The largest malignant peripheral nerve sheath arising from the gluteal region: case report.

We report a unique case of a huge malignant peripheral nerve sheath tumor with probable smooth muscle differentiation.

Unique case of successful surgical treatment of recurrent spinal epidural hematoma after lumbar disc surgery in a Glanzmann thrombasthenia patient.

We report a case of recurrent postoperative spinal hemorrhage after lumbar disc surgery in a Glanzmann thrombasthenia patient.

Evaluating the Prognostic Role of Monocytopenia in Chemotherapy-Induced Febrile Neutropenia Patients Treated with Granulocyte Colony-Stimulating Factor.

OBJECTIVE: Chemotherapy-induced febrile neutropenia is a common and serious oncological emergency which carries a substantial mortality and morbidity. The main objective of this study is to evaluate the usage of absolute monocyte count (AMC) at presentation as a prognostic factor for patients with chemotherapy-induced febrile neutropenia who were subsequently treated with granulocyte colony-stimulating factor (G-CSF). STUDY DESIGN: The electronic medical records of our center were used retrospectively to identify patients diagnosed with unprecedented chemotherapy-induced febrile neutropenia treated with G-CSF between January 2010 to December 2020 and diagnosed with solid and hematological malignancies. Patient's demographics, disease characteristics and laboratory investigations were extracted. Disease progression measures were statistically compared between the study groups in the short-term period of follow-up (six days) including absolute neutrophil count (ANC), ANC difference compared to the baseline readings, hospitalization period, and mortality. RESULTS: A total of 80 patients were identified and categorized into two groups namely monocytopenia (n = 34) and non-monocytopenia (n = 46) with an AMC cutoff point of 0.1×109 cells/L. The monocytopenia group exhibited a worse prognosis with lower ANC values and slower improvement illustrated by the low ANC difference values at all follow up points (P-value ≤ 0.05) apart from day 5. A statistically significant lower hospitalization period was also observed in the non-monocytopenia group (P-value = 0.006). Linear regression analysis evaluated the association between AMC values at admission and ANC values at admission along with subsequent days of follow up which were found to be statistically significant (P-value ≤ 0.05). Receiver operating characteristic curves suggest a satisfactory predictability of ANC changes by AMC values at admission, days1, 2, 3, 4 and 6. CONCLUSION: Monocytopenia holds a worse prognosis in chemotherapy-induced febrile neutropenia patients treated with G-CSF. In addition, AMC values at presentation represents a potential risk factor that can predict short-term changes regarding ANC measures.

Inter-Gender Pelvic Shape Variations as a Cause of DDH Overdiagnosis.

OBJECTIVE: Developmental dysplasia of the hip (DDH) is an abnormal relationship between the acetabulum and the head of the femur. Plain x-ray of both hips at the age of 3 months is still in use in some countries. On plain films, classic lines and angles are evaluated to meet current guidelines for positive DDH. Among these is the acetabular angle (AA), which most did not exceed 30° in normal pelvis regardless of gender. A flat promontory gives the impression of a high AA angle, whereas a sharp promontory gives the impression of a low AA angle. MATERIALS AND METHODS: All anteroposterior (AP) pelvic digital x-ray studies performed to rule out DDH were collected from the PACS systems. A novel angle was measured between a line parallel to the lateral aspect of the region of the inferior iliac spines and a line that extends along the acetabular roof to quantify the roundness of the iliac promontory. We called the former line the Miral line and the formed angle the iliac promontory angle. RESULTS: We show that the promontory shape is significantly different between genders, and therefore it is mistaken to generalize an upper AA limit for males and females. In addition, we show that the current guideline of the upper limit of AA did not predict the incidence of DDH. CONCLUSION: We suggest that the current practice is introducing a high rate of false positive, especially among females, and the current guidelines on AA should be reviewed and assigned separately for males and females. This is more important for countries that did not utilize the ultrasonographic assessment for DDH.

Coronary artery anomalies in patients with zero calcium score: A new evidence supports the 2016-NICE guidance.

