Hemorrhagic giant adrenal myelolipoma discovered incidentally: a case report.

Adrenal myelolipomas are rare, benign, nonfunctional tumors composed of mature adipose tissue and hematopoietic elements. Hemorrhage within an adrenal myelolipoma is an uncommon occurrence, and when it happens, it can present with various clinical manifestations. Here, we report a case of a hemorrhagic giant adrenal myelolipoma in a 45-year-old female that was discovered incidentally. We discuss the clinical presentation, radiological findings, surgical intervention, and postoperative outcomes in this case report.

The Vitamin D Binding Protein Gene Polymorphism Association with Covid-19-Infected Iraqi Patients.

Vitamin D deficiency, in general, is usually correlated with increased risks of chronic pulmonary disease such as COVID-19 infection. However, the mechanisms are still unknown. Herein, this study aimed to investigate the correlation between vitamin D binding protein gene polymorphism and COVID-19-infected Iraqi patients. The study has been conducted on patients with Covid-19 during the period extended from June, 2021 to April, 2022. 300 samples were collected from healthy and infected people. The demographic characteristics of patients (age, gender and residency) are shown non-significant in all. However, the distribution of DBP (rs12785878-T/G) Polymorphism was detected by Allele Specific PCR technique. The association between DBP (rs12785878) gene polymorphism and risk of Covid-19 is also shown, the heterozygous genotype TG was more frequent in the patients' group in comparison with the control group, 66 versus 58, respectively. Therefore, genotype TG was a genetic risk factor for Covid-19 with an odds ratio of 2.4074 (95% confidence interval of 1.2462-4.6505) and an etiologic fraction of 0.2963. In the addition, the homozygous genotype GG was more frequent in the patients' group in comparison with the control group, 65 versus 54, respectively, Therefore, genotype GG was a risk factor for Covid-19 with an odds ratio of 1.0578 (95% confidence interval of 0.6386-1.7522) and an etiologic fraction of 0.0299. thus, it can be seen that Covid-19 disease has a direct effect on the level of vitamin D in patients infected with the virus compared to healthy people.

Resident Physicians' Knowledge and Preparedness Regarding Human Monkeypox: A Cross-Sectional Study from Saudi Arabia.

This study aimed to evaluate knowledge about monkeypox and confidence in dealing with monkeypox diagnosis and management among resident physicians in the Asir region of Saudi Arabia. The data of this cross-sectional study were collected online through a structured questionnaire (N = 315). Knowledge about monkeypox was assessed by 24 questions and a three-item scale assessed confidence in managing monkeypox cases. Multiple logistic regression analysis was performed to assess the associations. Overall, two-thirds of the respondents (67.3%) showed good knowledge about monkeypox and the rest of them (32.7%) had poor knowledge. Respondents who received a copy of the Saudi MOH protocol for monkeypox and attended any conference or lecture about monkeypox were more likely to have good knowledge about monkeypox. Moreover, almost two-thirds of the participants were not confident that they could diagnose or manage the monkeypox. Respondents who received information about monkeypox during residency or medical school had higher confidence in managing monkeypox cases. It can be concluded that the Saudi healthcare system has scope to take necessary steps to contain the monkeypox endemic. The Saudi MOH should arrange conferences and educational programs on monkeypox so that healthcare professionals can improve their knowledge and be confident in the management and diagnosis of monkeypox cases.

Esophagectomies for Malignancy Among General and Thoracic Surgeons: A Propensity Score Matched National Surgical Quality Improvement Program Analysis Stratified by Surgical Approach.

Previous studies of esophagectomy outcomes by surgical specialty do not address malignancy or surgical approach. We sought to evaluate these cases using a national database. The National Surgical Quality Improvement Program (NSQIP)-targeted esophagectomy data set was queried for esophagectomies for malignancy and grouped by surgeon specialty: thoracic surgery (TS) or general surgery (GS). 1:1 propensity score matching was performed. Associations of surgical specialty with outcomes of interest (30-day mortality, anastomotic leak, Clavien-Dindo grade ≥ 3, and positive margin rate) were assessed overall and in surgical approach subsets. 1463 patients met inclusion criteria (512 GS and 951 TS). Propensity score matching yielded matched groups of 512, with similar demographics, preoperative stage, and neoadjuvant therapy rates. All outcomes of interest were similar between TS and GS groups, both overall and when stratified by surgical approach. Esophagectomy for malignancy has a similar perioperative safety profile and positive margin rate among general and thoracic surgeons, regardless of surgical approach.

