope. Results were evaluated using the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS). RESULTS: The mean preoperative SCHNOS score was 7.21; the mean obstructive score was 2.95 ± 1.068 and the mean aesthetic score was 4.27 ± 0.771. The average lowering of the dorsal hump was 4.4 mm. Approximately 96% of patients showed improvement in the SCHNOS score after surgery, 86.7% (98 patients) showed improvement in the obstructive symptoms and 95.6% (108 patients) showed improvement in the aesthetic score. Complications were seen in 22.11% (most commonly residual hump in 13.27% of cases and dorsal indentation in 5.31%), bleeding was seen in 2.65%, and granuloma formation at the dorsal osteotomy site was seen in 0.88%. There was a very significant improvement in the aesthetic, obstructive, and overall SCHNOS score ( P = 0.000) for each parameter. CONCLUSIONS: DP rhinoplasty is a safe and very effective procedure, with very low risk of complications. Most of the treated patients have improvement of the obstructive and aesthetic outcome after surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Emergency Presentations of Meckel's Diverticulum in Adults.

Introduction: Meckel's diverticulum is the commonest congenital anomaly of the gastrointestinal tract in humans that is commonly encountered during surgical practice as the cause of the patient's presentation or as an incidental finding during other unrelated procedures. Most clinical symptoms are caused due to its complications. Results: The mean age of the involved patients was 24.79 years with slight male predominance, 62.9% males compared to 37.1% females. The mean length of the diverticulum was 55.21 cm. The most common emergency presentation was right lower quadrant abdominal pain in 31% of the patients, intestinal obstruction in 28.6%, acute lower abdominal pain and guarding and acute abdomen in 18.6% and 15.7% of patients, respectively, bleeding per rectum in 2.9%, acute right upper quadrant abdominal pain in 1.4%, and obstructed paraumbilical hernia containing the diverticulum in one patient. Perforation of the Meckel's diverticulum was reported in 18.6%. Histopathological examination showed acute inflammation in the wall of the diverticulum in 37.1%, lymphoid hyperplasia in 24.3%, hemorrhagic necrosis in 22.9%, and chronic inflammation in 8.6%. Ectopic mucosa was detected in 50% of the cases, gastric mucosa was detected in 42.86%, ectopic pancreatic mucosa was detected in 5.71%, and both gastric and pancreatic types in 1.43%. Conclusion: Long diverticula are more liable to develop complications. At surgery, inspection and palpation of the wall of the diverticulum must be done for any evidence of inflammation, necrosis, perforation, or abnormal thickening of the walls of the diverticulum. Resection of the segment of the bowel that contains the diverticulum with primary anastomosis is preferable to other procedures due to the risk of leaving behind an abnormal heterotopic mucosa.

Insights into Human Cystic Echinococcosis in the Kurdistan Region, Iraq: Characteristics and Molecular Identification of Cysts.

Cystic echinococcosis (CE) is a neglected worldwide distributed parasitic disease caused by the Echinococcusgranulosus sensu lato (s.l.) species complex. For a better understanding of the pathways of transmission of this parasite, clinical and molecular epidemiological studies are particularly needed from endemic areas where data are scant, such as in the Middle East. The study aimed to identify the characteristics, location, cyst stage and species/genotypes of E. granulosus s.l. complex in humans from the Kurdistan region, Iraq. To this aim, from June 2019 to February 2021, 64 echinococcal cysts were surgically removed from 62 patients in Azadi and Vajeen reference Hospitals at Duhok city, Duhok governorate (Kurdistan region, Iraq). The results confirmed the liver as the most common anatomical site of CE with 72.58% of the cases, followed by the lungs in 19.35%, while 66.13% of CE cases were females. The highest rate of infections occurred in the age class 21−30 (27.42%). High rates of CE were reported among patients living in rural areas and housewives, which were 54.84% and 43.55% of the CE patients, respectively. The fertility of echinococcal cysts was 82.81%, and the viability of fertile protoscoleces was 70.53%. Cysts were staged with ultrasound according to the WHO-IWGE classification as 32.8% CE1, 32.8% CE2, 7.8% CE3a, 9.4% CE3b, 15.6% CE4 and 1.6% CE5. Molecular analyses using mitochondrial NAD5 gene showed that all analyzed samples (n = 59) belonged to the genotypes G1 or G3 of E. granulosussensu stricto (s.s.), thus, confirming sheep−dog−human transmission in the Kurdistan region, Iraq. No statistically significant correlation was found between the genotypes G1−G3 of E. granulosus s.s. and variables, such as the fertility, location and cyst stage classification. Based on the present findings, it is necessary to implement monitoring and control programs in sheep and dog populations to decrease the odds of human infections. Public health education campaigns are required to be implemented at the community level to reduce the risk of acquiring CE in humans in the Kurdistan region, Iraq.