BACKGROUND: Currently, guidelines from around the world endorse measurement of coronary artery calcium (CAC) to improve clinical risk prediction in appropriately selected asymptomatic and stable symptomatic individuals. A CAC score of zero may discourage from further testing as coronary computed tomography angiography (CCTA). We investigate the presence of malignant coronary artery anomalies (CAA)s among stable symptomatic patients with zero CAC. METHODS: A total of 281 individuals' information was obtained. These individuals had low to intermediate pre-test probability of coronary artery disease, complained of stable typical or atypical chest pain, were not known to have CAD, and had CAC scan score of zero. After investigating the CCTA, Angelini's classification system for CAA was utilized in adapted form to determine the presence, the class and type of the CAA. RESULTS: The CAAs were detected in 16 (5.7 %) patients on CCTA, 15 (8.1 %) of them were below 45 years. The mean age for patients with CAAs was 31.8. According to Angelini classification system, most of the detected CAAs were malignant such as the origination of the coronary artery from the opposite sinus with arterial course between the aortic and pulmonary trunks and the intramural muscular bridge course. CONCLUSION: It is preferable to perform CCTA in young patients with cardiac symptoms, especially in Asian and Middle Eastern countries even of the CAC score is zero.

Prevalence of sleep disorders among medical students and their association with poor academic performance: A cross-sectional study.

BACKGROUND: Sleep quality is of paramount importance for human health. This multi-site study measures the proportion and types of self-reported sleep disorders in medical students and evaluates their association with academic performance by Grade Point Average (GPA). MATERIALS AND METHODS: A cross-sectional survey was conducted on medical students from two medical schools in Jordan during the 2018/2019 academic year. The study utilized the SLEEP-50 questionnaire to estimate the proportion of several sleep disorders and their effects on daily functioning. Below average GPAs were considered poor academic performance. RESULTS: 1041 medical students' online surveys were analyzed from two medical schools' campuses, representing a 29.7% response rate. Their mean age was 22 ± 2.1 years (ranging from 18 to 37) and 52.6% were female. The mean body mass index was 24.2 ± 4.4 kg/m2. According to the SLEEP-50 questionnaire, the prevalence of sleep disorders among studied medical students ranged from 0.6% for sleep state misperception (SSM) to 23.1% for hypersomnia. Using binary logistic regression, after adjusting for gender and obesity, poor academic performance was associated with a risk for insomnia [adjusted odds ratio (OR) = 1.96, p < 0.001]; affective disorder [OR = 2.24, P < 0.001]; SSM [OR = 6.40, p = 0.045]; narcolepsy [OR = 9.54, p = 0.045]; and circadian rhythm disorders [OR = 2.03, p < 0.001]. CONCLUSION: Sleep disorders are common among medical students. Several sleepdisorders were associated with poor academic performance. Proper diagnosis and treatment of sleep disorders may remedy this issue.

Chronic rhinosinusitis due to cyano-acrylic glue after endoscopic transsphenoidal pituitary surgery.

BACKGROUND: To reduce the risk of cerebrospinal fluid leak, clinicians utilize a filling material placed in the sella followed by floor reconstruction with various materials, including glue sealing. Cyano-acrylic glue Glubran®2 glue is commercially available and is generally used as embolizing agent and for the prevention of cerebrospinal fluid leakage. CASE DESCRIPTION: A 25-year-old woman underwent endoscopic endonasal transsphenoidal surgery for pituitary adenoma. After tumor resection, sellar floor reconstruction was performed by mucosal graft and Glubran®2 glue. The early post-operative period was uneventful. However, 2 months after surgery, the patient complained of headache, facial pain and greenish foul-smelling nasal discharge with solid particles dripping from the nose. Medical treatment was unsuccessful. Brain MRI showed inflammation and thickening of the sphenoidal and para-sphenoidal mucosa. The patient underwent endoscopic endonasal surgery and a solid glass-like mass surrounded by inflamed infected mucosa was seen in the inferior and lateral aspects of the sphenoid sinus. Efforts were made to erupt and de-crust the solid mass until total resection was achieved. Early post-operative period was uneventful, and a course of antibiotics was continued until total disappearance of the discharge. CONCLUSION: To the best of our knowledge, this is the first case reporting of acrylic glue (Glubran®2)-related sinusitis. Surgeon should be aware about similar side effects for the glue material that would complicate the surgery.

