Lutembacher's Syndrome Accompanied by Partial Anomalies of Pulmonary Veins in a 70-Year-Old Male: A Case of Congenital Heart Disease in the Elderly.

Lutembacher's syndrome is a rare disease defined as the combination of atrial septal defect and mitral stenosis, which relieves the progression of symptoms resulting from mitral stenosis. We present a case of a previously asymptomatic 70-year-old man having Lutembacher's syndrome with sinus venosus type of interatrial defect associated with partial anomalous pulmonary venous drainage. Our patient's only complaint was of mild exertional dyspnea, which started six months prior to referral. Clinical suspicion of the combination of defects arose during transthoracic echocardiography. The patient underwent transesophageal echocardiography and multi-slice computed tomography for defect confirmation. The combination of Lutembacher's syndrome with this complex deformity of pulmonary venous drainage has rarely been described. Such complex congenital defects with multifaceted physiological repercussions can go largely undiagnosed for the patients affected for most of their lifetimes. LEARNING POINTS: Despite the complexity of Lutembacher's syndrome, including the involvement of several deformities and pathological mechanisms of mitral stenosis, sinus venosus type of interatrial defects with partial anomalous return in the pulmonary veins, the multiplicity of mechanisms involved contribute to altered hemodynamics.Multiple intersecting mechanisms can further contribute to delaying congenital heart disease presentation. Congenital heart disease remains a plausible differential in the evaluation of elderly patients presenting with exertional dyspnea.Adult congenital heart defects can have very late onset for presentation, especially with physiological processes that paradoxically reduce the severity and progression of symptoms.

Hereditary chromosomal 9 inversion (p22q13) 9 as a cause for recurrent pregnancy loss: a case report.

BACKGROUND: Chromosomal aberrations are as common as 13.8% in the infertile population. The incidence of pericentric inversion of chromosome 9 is approximately 1-3%. However, although these inversions do not alternate phenotype, there have been conflicting data about their effect as they were correlated with infertility, recurrent pregnancy loss, and deceased children, with no clear evidence of the inversions being the causative factor for these events. CASE PRESENTATION: We report a case report of an Arab family with many members with inv(9)(p22q13). Our proband male aged 35 years at time of presentation with primary infertility. Some members, such as a brother aged 34 years, who had this inversion suffered from recurrent pregnancy loss while other members of similar reproductive age did not. CONCLUSIONS: inv(9)(p22q13) might be a hereditary anomaly that might be a risk factor for recurrent pregnancy loss in its members.

Post-traumatic stress disorder (PTSD), anger and mental health of school students in Syria after nine years of conflict: a large-scale school-based study.

BACKGROUND: The Syrian crisis has entered its ninth year with many being affected by the war. This is the largest-scale study that aims to evaluate the psychological profile of secondary school students in Syria. METHODS: This is a cross-sectional study in schools in Damascus, Syria. The surveys assessed working habits, smoking, war exposure, grades, socioeconomic status (SES), social support, health-related quality of life (HRQL), post-traumatic stress disorder (PTSD), problematic anger, and other parameters. RESULTS: This study included 1369 students of which 53% suffered from PTSD and 62% from problematic anger. Around 46% declared a fair or worse general health and 61% had moderate or severe mental health. Only 9.3% did not report exposure to any war-related variable. War exposure had an impact on PTSD, anger, and HRQL, but not on students' grades. Smoking, having consanguineous parents, and working did not have a clear association with grades or anger. Social support weakly reduced PTSD and anger scores. Interestingly, working was associatedwith lowerPTSD scores but was associated with a worse physical component of HRQL. CONCLUSION: This is the largest study on school students in Syria that reports the psychological ramifications of war. Although the direct effects of war could not be precisely described, the high burden of PTSD and anger distress was a strong reflection of the chronic mental distress.

Ovulation stigma and rupture of ovarian tunica albuginea in a patient with polycystic ovary syndrome (video).