The clinical behavior of different molecular subtypes of breast cancer.

BACKGROUND: Breast cancer is a heterogeneous group of tumors classified, according to different gene expressions that encodes for the hormone receptor status, into 4 main categories which are: luminal types A and B, triple negative/basal-like, and Her-2 molecular subtypes. PATIENTS AND METHODS: This retrospective study included 311 breast cancer females. Patients were classified according to the expression of hormone receptors into: Luminal-A, luminal-B, HER-2 enriched and basal-like types. All groups were then studied for differences in clinical course of the disease. RESULTS: Luminal-B type was the commonest molecular type (43.73%). Invasive ductal carcinoma was the commonest histological type (89.1%). Stages IIB and IIIA were the commonest clinical stages (24.4% & 22.2%) respectively. Most patients had no recurrence (85.5%), the commonest recurrence was local and axillary ones (7.1%). Low grade tumors were less frequent than intermediate and high grades (3.5%, 51.1%, and 45.3%). We found a significant correlation between molecular subtypes and survival status, tumor grade, and histopathological types (P values 0.029, 0.001, and 0.006) respectively, while it was not significant with age, BMI, recurrence & metastatic disease, overall survival, and TNM stage (P values 0.648, 0.398, 0.5, 0.063 and 0.319). CONCLUSION: Luminal types A and B are the commonest molecular subtypes of breast cancer. Luminal type A is associated with improved survival, and basal like has the highest breast cancer fatality rates. Invasive ductal carcinomas of specific types mostly found in patients with luminal types A and B, while other rare forms like Paget's disease was diagnosed HER-2 enriched types.

Mammary duct ectasia in adult females; risk factors for the disease, a case control study.

INTRODUCTION: Mammary duct ectasia is a common clinical condition characterized by abnormal dilatation of the central milk ducts with chronic inflammation and fibrosis, it may affect one or both breasts. Patients may be completely asymptomatic or have mastalgia or nipple discharge which is usually from multiple ducts. It mostly affects females and is very rare in males. PATIENTS AND METHODS: This is a case control study which included 236 females grouped into two equal groups, the first group were patients with duct ectasia compared and the other one apparently healthy females and both groups were compared regarding different characteristics. RESULTS: Most patients were young with a mean age of 35 years, a most of them were overweight (42.4%) and obese (33.1%). Most were menstruating (86.4%) with regular cycles (79.7%). Most patients had breast pain (67.8%), tenderness (54.2%), and no nodularity (98.3%). About 47.5% had nipple discharge mostly from multiple ducts (43.2%), 52.5% had no discharge. There was a significant correlation between the development of duct ectasia and each of marital status, lactational status, coffee consumption, pain, nodularity, and breast tenderness (P values 0.026, 0.016, 0.034, 0.000, 0.000, and 0.000). CONCLUSION: Duct ectasia is a very common complaint in females, it is commoner in overweight and obese females, married females and those with history of lactation. Coffee consumption may be a cause. The regularity of the menstruation has no correlation with its development. The presence of mastalgia, tenderness, and nodularity are highly suggestive for the disease.

Dorsal urethro-cutaneous fistula caused by an impacted stone at the bulbar urethra: Case report.