Clear cell sarcoma of the kidney with inferior vena cava thrombus: a case report.

BACKGROUND: Clear cell sarcoma of the kidney is an uncommon pediatric renal malignant neoplasm that is typically characterized in 2-3-year-olds by aggressive behavior and late relapses. Our literature review revealed fewer than ten previously reported cases of CCSK with inferior vena cava thrombus, with only five in the pediatric age group. CASE PRESENTATION: We report the case of a 14-year-old Syrian girl who complained of mild pain in the left lumbar region pain with hematuria. On physical examination, a mass was palpated in the left flank. Abdominal ultrasonography revealed a left renal mass (7 × 5 × 2 cm3), associated with dilatation of the left renal vein. Contrast abdominal computed tomography showed a mass measuring 7 × 5 × 3 cm3 with the presence of thrombus extending into the inferior cavity down to the right atrium that was initially diagnosed as Wilms' tumor. Radical right nephrectomy with excision of the thrombus was undertaken. Histological immunostaining revealed a diagnosis of the tumor as clear cell sarcoma with vascular tumor thrombus extending to the inferior vena cava. CONCLUSION: Clear cell sarcoma and Wilms' tumor are similar in terms of typical age of appearance, clinical features, and histopathology, but with different methods of treatment and prognosis. The differential diagnosis of such masses is thus very important. We present the case of a patient with clear cell sarcoma with unusual age, with complete removal of the thromboses in the inferior vena cava and the right atrium.

Intraoperative Nerve Monitoring in Thyroidectomies for Malignancy: Does It Matter?

BACKGROUND: Recurrent laryngeal nerve (RLN) injury and postoperative hypocalcemia are potential complications of thyroidectomy, particularly in malignancy. Intraoperative nerve monitoring (IONM) remains controversial. We sought to evaluate the impact of IONM on these complications using a national data set. METHODS: The American College of Surgeons National Surgical Quality Improvement Program thyroidectomy-targeted data set was queried for patients who underwent thyroidectomies from 2016 to 2017. Patients were grouped according to IONM use. Logistic regression models were constructed to evaluate associations of variables with 30-day hypocalcemic events (HCEs) and RLN injury. Associations were expressed as odds ratios (ORs) with 95% confidence intervals (95% CIs). A subgroup analysis was performed of patients with malignancy. RESULTS: A total of 9527 patients were identified; 5969 (62.7%) underwent thyroidectomy with IONM and 3558 (37.3%) without. By multivariable analysis, IONM had protective associations with HCE (OR = .81, 95% CI = .68-.96; P = .013) and RLN injury (OR = .83, 95% CI = .69-.98; P = .033). Malignancy increased risk of HCE (OR = 1.21, 95% CI=1.01-1.45; P = .038) and RLN injury (OR = 1.22, 95% CI = 1.02-1.46; P = .034). A large proportion (5943/9527, 62.4%) of patients had malignancy; 3646 (61.3%) underwent thyroidectomy with IONM and 2297 (38.7%) without. In the subgroup analysis, IONM had stronger protective associations with HCE (OR = .73, 95% CI = .60-.90; P = .003) and RLN injury (OR = .76, 95% CI = .62-.94; P = .012). DISCUSSION: Malignancy was associated with increased risk of HCE and RLN injury. Intraoperative nerve monitoring had a protective association with HCE and RLN injury, both overall, and in the malignant subgroup. Intraoperative nerve monitoring was correlated with improved thyroidectomy outcomes, especially if the indication was malignancy. This warrants further study to clarify cause and effect.

Lateral border and scapular tip free flaps: Old school versus new school.

Free tissue transfer from the subscapular system provides a wide array of options for both soft tissue and bony reconstruction. When bone stock is required for head and neck reconstruction, both the lateral scapular border free flap (LSBFF), supplied by the circumflex scapular artery, and the scapular tip free flap (STFF), supplied by the angular artery, are excellent options. Issues with positioning had previously prevented the widespread use of these bony subscapular system flaps. However, through the use of a Spider Limb Positioner, current clinical practice patterns allow for two team approaches in both of these free flaps. The following pictorial essay compares and contrasts the specific positioning and harvesting technique used for both the LSBFF and STFF, while discussing the clinical advantages and drawbacks of each. Both the lateral border scapula and scapular tip free flaps provide excellent bone stock for head and neck reconstruction. By positioning with currently available technology, both of these free flaps can be harvested through a two team approach.