The practice of intracytoplasmic sperm injection in Jordan: A clinical outcome study.

OBJECTIVE: The lack of appropriate guidelines and justified practice in most developing countries is a serious limitation to efforts to qualify the services provided. In this paper, we evaluate and assess the clinical practice of an assisted reproductive technique of intracytoplasmic sperm injection (ICSI) in Jordan. METHODS: Retrospectively, we identified women who achieved a successful pregnancy by ICSI over a period of ten years. Information related to the ICSI procedure, foetus abnormalities, maternal complications and delivery outcomes were included. A control group of normal pregnancies were incorporated. RESULTS: In total, 291 cases were included as successful cases of ICSI with a success rate of 14.1%. For the control group, 466 pregnant women with normal pregnancies were included. No statistical difference was observed between both groups in foetus malformation. In normal pregnancy women, 42.1% delivered through caesarean section (CS) while 87.6% of ICSI patients underwent CS. Women with ICSI had significantly higher rates of multiple gestations, and their neonates were lower in birthweight. Women in the ICSI group tended to deliver females compared to the control group. Pregnancy-related hypertension was more commonly reported in the normal pregnancy group, while gestational diabetes, antepartum haemorrhage and preterm labour were more common in ICSI group. CONCLUSION: Services for the management of infertility are increasing in the Middle East. The clinical outcomes in Jordan is approaching that of other developed regions, although the success rate is lower than in other regions. Further studies and efforts should be carried out to maximize effective and successful practice in such low-income areas.

WITHDRAWN: Mechanical ventilation in COVID-19: Is it due to patient or virology factors?

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Abdominal Intraluminal Gossypiboma: Demographics, Predictors of Intraluminal Site, Diagnostic and Treatment Measures.

OBJECTIVE: Intra-abdominal gossypiboma may present with variable clinical presentations. The clinical picture that the patient presents with depends on the site of the retained gauze in the abdomen, with transmural migration leading to intraabdominal gauze being a rare occurrence. We systemically analyze articles and reports related to the transmural migration of gossypiboma. In addition, we report a case of ileal transmigration of gossypiboma in a 53-year-old female. METHODS: A systematic literature review was conducted using Embase and Medline for articles pertaining to transmural migration of gossypiboma. Three of the authors extracted the data from the selected studies that relate to the topic. All articles included were in English language and published in peer-reviewed journals. This study was conducted according to the guidelines set out by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. RESULTS: A total of 93 cases of intraluminal gossypiboma were found in the literature. The mean age of the patients was 40.4 years and females (77.7%) were affected more than males. The obstetric and gynecologic surgeries were the leading causative operation (41.5%). However, cholecystectomy is the most common single surgery associated with intraluminal gossypiboma. The mean time from the causative operation was 35.16 months. Most patients presented as intestinal obstruction. CT scan was the most sensitive tool to detect any non-specific finding while the endoscopic interventions were the most specific. Ileum is the most common site for intraluminal for migration. Intra-gastric location is related mostly to the hepato-biliary operations. Laparotomy with segmental resection provides a primary treatment and cure. CONCLUSION: Clinicians should keep the possibility of gossypiboma, including intraluminal, in their mind when a patient presents with abdominal pain, signs of infection, intestinal obstruction, or a palpable mass any time after abdominal surgery. Measures for prevention and education are the most useful tool to avoid such complications.

Spinal versus General Anesthesia for Patients with Parkinson's Disease.