BACKGROUND: Penile urethral stones are very and constitutes less than 1% of the urinary tract stones and commoner in males. They are either primary or secondary. The clinical diagnosis require high index of suspicion. CASE PRESENTATION: A 30-year-old male was complaining of penile pain, weak urinary stream and dribbling at the end of micturition for 2 months, later on he developed severe dysuria and a tender nodule over the dorsal penile surface. An attempted urethral catheterization was failed. There was no history of urethral trauma or instrumentation. Examination of genitalia revealed a normal meatus with a fistula at dorsal mid penile shaft and the urine were coming out from that opening with surrounding redness and edema with palpable firm nodule in the penile shaft. A pelvic x-ray revealed a mid-urethral radiopaque shadow, cystoscopy revealed an impacted stone in mid-bulbar urethra, attempts of stone extraction was failed. An open ventral urethral incision was made and the stone was removed, dorsal fistulectomy and repair was performed. Foley's catheter was placed and removed later after 21 days. The patient had uneventful postoperative period and the follow up was done up to 6 months with no postoperative complications. CONCLUSION: The clinical diagnosis of penile urethral stones require high index of suspicion. Management options are variable depending on impaction site, the size, and associated urethral pathologies. The fistula tract require excised and repair.

Gallbladder agenesis: An accidental finding during laparotomy for hepatic tumor.

BACKGROUND: Anomalies of the biliary system are frequently encountered. Agenesis of the gall bladder is a rare. The exact incidence is not known as most cases are asymptomatic and diagnosed incidentally during surgeries for unrelated conditions or at autopsy. This anomaly may occur alone or in association with other anomalies such as other biliary anomalies, portal vein anomalies and other vascular anomalies, or in some cases hepatic, gastrointestinal or anomalies in other body systems. CASE PRESENTATION: An elderly man diagnoses with segment VI liver tumor and planned for surgical resection. During surgery we accidentally discovered gall bladder agenesis with slightly dilated common bile duct. The tumor resected successfully and the final diagnosis was well differentiated with hepatocellular carcinoma. CONCLUSION: Careful search for the gall bladder must be done before diagnosing agenesis of the gall bladder. No conversion is required provided adequate visualization and search for the gall bladder is done during laparoscopy. Postoperative MCRP will define the biliary anatomy and to help the surgeons to have postoperative accurate decision.

Two Concomitant Right Nonrecurrent Laryngeal Nerves Encountered During Thyroidectomy (Type 4 Course): Reported for the First Time.

INTRODUCTION: The recurrent laryngeal nerve gains its name because after branching from the vagus nerve, it turns superiorly (recur) around the subclavian artery on the right and around the ligamentum arteriosum on the left, the nonrecurrent nerve has a straight direct course to the larynx and doesn't follow this course. It presents mostly on the right side. The presence of this variation places the nerve at higher risk of injury during neck surgery especially thyroid operations. CASE PRESENTATION: A 45-year-old lady presented with painless thyroid enlargement for 1 year. Thyroid examination showed a 3-cm firm nodule at the right thyroid lobe with normal thyroid function tests. Right thyroid lobectomy was done and the histopathology showed a benign follicular lesion. During surgery, we discovered 2 nonrecurrent laryngeal nerves at the right side which were arising from the vagus nerve and both were entering the larynx. CONCLUSION: Failure in identification of the nerve or overlooking the possibility of the non-recurrent laryngeal nerve may result in a serious sequelae of nerve damage, ipsilateral injury may lead to permanent hoarseness and bilateral injury may result in severe dyspnea or aphonia. Currently, there are 3 types of nonrecurrent laryngeal nerve courses. Type 1 passes near to the superior thyroid vessels. Type 2 (2A) passes parallel to the inferior thyroid artery and has a transverse course above it. Type 3 (2B) passes parallel to the inferior thyroid artery and transversely between branches of or under the inferior thyroid artery, we can add to this classification type 4, which are 2 nonrecurrent laryngeal nerves (double nerves) passing above and parallel to the inferior thyroid artery.

Hydatid cyst of the ovary - a very rare type of cystic ovarian lesion: A case report.