Revisiting pedicled latissimus dorsi flaps in head and neck reconstruction: contrasting shoulder morbidities across mysofascial flaps.

Free tissue transfer has become the gold standard for reconstruction within the head and neck. However, there are still many instances where pedicled locoregional flaps are the optimal reconstructive option. When myofascial tissue is needed, several options have been described throughout the literature. Various trapezius flaps have been used, although these have variable vascular anatomy and significant donor site morbidity. The pectoralis major myofascial flap has become a mainstay in head and neck reconstruction for its ease of harvest and reliability but suffers from similar issues with donor site morbidity. The pedicled latissimus dorsi flap (PLDF) is another reliable option that has been used for multiple different ablative sites within the head and neck. The thin, pliable structure of the latissimus dorsi makes it a viable option for many defects, and recent reports also support its feasibility for use in an interdisciplinary two-team approach. Furthermore, the donor site morbidity of the PLDF is minimal compared to other similar myofascial options. In this article, we describe the surgical considerations and operative techniques for PLDF transfer along with a review of its associated donor site morbidity.

Congenital anomalies in neonates in Fayoum Governorate, Egypt

Background: The worldwide incidence of congenital anomalies (CAs) is estimated at 3–7%, but actual numbers vary widely among countries. Birth defects are the most common causes of infantile mortality, accounting for ~25% of all neonatal deaths. Aims: To determine the prevalence of congenital anomalies in neonates in Fayoum Governorate; to classify malformations; and to clarify the association between congenital anomalies and possible risk factors. Methods: A cross-sectional study was conducted on 1000 infants in the neonatal intensive care unit and outpatient clinics of Fayoum University Hospital and Fayoum General Hospital during August 2017 to April 2018. Detailed history, clinical examination and relevant investigations were performed. Results: The prevalence of CAs was 7.4%. Major malformations accounted for 78.4% and minor malformations 21.6%. The most common CAs involved the cardiovascular system (32.4%), followed by musculoskeletal anomalies (18.9%), chromosomal anomalies (10.8%), anomalies of the central nervous system (9.5%), gastrointestinal tract (6.8%), genital system (5.4%), eyes, head and neck (5.4%), respiratory system (4.1%), multisystems (2 or more) (4.1%), and renal and urinary systems (2.7%). 82.4% of cases were from rural areas, 62.1% were male, 36.5% were female and 1.4% were ambiguous. 85.1% of neonates with malformations were full term. Conclusion: Cardiovascular, musculoskeletal and chromosomal anomalies were the most common CAs in our study. Positive consanguinity, poor attendance at antenatal clinics, rural residence and multiparty were the most common risk factors associated with CAs.

A Global Survey of COVID-19 Vaccine Acceptance Among Healthcare Workers.

Objectives: Even though several effective vaccines are available to combat the COVID-19 pandemic, wide disparities in vaccine distribution, and vaccine acceptance rates between high- and low-income countries appear to be major threats toward achieving population immunity. Our global descriptive study aims to inform policymakers on factors affecting COVID-19 vaccine acceptance among healthcare workers (HCWs) in 12 countries, based on income index. We also looked for possible predictors of vaccine acceptance among the study sample. Methods: A structured questionnaire prepared after consultation with experts in the field and guided by the "Report of the SAGE working group on vaccine hesitancy" was administered among 2,953 HCWs. Upon obtaining informed consent, apart from demographic information, we collected information on trust in vaccines and health authorities, and agreement to accept a COVID-19 vaccine. Results: Although 69% of the participants agreed to accept a vaccine, there was high heterogeneity in agreement between HCWs in low and lower-middle income countries (L-LMICs) and upper-middle- and high-income countries (UM-HICs), with acceptance rates of 62 and 75%, respectively. Potential predictors of vaccine acceptance included being male, 50 years of age or older, resident of an UM-HIC, updating self about COVID-19 vaccines, greater disease severity perception, greater anxiety of contracting COVID-19 and concern about side effects of vaccines. Conclusions: COVID-19 vaccine acceptance among HCWs in L-LMICs was considerably low as compared to those from UM-HICs. The lowest vaccine acceptance rates were among HCWs from the African continent. This underlines the need for the implementation of country-specific vaccine promotion strategies, with special focus on increasing vaccine supply in L-LMICs.

Factors influencing the choice between laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass.