BACKGROUND: Anesthesiologists prefer using general anesthesia (GA) in Parkinson's disease (PD). However, GA may mask neurological symptoms in the intraoperative period and exacerbate them postoperatively. Furthermore, the anesthetics used in GA have clear interactions with the drugs used to control PD. On the other hand, drugs used in spinal anesthesia (SA) might be safer for patients with PD. The aim of this study is to evaluate the effect of SA and GA in patients with PD who underwent hip fracture repairs. METHODS: Retrospectively, we identified those patients with PD who were admitted due to hip joint fracture. The following information were obtained: demographics, preoperative assessment information of the patients, type of anesthesia, and types of fractures and orthopedic procedures. In addition, intraoperative and postoperative complications were studied. The patients were divided based on the type of anesthesia received and were compared. RESULTS: Ten (8 males) patients with PD who underwent hip fracture surgery included in the study. Six patients received SA and 4 patients received GA. The mean age was 73.2 years. The preoperative assessment was not significant for all patients. Postoperatively, within the inpatient period, 3 out of 4 patients received GA developed complications (two atelectasis and urinary tract infection) while no patient developed complication from the SA group. Postoperative outpatient complications within one-month included 3 out of 4 cases in the GA group and only one complication in the SA group. The mean hospitalization period was 9 days for patients received GA and 5.8 days for patients received SA. CONCLUSION: This study reported less perioperative complications in the SA. Accordingly, further investigations and rp-randomized controlled trials evaluating various anesthetic techniques or drugs are needed.

Ischio-anal fossa hydatid cyst.

Extrahepatic hydatid disease has been reported in several locations, including the pelvis, and it often poses a diagnostic challenge. There are very few reported cases of primary perineal ischio-anal fossa hydatid cysts. We present a case of a 46-year-old female who had complained of painless left perianal mass for 8 months. The first clinical and radiological diagnosis was a cystic lesion of the perianal region. However, surgical and pathological examination revealed the diagnosis of hydatid disease of ischio-anal fossa. The patient underwent surgical excision. At 1-year follow-up, the patient was disease-free. Hydatid disease of the perianal area, although rare, must be kept in the differential diagnosis of pathologies of any perianal mass or lump.

Avascular necrosis of the femoral head after single steroid intra-articular injection.

Femoral head avascular bone necrosis (AVN) is the loss of blood supply to the bone tissue of femoral head that results in cellular death. This condition causes a significant limitation in patient daily life activities and has a poor functional outcome. Long-term steroid intake was established as a cause of AVN. However, few cases reported femoral head AVN post-single steroid intra-articular injection. We review all cases of AVN that results from single intra-articular steroid injection and present a case of femoral head AVN developed in a 78-year-old male. The patient, who was not known to have any medical illness, presented complaining of mild left hip pain for 4 months with long distant ambulation and weight standing. He was diagnosed to have left hip joint osteoarthritis for which he received intra-articular steroid injection 2 months prior visiting our orthopedics center. MRI of the pelvis revealed AVN of the femoral head. He underwent total hip arthroplasty. The pathological examination confirmed the diagnosis of AVN. To best of our knowledge, this is the fifth case of AVN of femoral head AVN after single intra-articular steroid injection. We reviewed all cases of AVN of femoral head after single steroid injection. Intra-articular steroid injection can cause femoral head AVN, and the patient receiving these injections should be aware about this rare but significant complication that results in poor functional outcome and significant morbidity.

Primary Leiomyosarcoma of the Pancreas: a Comprehensive Analytical Review.

PURPOSE: Primary leiomyosarcoma of the pancreas (PLMSP) is rare. The clinical features and outcomes are still unclear. The present study aims to identify the clinical features, outcomes, and racial differences of PLMSP. METHODS: PLMSP cases reported in Chinese, English, French, and Japanese journals were collected and reviewed. Data from these reports were summarized and analyzed statistically. RESULTS: In addition to a female patient presented to our department with PLMS, a total of 87 cases reported in the literature were included in the present study. An equal incidence in gender was observed. The mean age was 53.8 years. Common symptoms were abdominal pain and abdominal mass. At the time of diagnosis or after a period of follow-up, 37.5% of patients had distant metastasis and 31.8% of patients had regional organs/vessels invasion. The 5-year mortality rate was 77.8%. The presence of distant metastasis and the absence of radical surgery are significantly associated with poor outcomes. Regional invasion was significantly more common in East Asians. CONCLUSION: PLMSP is an aggressive tumor with a poor prognosis. Radical resection can decrease the mortality of the patients. Early detection of such tumor is recommended.