BACKGROUND: Hydatid disease is a zoonotic condition caused by the adult or the larval stages of tapeworms belonging to the species Echinococcus granulosus or less commonly Echinococcus multilocularis. The presentation depends on the site of involvement. Many cases are not symptomatic and may be discovered accidentally. Hydatid cyst of the ovary is an extremely rare presentation and accounts for 0.2-1% of the diagnosed cases. It may be mistaken for ovarian cysts or cystic tumors of the ovary. CASE PRESENTATION: An 18-year-old woman complained of episodes of lower abdominal pain and frequent urination for the last 3 months. During abdominal examination, there was deep tenderness in the supra-pubic region with no palpable organs or masses. Ultrasound of the abdomen showed evidence of cystic left adnexal lesions. A computerized tomography scan of the abdomen revealed evidence of cystic left adnexal lesion with no enhancement after contrast injection. Laparoscopy was performed and there was evidence of a hydatid cyst of the left ovary. The cyst was extracted from the cavity using a retrieval bag. Anthelmintic medications were prescribed for 3 months, and follow-up ultrasound after 6 months was normal. CONCLUSION: A high index of suspicion is required for the diagnosis, particularly in the presence of any cystic lesion, in any part of the world. The enzyme-linked immunosorbent assay test may be informative in the active stages of the disease. Laparoscopic management involves cyst excision. Anthelmintic drugs are required after surgery to decrease the recurrence rate.

Strangulated small-bowel internal hernia through a defect in the broad ligament of the uterus presenting as acute intestinal obstruction: A case report.

BACKGROUND: Internal hernias rarely lead to bowel obstruction; they are caused by a natural or unnatural opening within the peritoneal cavity. Defects in the broad ligament are extremely rare. Patients present with features of intestinal obstruction and most cases are diagnosed during surgery. CASE PRESENTATION: A 62-year-old parous woman presented with epigastric pain and attacks of vomiting for 1 week. The patient had had constipation for the last 5 days. She had no history of abdominal surgery. Abdominal examination revealed a distended abdomen with evidence of generalized abdominal tenderness.Abdominal CT scan showed evidence of intestinal obstruction. During laparotomy there were dilated small-bowel loops with an evidence of internal hernia through a 3 cm × 3 cm defect in the left broad ligament, through which a segment of strangulated terminal ileum was passing. Resection of the strangulated bowel was performed with end-to-end intestinal anastomosis. The broad ligament defect was closed with a slowly absorbable suture material. CONCLUSION: Surgery for intestinal obstruction due to internal hernias should follow the same principles of any case of intestinal obstruction, whether performed by the open conventional technique or laparoscopically. Surgery should not be delayed, to avoid increased morbidity and mortality. During surgery it is mandatory that the surgeon looks for any other possible defects and close them to avoid recurrence. Internal hernias caused by broad ligament defects are best managed by either closure of the defect or salpingectomy; the course of the ureter must be identified during surgery to prevent injury.

Mature cystic teratoma of the neck misdiagnosed at cystic hygroma; Case report.

BACKGROUND: Teratomas arise from primordial germ cells which arrest during its migration from the hindgut allantois the gonads during the first weeks of gestational life, they may occur in both gonadal and extra-gonadal locations. They occur in 1/40,000 live births. The most common anatomical locations are the sacro-coccygeal region and the ovary, neck teratomas constituted about 1.5%. Malignant transformation has been reported. CASE PRESENTATION: A 2-year-old boy presented with a gradually enlarging mass in the left side of the neck causing stridor and difficulties in respiration especially during sleep, the parents noticed difficulties during swallowing. The mass was misdiagnosed as cystic hygroma and the patient underwent 2 sessions of sclerotherapy with no improvement. Clinical examination showed a large mass in the left side of the neck which was multilobulated causing tracheal shift to the opposite side. There were no signs of inflammations over the mass. CT-scan showed evidence of enhancing multi-cystic lesion with multiple flecks of calcification. Complete surgical resection was done successfully and the histopathological study of the mass showed mature elements of ectodermal, mesodermal, and ectodermal germinal layers which was consistent with mature cystic teratoma. The follow up showed no postoperative complications. CONCLUSION: Mature cystic teratoma of the neck is very rare and may be difficult to be differentiated both clinically and radiologically from other neck masses. The accurate diagnosis must be made before any kind of treatment is started. Complete surgical resection is the main management option and required to decrease the recurrence.

Uterocutaneous fistula after cesarean section; Case report.

