Atherosclerotic Carotid Artery Disease: Where to from the emergency room? University hospital experience.

Objectives: Stroke is the second leading cause of death worldwide, resulting in 5.5 million deaths in 2016. Vascular interventions, including carotid endarterectomy (CEA) and carotid artery stenting, play a major role in stroke prevention, especially when performed early after onset of symptoms. This study aimed to define the role of vascular surgeons in ischaemic stroke management and hence improve referral patterns by creating an algorithm for the referral process. This could reduce time to intervention and optimise patient benefit from intervention. Methods: This retrospective study reviewed symptomatic and asymptomatic patients with atherosclerotic disease of the carotid artery who were referred to the Vascular Surgery Unit of Sultan Qaboos University Hospital, Muscat, Oman, from April 2018 to March 2020 to examine factors influencing recognition of suitable candidates for intervention. Following analysis of the data, algorithms/protocols were created to simplify the referral process of symptomatic and asymptomatic carotid artery disease for surgical intervention. Results: A total of 38 patients with ischaemic stroke were recognised as having carotid artery stenosis and were referred to the vascular surgery service during the study period. Only six met the criteria for CEA, four of which underwent the procedure. Conclusion: Choice of patients for CEA involves multiple steps, with potential for missed opportunities. By involving a multidisciplinary team approach, the recommended protocol aims to lead to early and appropriate referral to a vascular surgeon or an interventional radiologist, resulting in increased and optimised intervention in stroke prevention.

Bronchial Mucoepidermoid Carcinoma Misdiagnosed as Adenocarcinoma: A Word of Caution.

Tracheobronchial mucoepidermoid tumors (METs) typically occur in the head and neck region but rarely in the trachea and lung. They are salivary-type tumors that arise from the glandular component of the tracheobronchial epithelium. The most common type, mucoepidermoid carcinoma (MEC) has histological features that overlap with more aggressive lung carcinomas such as adenosquamous carcinoma. It is important to realize the histological features and limitations of a diagnostic biopsy. This case illustrates this point where an initially diagnosed lung adenocarcinoma turns out to be MEC. We report a case of a 43-year-old woman with a one-year history of recurrent episodes of cough and fever. Initial bronchial biopsy diagnosed her as having adenocarcinoma of the lung. However, her surgical biopsy confirmed it was MEC. High clinical suspicion that the diagnosis may not have been correct saved her from a potential pneumonectomy. She instead underwent bi-lobectomy sleeve resection. This case illustrates the importance of recognizing less common and less aggressive lung tumors that may appear histologically as adenosquamous carcinoma. High clinical suspicion, not only biopsy results, from clinical history, imaging and gross appearance is always needed in all cases. The use of intraoperative frozen section is mandatory. It is important to be aware that because of morphological limitations of small endobronchial biopsies, diagnosis of a more common pathology may be favored.

Managing Vascular Surgery Emergencies and Referrals During the COVID-19 Pandemic at a Tertiary Centre in Oman.

OBJECTIVES: This study aimed to discuss the different challenges faced while managing emergency vascular surgery cases during the COVID-19 pandemic and how these challenges were overcome. METHODS: This study details 14 emergency cases that were managed during a period of one month from mid-March to mid-April at Sultan Qaboos University Hospital, Muscat, Oman. The cases included acute limb ischaemia, critical limb ischaemia, type B dissection of the thoracic aorta, thoraco-abdominal aneurysm, critical internal carotid artery stenosis, trauma, infected arteriovenous forearm loop graft and thrombosed arteriovenous fistulas. RESULTS: Only one patient was confirmed to have COVID-19. Five were negative for COVID-19 while the remaining eight were not tested. Various strategies on how the vascular surgical team accommodated changes in hospital protocols and nationwide lockdown are discussed in detail. CONCLUSIONS: With the judicious use of personal protective equipment and consumable surgical and endovascular devices, communication with support services and other hospitals and implementation of triage protocols, it was possible to manage vascular surgery emergencies effectively.

Clear Cell Hidradenoma of the Breast Diagnosed on a Core Needle Biopsy: A case report and review of the literature.

Clear cell hidradenoma (CCH) is a tumour originating from the eccrine sweat glands. It usually presents in the limbs, axilla or trunk. CCH of the breast is rare and can present as a cystic lesion in the breast that can be easily misdiagnosed as malignancy. We report a 36-year-old female patient who presented at the Sultan Qaboos University Hospital Breast Clinic, Muscat, Oman, in 2018 with a lump in her left breast. Ultrasound examination reported a complex cystic lesion with a solid, vascular component. An ultrasound-guided core needle biopsy was suggestive of clear cell hidradenoma. Surgical excision was performed and histopathology confirmed the diagnosis of CCH of the breast. This is the first ever case of a diagnosis of CCH made using core needle biopsy. CCH can be challenging to diagnose; therefore, awareness of its histopathological and ultrasonographic features are essential to avoid misdiagnosis and over treatment.