A 25-year-old patient was referred to the fertility clinic in our hospital, complaining of primary infertility for 3 years. The patient reported having irregular menses, and physical examination showed clinical hirsutism, while transvaginal ultrasound revealed polycystic ovarian morphology. Hormonal workup showed elevated Anti-Müllerian Hormone (7 ng/ml), and normal levels of prolactin and thyroid stimulating hormone. Hysterosalpingogram revealed bilateral obstruction of fallopian tubes. Semen analysis of the husband was within normal limits.

Smoking habits and the influence of war on cigarette and shisha smoking in Syria.

Tobacco smoking might be impacted by various influences, including psychological, socio-cultural, and economic factors. A community-based cross-sectional survey was conducted in Syrian Arab Republic from March to April 2019 using a web-based questionnaire. The survey aimed at assessing tobacco use (shisha and cigarettes) as well as examining the association between current tobacco use and various sociodemographic and war-related factors. The sample comprised 978 participants (251 males: 727 females) and had a mean age of 24.7 years (SD: 7.60). Most participants were single (n = 825, 84.4%), reside in Damascus and Rif-Dimashq (n = 579, 59.2%), and had a college/university education (n = 911, 93.1%). Concerning smoking, a total of 371 participants (37.9%) were identified to be current tobacco smokers, of whom 211, 84, 76 were exclusive shisha smokers, exclusive cigarette smokers, and dual smokers, respectively. The prevalence of cigarette smoking (exclusive and dual) among males and females was found to be 34.7%, and 10.0%, respectively. On the other hand, the prevalence of shisha smoking (exclusive and dual) among males and females was around 34.3% and 27.6%, respectively. Additionally, various factors have predicted a higher likelihood of cigarette smoking including male gender (AOR = 4.152; 95% CI: 2.842-6.064; p<0.001), and losing someone due to the war (AOR = 1.487; 95% CI: 1.028-2.151; p = 0.035), while unemployed individuals were found to have lower odds of being cigarette smokers (AOR = 0.634; 95% CI: 0.429-0.937; p = 0.022). Concerning shisha smoking, married (AOR = 0.622; 95% CI: 0.402-0.963; p = 0.033), and unemployed individuals (AOR = 0.679; 95% CI: 0.503-0.916; p = 0.011) were found to have lower odds of shisha smoking. Amid the tobacco epidemic in the region, rates of tobacco use in Syria are still worrying. The Syrian armed conflicts may possess a double-edged effect on smoking, and tobacco users who adopt smoking to cope with various stressors should be targeted with well-structured health education, along with appropriate psychological services.

Allergic rhinitis, asthma and laryngopharyngeal reflux disease: a cross-sectional study on their reciprocal relations.

Allergic rhinitis (AR) is a common medical condition worldwide. It is an inflammation in the nasal mucosa due to allergen exposure throughout the year. Laryngopharyngeal reflux (LPR) is another medical condition that can overlap with AR. LPR can be considered an extra oesophageal manifestation of gastro-oesophageal reflux disease (GORD) or a different entity. Its diagnosis imposes a real challenge as it has a wide range of unspecific symptoms. Although AR and LPR are not life-threatening, they can severely affect the quality of life for years and cause substantial distress. Moreover, having AR is associated with having asthma which is also in turn associated with GORD. This is a cross-sectional study which used surveys distributed online on Social Media and targeted people across Syria. All participants who responded to the key questions were included. Reflux symptom index (RSI) was used for LPR, and score for allergic rhinitis (SFAR) was used for AR. Demographic questions and whether the participant had asthma were also included in the survey. We found that there was an association between the symptoms of LPR and AR p < 0.0001 (OR, 2.592; 95% CI 1.846-3.639), and their scores were significantly correlated (r = 0.334). Having asthma was associated with LPR symptoms p = 0.0002 (OR 3.096; 95% CI 1.665-5.759) and AR p < 0.0001 (OR 6.772; 95% CI 2.823-16.248). We concluded that there was a significant association between having LPR, AR, and asthma. We need more studies to distinguish between their common symptoms and aetiologies.

Laryngopharyngeal reflux in war-torn Syria and its association with smoking and other risks: an online cross-sectional population study.