INTRODUCTION AND IMPORTANCE: Fistula is an abnormal tract communicating two epithelial surfaces, uterocutaneous fistula is an extremely rare. The classical presentation is cyclical bleeding from an abnormal opening in the scar of previous cesarean section. CASE PRESENTATION: A 28 year-old was presented 6 months after cesarean section with history of severe pain and blood discharge during menstruation from the previous transverse supra-pubic scar. The patient had history of previous 2 cesarean sections. Abdominal examination revealed a localized tenderness at site of previous operation scar with 1*1 cm opening at the central part of the scar which was discharging blood during pressure over the lower abdomen. There was no urine discharge from the scar. Vaginal examination by the speculum was normal. CLINICAL DISCUSSION: Endometriosis was suspected and the patient received medical treatment with little improvement. Later, surgical intervention was done, the scar was excised with an abnormal fistulous tract connecting endometrial cavity at the site of the previous scar was found. Complete excision of the tract was done and the uterus was re-sutured using a slowly-absorbable suture material. The patient had no complications with regular cycles. CONCLUSION: Uterocutaneous fistula is rare and usually follow cesarean section, suturing the uterus with non-absorbable suture material is reported in this case to be one of the underlying causes, other causes include infection, necrosis, foreign bodies, or malignancy. The fistula tract must be defined and any associated infection controlled, complete resection of the fistulous tract and suturing the uterus with absorbable suture material is required.

Can mini PCNL achieve the same results as RIRS? The initial single center experience.

BACKGROUND: Urolithiasis is a prevalent disease worldwide with high recurrence rate, minimally invasive interventions have largely replaced open ones, namely PCNL and RIRS. Miniaturization, optical improvements, and modern laser types made these procedures safe and effective in the management of single renal stones.Aim of the study: Is to compare the effectiveness of mini PCNL with RIRS in the treatment of single renal stone of ≤25 mm. PATIENTS AND METHODS: This prospective study that included 60 patients with single renal stones of ≤25 mm and were treated by either mini PCNL (group A) or RIRS (group B). The study was performed during the period from October 2020 to April 2021. RESULTS: The mean operative time RIRS group was 43.6 ± 10.493, while for miniPCNL it was 36.6 ± 7.035 (P = 0.004). The stone free rate in RIRS and miniPCNL group was 70% and 90% respectively (P = 0.053). The need for JJ stent was higher in RIRS compared to miniPCNL group (70% vs. 40%) respectively (P = 0.02). The duration of hospital stay in miniPCNL was 38.2 h compared to 16.7 h for RIRS group (p = 0.0001). The rate of postoperative hemoglobin drop was higher in MiniPCNL compared to RIRS (P = 0.0001). There was no significant difference regarding complication rates between both groups. CONCLUSION: Mini-PCNL FOR the treatment of renal stones sized ≤25 mm has high stone free rate, shorter operative time, less requirement for JJ stent and near similar post-operative pain and complications compared to RIRS.

The correlation of antioxidant levels of breast cancer: A case controlled study.

ABSTRACT: Many free radicles are implicated to activate a number of oncogenic signaling, cause damage to deoxyribonucleic acid and tumor suppressor genes, or promote expression of proto-oncogenes. Reduced level of antioxidants and increases oxidative stress markers are associated with the development of various types of cancer.This prospective study included 60 women who were grouped into equal groups. Patients group included 30 breast cancer women and control group consisting of 30 apparently healthy women. Both groups were compared regarding the serum levels of antioxidants biomarkers (vitamin C, ceruloplasmin, glutathione) and oxidative stress biomarkers, malondialdehyde (MDA), peroxynitrite, and gamma-glutamyl transferase.In regard to the antioxidant biomarkers, there was a significant difference between the patients and the controls regarding the levels of serum ceruloplasmin and glutathione, (P values .000) for each while vitamin C showed no significant correlation (P value .053), while regarding oxidative stress biomarkers, the correlation was significant for both peroxynitrite and MDA (P value .000 and .001) respectively, and not significant for gamma-glutamyl transferase (P value 1.00).Reduced level both ceruloplasmin and glutathione is seen in patients with breast cancer while vitamin C is not associated. Elevated levels of both peroxynitrite and MDA is seen in patients with breast cancer which may be used as serum markers for the early detection of breast cancer.

Impact of vitamin D level on glycemic control in diabetes mellitus type 2 in Duhok.