A 23-Year-Old Joradanian Woman with a Desmoplastic Small Round Cell Tumor Involving the Ovary.

BACKGROUND Desmoplastic small round cell tumor (DSRCT) is a rare soft tissue sarcoma that usually arises in the abdomen or pelvis in young boys and adolescents. Presenting symptoms include abdominal pain and ascites. However, DSRCT is often disseminated throughout the peritoneal cavity at diagnosis, and the prognosis is poor. This report is of a case of DSRCT in a 23-year-old Jordanian woman who presented with abdominal pain. CASE REPORT An unmarried 23-year-old woman presented with abdominal pain. On examination, she was found to have ascites. A computed tomography (CT) scan of the abdomen and pelvis showed a complex cystic mass in the left ovary, multiple peritoneal deposits, a large amount of ascitic fluid, two hypodense lesions in the liver, and multiple enlarged lymph nodes. Diagnostic laparoscopy was performed, and multiple tumor biopsies were obtained. Histopathology showed a cellular tumor composed nests of small round cells embedded in desmoplastic stroma. Immunohistochemistry showed positive staining of the tumor cells for pan-cytokeratin, desmin, Wilms tumor 1 (WT1) antigen, epithelial membrane antigen (EMA), and CD56, which supported the diagnosis of DSRCT. After the second cycle of the P6 Protocol, which included seven courses of chemotherapy, the patient developed a severe and fatal infection. CONCLUSIONS It is important to consider the diagnosis of DSRCT that may present atypically, particularly in patients who present with abdominal and pelvic masses. DSRCT has a rapid and aggressive course that requires early and definitive diagnosis with prompt treatment that includes systemic chemotherapy.

Primary renal Ewing's sarcoma in a young male treated completely by surgical excision without chemotherapeutic agents: Case report.

INTRODUCTION: Primary renal Ewing's sarcoma is a rare tumor with dismal prognosis. The main treatment modality of treatment is surgical excision with adjuvant or neoadjuvant chemotherapy. CASE PRESENTATION: We present a case of primary renal EWS in 27-year-old male. He presented to our center complaining of three days history of severe left flank pain associated with nausea and vomiting. Computerized tomography (CT) revealed a 10 × 7 × 6.5 cm left lower pole renal mass. Left radical nephrectomy was performed and revealed a tumor with uniform round to oval nuclei cells. The cells stained strongly positive for CD 99. The diagnosis was established as primary renal Ewing's sarcoma. The patient refused the chemotherapy. Fortunately, he was free of the disease on regular clinical and radiological follow-up, the last follow up was 30 months post-nephrectomy. CONCLUSION: This case highlights the importance of proper surgical treatment and its role in the managing this type of malignancy especially in localized disease at presentation.

The Effects of Laparoscopic Sleeve Gastrectomy on the Parameters of Leptin Resistance in Obesity.