OBJECTIVES: To demonstrate the burden of laryngopharyngeal reflux (LPR) in Syria and its associated variables. DESIGN: This is a cross-sectional study that used online questionnaires that included demographics, smoking, war-related questions and reflux symptom index (RSI). SETTING: This research was conducted online across Syria and included the general population. PARTICIPANTS: Participants who lived in Syria, agreed to participate, and responded to all the RSI questions were included. This research comprised 734 participants, with 94.6% response rate, 75.5% being females, and a mean age of 24 years. RESULTS: Overall, 31.9% of subjects had symptoms suggestive of LPR. Participants who were 30 years and younger had fewer symptoms suggestive of LPR compared with the older group p=0.012 (OR 0.534; 95% CI 0.325 to 0.877). While having an epigastric burning sensation, chest pain and indigestion were the most common symptoms, having a sore throat was the least common. Being distressed from war noises was associated with more symptoms p=0.009 (OR 1.562; 95% CI 1.117 to 2.183). However, losing someone or changing place of living due to war were not significantly associated with these symptoms p>0.05. RSI scores were associated with cigarette and/or shisha smoking p<0.05. Finally, asthma, allergic disorders and having a job were associated with having LPR symptoms p<0.05. No significant findings were observed in consanguinity, marital status, educational level and socioeconomic status. CONCLUSIONS: War, smoking, asthma, allergies, respiratory conditions and having a job were associated with LPR symptoms. However, they may be associated with these symptoms independently from LPR; for instance, similar symptoms can be caused by the mental disorders from war, the unique environment and irritant substances of the laryngeal mucosa.

Calcified Leiomyomata Presenting as Recurrent Pregnancy Loss.

Recurrent spontaneous abortion (RSA) is a problem that faces women for a variety of reasons. Although leiomyomata is relatively common, calcified leiomyomata which is called "womb stones" is a very rare cause of RSA. These womb stones are correlated with retained products from conception and osseous metaplasia. We report a very rare case of a large calcified leiomyomata which caused secondary infertility and pregnancy loss of 7 pregnancies due to spontaneous abortions.

Allergic Rhinitis and Its Epidemiological Distribution in Syria: A High Prevalence and Additional Risks in War Time.

BACKGROUND: Allergic rhinitis (AR) is a global disease that affects a huge proportion of people around the world especially in the Middle East, where multiple allergy-promoting factors can be found. Although AR is not fatal, it severely affects the quality of life. However, it is usually overlooked in developing countries due to resource scarcity. METHODS: An online questionnaire on social media was used which included demographics, smoking, socioeconomic-status (SES), war-related questions, and the score for allergic rhinitis (SFAR), a simple self-reporting tool with the cut-off point at 7. Findings. This study included 968 subjects with 721 (74.5%) females. The mean age was 24.69 years with AR prevalence at 47.9%. AR was associated with male gender [P = 0.001 (OR, 1.677; 95% CI 1.249-2.253)], having a job [P = 0.049 (OR, 1.309; 95% CI 1.001-1.713)], the having a chronic medical condition (P < 0.0001) mainly other allergies [P < 0.0001 (OR, 9.199; 95% CI 3.836-22.063)] and asthma [P = 0.006 (OR, 5.060; 95% CI 1.396-18.342)], using medications (P < 0.0001) and living in particular provinces (P = 0.010). However, no significant correlation was found with type of work and war factors except being distressed by war sounds [P = 0.027 (OR, 1.348; 95% CI 1.034-1.757)]. Finally, no associations were found with age, consanguinity, SES, educational level, and cigarette or/and shisha smoking (P > 0.05). Interpretation. Approximately half of the sample displayed AR symptoms, indicating a potentially high burden of AR in the community. A correlation to being distressed from war noises was found with AR which could reflect a psychological aspect. In addition, in war harmful allergens are released which can be an additional AR risk factor which adds to the environment in the Middle East that is associated with AR. However, we need further studies to discover and minimize this huge prevalence of AR.

48,XXYY syndrome presenting with long-term infertility and newly observed neck deformities: a case report.