BACKGROUND: Vitamin D deficiency is prevalent in most parts of the world. Its insufficiency or deficiency is implicated in bone diseases, some cancers, infectious diseases, heart disease, autoimmune and metabolic diseases including type 2 diabetes mellitus. RESULTS: The mean age of patients was 49.94 ± 9.36, while the mean age the controls was 48.95 ± 10.56. Females constituted 56.1% and males 43.9% in the cases group, while for the control group females were 54.8% and males were 43.9%. Low vitamin D levels were detected in 110 (71%) of cases and 63 (40.6%) of controls. There was a significant difference in vitamin D levels among cases and controls (p < 0.001), vitamin D level was lower among females compared to males, p < 0.001 and those living in urban areas compared to rural areas, p < 0.001, BMI and dyslipidemia had a significant effect on vitamin D levels among diabetics, p values 0.002 and < 0.001 respectively. The serum 25(OH)-D level was significantly lower in patients with poor glycemic control compared to those with good glycemic control and in patients with a diabetes duration greater than 5 years, p values < 0.001 and 0.002 respectively. No significant correlation was detected with age and smoking, p values 0.181 and 0.260 respectively. CONCLUSION: There is a high prevalence of hypo-vitaminosis D among patients with type-2 diabetes, particularly among patients with poor glycemic control and in those with longer diabetes durations. Vitamin-D deficiency is more prevalence in females, and those living in urban areas, those with obesity and patients with dyslipidemia.

Evaluation of mastalgia in patients presented to the breast clinic in Duhok city, Iraq: Cross sectional study.

INTRODUCTION: Mastalgia is a common condition that may affect up to two-thirds of patients during the reproductive period. It can be divided into cyclical and noncyclical. It is mostly due to benign causes, but breast cancer should be excluded. It may be associated with a high level of stress and anxiety. Patients need to be assessed fully, breast and general examinations, and investigations such as breast imaging and hormonal assay. PATIENTS AND METHODS: This is a prospective study that was done in the breast clinic in the period between February 2019 and July 2019. A total number of 445 patients with mastalgia included were in the study. Patients were examined and evaluated using various imaging modalities. RESULTS: The mean age of the patients was 34 years. Mastalgia was present in 54.2% of our patients, in about 70.1% of our patients it was noncyclical mastalgia. Mastalgia was positively correlated with smoking, oral contraceptive pills, and positive family history of breast cancer (p values: 0.000, 0.009, and 0.000) respectively with no correlation with other factors. The type of pain was less in women having early first pregnancy and with the site of the pain showed a positive correlation with the type of pain, (p values: 0.001 and 0.000) respectively. CONCLUSION: Mastalgia is a common complaint which may affect most females. It is caused by benign breast disorders in the majority of patients. A systematic approach must be followed for the management of mastalgia. Reassurance, regular exercise, and local analgesics may be very effective initial measures. In severe, intractable cases, hormonal therapy may be used.

Caput medusae sign; a unique finding during abdominal examination in patients with portal hypertension; case report.

Portal hypertension is an increase in the portal venous pressure resulting in the formation of dilated veins at the site of porto-systemic venous anastomosis causing shifting of the blood flow from the portal venous system to the systemic circulation. A 53-year-old male presented to the emergency department complaining from hematemesis. He was admitted to the emergency department. Abdominal examination showed hugely dilated veins in the abdominal wall with palpable spleen and liver. The hemoglobin level was low and liver enzymes were mildly elevated. The patient received two units of blood and four units of fresh frozen plasma, intravenous propranolol and intravenous vasopressin. Endoscopy showed variceal bleeding which was mild, multiple bandings were performed for the bleeding vessels. The past medical history was negative apart from idiopathic portal vein thrombosis. He was on regular anticoagulants and beta blockers. The patient was prepared to undergo surgical shunting procedure. Acute variceal bleeding is a medical emergency, and patients need aggressive form of treatment. Most drugs like beta-blockers, derivatives of vasopressin and somatostatins work by inducing splanchnic vasoconstriction and decrease the portal venous pressure. Endoscopic band ligation may be required but this has no effect on the portal venous pressure, other alternatives include trans-jugular intrahepatic portosystemic shunts or surgery.