Obesity is a growing public health problem worldwide. Bariatric surgical procedures achieve the most sustainable and efficacious outcomes in the treatment of morbid obesity. However, little is known about the underlying molecular pathways modulated by these surgical interventions. Since leptin resistance is implicated in the pathogenesis of obesity, we herein report the effects of laparoscopic sleeve gastrectomy (LSG) on the serum levels of leptin and leptin receptor, in addition to its overall effect on leptin resistance. This was an interventional and follow-up clinical study. In the first part, patients attending the general surgery outpatient clinics at our university hospital were first stratified according to their Body-Mass Index (BMI) into cases (n = 38) with BMI ≥ 35 who were scheduled to undergo LSG, and controls (n = 75) with a normal BMI. Serum leptin and leptin receptor levels were measured by sandwich ELISA technique. A leptin resistance index was estimated by adjusting leptin to BMI ratio to leptin receptor concentration. In the second part of the study, cases who underwent LSG were followed up one year postoperatively to assess their BMI and serum leptin and leptin receptor levels. Leptin to BMI ratio was significantly higher, while serum leptin receptor was significantly lower, in obese patients compared to controls. This translated into a significantly higher leptin resistance index in obese patients. LSG resulted in a significant reduction of BMI, leptin to BMI ratio, and leptin resistance index, as it significantly increased leptin receptor levels. In conclusion, LSG showed significant decrease in leptin resistance in obese patients after one year. Further studies are needed to determine the clinical impact of this finding on LSG outcomes.

Ingested sharp foreign body presented as chronic esophageal stricture and inflammatory mediastinal mass for 113 weeks: Case report.

INTRODUCTION: Impacted foreign bodies in the esophagus have the potential to cause serious complications. Ingested sharp objects carry the risk of acute complications as: perforation, acute mediastinitis, and acute bleeding. Rarely, such foreign bodies might migrate through the esophageal wall and present as chronic esophageal foreign body. CASE PRESENTATION: We present a case of a 36-month-old girl presented with solid food dysphagia and regurgitation proved to be secondary to esophageal stricture after 26 months of accidental ingestion of aluminum can tab which has migrated through the wall of the upper esophagus into the mediastinum. After two trials of endoscopic treatment; she underwent thoracotomy and partial esophagectomy. Multiple trials of dilation and Mitomycin C injection were followed because of re-stricture. CONCLUSION: Foreign body impaction or secondary stricture needs to be considered in the differential diagnosis of children presenting with new onset dysphagia and regurgitation. Metallic Foreign body might be even radiolucent. Practitioners should keep a high index of suspicion for a retained esophageal FB in the child with gastrointestinal or respiratory symptoms that do not respond to standard therapy.

Preoperative esophagogastroduodenoscopy in patients without reflux symptoms undergoing laparoscopic sleeve gastrectomy: utility or futility?

AIM: To evaluate the value of esophagogastroduodenoscopy (EGD) as a preoperative investigation in individuals without symptoms of Gastro-Esophageal Reflux Disease (GERD) who will undergo laparoscopic sleeve gastrectomy (LSG). MATERIALS AND METHODS: After Institutional Review Board approval was obtained, patients scheduled for LSG were prospectively enrolled in the study between January 2016 and March 2018. Patients with symptoms of GERD were excluded from the study. Participants were randomly allocated to two groups: individuals who underwent EGD before the surgery as a usual routine investigation (Group A), and individuals who were scheduled without preoperative EGD (Group B). Patient demographics, endoscopic findings, endoscopic biopsy results, and histopathological findings of the resected parts of the stomach after LSG were analyzed and recorded. Additionally, operative characteristics and outcomes, and follow up findings were recorded and analyzed with appropriate statistical methods. RESULTS: A total of 219 individuals without symptoms of GERD underwent LSG were enrolled. Group A included 111 individuals (25 males and 86 females). Group B comprised 108 individuals (20 males and 88 females). The mean age and mean Body Mass Index (BMI) were similar in both groups. From Group A, 86 out of 111 individuals (77.5%) had no pathology identified on EGD, while 21 individuals (18.9%) were found to have areas of gastric erythema and biopsies showed active gastritis. All LSG operations were performed without any major complication. After one year, all individuals were assessed for the presence of symptomatic GERD and no significant difference was found between the two groups. CONCLUSION: Preoperative EGD may not be mandatory for asymptomatic GERD individuals undergoing LSG as post-operative complications and early follow up for GERD symptoms are not significantly different. Further prospective studies with longer follow up are needed to evaluate the role of EGD in individuals undergoing LSG.