BACKGROUND: Long-term infertility can be attributed to many factors, with the genetic factor being the most overlooked due to its many nonspecific morphological or endocrine signs. We present a rare case of a patient with progressive testicular failure associated with 48,XXYY syndrome. CASE PRESENTATION: A 39-year-old Arab man presented to our fertility clinic for fertility treatment. He was diagnosed with primary infertility, which had been present for 20 years at the time of presentation. Our patient had nonspecific morphological features of an abnormally wide neck with front slouching neck posture, clinodactyly of the third finger, and had moderate hypoandrogenemic features. A semen analysis revealed azoospermia. Genetic tests for azoospermia, including sex-determining region Y (SRY) detection and chromosome Y microdeletion, revealed no deletion present on the Y chromosome. Karyotyping was used and our patient was diagnosed with 48,XXYY syndrome. CONCLUSION: Genetic testing (karyotyping and so on) played a key role in the diagnosis of our patient with long-term primary infertility secondary to 48,XXYY syndrome, and should play a vital role in all cases of long-term infertility, especially when presentation is accompanied by endocrine, skeletal, or morphological symptoms, signifying an underlying genetic factor.

Rates and trends of childhood acute lymphoblastic leukaemia: an epidemiology study.

Acute lymphoblastic leukaemia (ALL) is the most common childhood cancer and has a high survival rate when properly managed. Prognosis is correlated with many factors such as age, gender, white blood cell (WBC) count, CD10, French-American-British (FAB) classification, and many others. Many of these factors are included in this study as they play a major role in establishing the best treatment protocol. This study aims to demonstrate clinical and laboratory features of childhood ALL in Syria. They were treated at Children's University Hospital, the only working major cancer centre in Syria at the time of the study. Data of 203 patients who aged 0-14 years were obtained for this study. Most patients (48.8%) aged (5-9) years with a male predominance (60.9%). The major features for ALL included lymphadenopathy (82.9%), presenting with systemic symptoms (74.9%), T-ALL subclass (20.2%), L2 FAB classification (36.1%), low educational levels for fathers (53%) and mothers (56.2%), having a high risk (48.4%), and having a duration of symptoms before evaluation for more than 4 weeks (42.6%). Only three (1.5%) patients had normal full blood counts (FBC) and only one (0.5%) patient had an isolated high WBC count at time of presentation. Most patients had either abnormal platelet count (89.3%) or low haemoglobin level (88.8%) when presenting with only (2.0%) having normal levels for both. This suggests that having normal haemoglobin and platelet count can be used for quick screening in crisis time like in Syria for prioritising patients. Many prognostic factors were significantly different from medical literature which emphasises the importance of local studies in the developping countries. This study included a high prevalence of T-all, L2 FAB classification, high-risk and other variables which require further studies to evaluate the aetiology of these features, especially that treatment protocols may have a higher mortality in developing countries when not adjusted to local variables.

Interactions of Consanguinity and Number of Siblings with Childhood Acute Lymphoblastic Leukemia.

Acute lymphoblastic leukemia (ALL) is a common malignancy in children. Consanguinity has a high prevalence in developing countries and increases the probability of homozygosity for many genes which may affect ALL and its prognosis. We conducted a study to explore the impact of consanguinity and number of siblings on ALL as there are currently no studies to describe this effect. Data were collected from patients' records from the Children's University Hospital of Damascus University, which is the major cancer centre for children in Syria. This study included 193 children with ALL over one year. Number of siblings was not with the French-American-British (FAB) classification, gender, ALL subtype, or risk of ALL children. When comparing consanguinity degrees and complete blood counts at diagnosis, significant contradicting data were found in the third-degree and fourth-degree consanguinity when compared to one another and to not having consanguineous parents as third degree consanguinity was associated with normal platelets but lower WBC counts, and fourth-degree consanguinity was associated with normal haemoglobin levels and WBC counts, but lower platelet counts. Having consanguineous parents was also associated with acquiring ALL at an older age, L2 FAB classification, having a positive family history for malignancies, and not having hepatosplenomegaly (P < 0.05). Although L2 is known to be a poor prognosis indicatory, no association was found with consanguinity and risk. Finally, no association was found with ALL subtype or risk (P > 0.05). Although consanguinity and number of siblings have affected some variables and prognostic features of childhood ALL, the aetiology is not clear and we need further studies to clarify such an association as this will help in optimising therapy and accurately determine the risk.