Ingestion of huge number of metallic nails impacted in the stomach and cecum in a mentally abnormal woman: Case report.

BACKGROUND: Foreign bodies may be ingested unconsciously, intentionally or in patients who have psychological abnormalities. The majority of foreign bodies are passed smoothly with no problems if they passed the esophagus, however some may be lodged in areas of anatomical narrowing which may require endoscopic or surgical intervention. CASE PRESENTATION: A 37-year -old mentally abnormal woman presented to the emergency department complaining from abdominal pain for 2 days. The family reported a history of ingestion of multiple metallic nails one week before presentation. Abdominal examination showed generalized tenderness and guarding. Plain abdominal X-ray showed multiple metallic nails in the upper abdomen and the right lower abdomen. Laparotomy was performed, one of the nails was causing perforation of the gastric wall, huge number of metallic nails were extracted from the stomach and cecum, appendectomy was performed. CONCLUSION: Ingestion of sharp and long foreign bodies usually requires surgical intervention, after surgery close observation and psychological consultation is required to prevent repeated ingestions.

Crossed testicular ectopia: Case report with review of literature.

BACKGROUND: Crossed testicular ectopia is a rare form of urogenital anomalies in which both testes are migrated and descend through a single inguinal canal, one or both testes may be ectopic in the abdomen, the inguinal region or descent to the hemi-scrotum with empty contralateral hemi-scrotum. CASE PRESENTATION: A 1.5-year-old male patient had an empty left scrotum with no palpable testis in the inguinal region with a palpable testis in the right scrotum with palpable other testis in the right inguinal region. Ultrasound examination showed the right testis in the right scrotum and another testis measuring in the right inguinal region giving suggestion of both testes in the right side. During operation two testes was found in the right inguinal region with two small indirect inguinal sacs. Herniotomy was performed for both sacs. The right testis was placed and fixed in the right hemi-scrotum and the left testis was fixed in the left hemi-scrotum through trans-septal window. CONCLUSION: During surgery, the surgeon should adopt a conservative approach to preserve the fertility. Trans-septal orchiopexy or extra-peritoneal transposition orchiopexy is advised. In case of persistent Müllerian duct syndrome, preservation of the Müllerian remnants is recommended to preserve blood supply to the vas deferens and testis. Karyotyping may be required in some cases specially if associated with other congenital anomalies of the genitalia. Patients usually need long term follow up because such patients may have future fertility problems and there is an increased risk of the development of testicular cancer.

The consequences of the COVID-19 pandemic on perceived stress in clinical practice: experience of doctors in Iraqi Kurdistan.

Introduction. The healthcare workers are at high risk of developing stress-related problems during outbreaks. This study aimed to explore the perceived stress and its relation to the duration of dealing with COVID-19 patients in medical doctors.Methods. The doctors who work in different medical settings in Iraqi Kurdistan during coronavirus outbreak were invited into this cross-sectional study. The doctors were invited from one pediatric, one emergency, one special corona, and one maternity and gynecology hospital. The "Perceived Stress Scale-10 (PSS)" measured the perceived degree of a doctor who experienced stress. The information was collected through a web-based technique to avoid the disease spread.Results. Doctors' mean duration of dealing with suspected/confirmed cases of COVID-19 was 1.2 (Range: 0-16 days). The mean stress score was 18.81 out of 40. Most of the doctors had a moderate level of stress (69.4%), followed by a low (21.1%) and a high level of stress (9.6%). The general physicians and medical lab specialties had higher stress scores; 21.56 and 19.88, respectively. The high level of stress was among general physicians and community and family medicine doctors; 20.0% and 25.0%, respectively. Whether or not doctors dealt with suspected/confirmed cases of COVID-19, did not have a significant difference over the perceived stress score; 19.02 vs. 18.87; P = 0.786). The mean score of stress was raised with increasing duration of dealing with suspected/confirmed cases of COVID-19; r = 0.202; P = 0.004 and decreased with increasing age (r = -0.141; P = 0.045), and clinical experience (r = -0.139, P = 0.048).Conclusion. This study showed that medical doctors are at a moderate level of perceived stress during the COVID-19 outbreak in Iraqi Kurdistan.