BACKGROUND: While laparoscopic sleeve gastrectomy (LSG) continues to be the most commonly performed bariatric operation, several variables influence surgeons' practice patterns and patients' decision-making in the type of bariatric procedure to perform. The aim of this study was to evaluate patient factors that influence the decision between laparoscopic Roux-en-Y gastric bypass (LRYGB) versus LSG. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried for patients undergoing LSG and LRYGB between 2015 and 2017. Univariate analysis and multivariate logistic regression were used to evaluate factors associated with performing LRYGB compared to LSG. RESULTS: A total of 252,117 (72.3%) LSG and 96,677 (27.7%) LRYGB cases were identified. Patients undergoing LSG were younger (44.3 ± 12.0 vs 45.2 ± 11.8 years; p < 0.01) and had a lower body mass index (BMI; 45.1 ± 7.8 vs 46.2 ± 8.1 kg/m2; p < 0.01). Most of the patients were females (79.4%), white (73.0%), with an American Society of Anesthesiology (ASA) class ≤ 3 (96.4%). The factors associated with undergoing LRYGB compared to LSG were diabetes mellitus, gastroesophageal reflux disease, BMI ≥ 50 kg/m2, ASA class > 3, obstructive sleep apnea, hypertension, and hyperlipidemia. However, patients with kidney disease, black race, chronic steroid use, age ≥ 60 years, recent smoking history, chronic obstructive pulmonary disease, and coronary artery disease were more likely to undergo LSG. CONCLUSIONS: The decision to perform LRYGB is primarily driven by obesity-associated comorbidities and higher BMI, whereas LSG is more likely to be performed in higher risk patients.

Comparison of early outcomes between Roux-en-Y gastric bypass and sleeve gastrectomy among patients with body mass index ≥ 60 kg/m2.

BACKGROUND: There is no consensus on the ideal bariatric operation to choose for patients with extremely high body mass index (BMI). The aim of this study was to compare the perioperative complications, weight loss, and comorbidity remission between laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) among patients with BMI ≥ 60 kg/m2. METHODS: Data from a statewide bariatric surgery registry were used to identify all patients with BMI ≥ 60 kg/m2 undergoing LRYGB or LSG between January 2006 and June 2019. Risk and reliability adjustment were used to compare outcomes between the two groups. RESULTS: A total of 6015 patients were identified and 2505 (41.6%) underwent LRYGB and 3510 (58.4%) underwent LSG. The overall mean age was 43.1 ± 11.2 years with a mean preoperative BMI of 66.7 ± 6.4 kg/m2. Females accounted for 69.3% and the majority were either white (68.5%) or black (21.2%). LRYGB was associated with a higher rate of adjusted 30-day postoperative serious complications (4.0% vs 2.2%; p < 0.01) including anastomotic leak, obstruction, and bleeding. Resource utilization was also higher with LRYGB (23.7% vs 14.8%; p < 0.01) and included more emergency department visits, readmissions, reoperations, and length of stay ≥ 4 days. The overall 1-year follow-up rate was 38.8%. The adjusted percent total weight loss at 1 year was significantly higher following LRYGB compared to LSG (36.6 ± 9.3 vs 31.3 ± 9.3%; p < 0.01). LRYGB was associated with a higher rate of treatment discontinuation for diabetes mellitus, hyperlipidemia, and obstructive sleep apnea. CONCLUSIONS: In patients with BMI ≥ 60 kg/m2, LRYGB was associated with better weight loss and medication discontinuation 1 year following surgery at the expense of an increase in perioperative complications and resource utilization compared to LSG.

Contemporary management of chronic indwelling inferior vena cava filters.

OBJECTIVE: Despite increasing retrieval rates of the inferior vena cava (IVC) filter, less than one-third are removed within the recommended timeline. Prolonged filter dwell times may increase the technical difficulty of retrieval and filter-related complications. We sought to evaluate the contemporary outcomes of patients with chronic indwelling IVC filters at a tertiary care center. METHODS: A retrospective analysis was performed from August 2015 through August 2019 of all patients who were referred for removal of a prolonged IVC filter with a dwell time >1 year. Descriptive analysis was used to evaluate patients' characteristics and procedural outcomes, which were reviewed through electronic medical records. Data were expressed as median with interquartile range (IQR) or number and percentage, as appropriate. RESULTS: A total of 47 patients were identified with a median filter dwell time of 10.0 years (IQR, 6-13 years); 34 patients underwent IVC filter removal, and 13 patients refused retrieval. The median age of patients was 54.9 years (IQR, 42.5-64.0 years); the majority were female (57%) and white (53%). The most common indication for filter placement was high risk despite anticoagulation (49%), followed by venous thromboembolism prophylaxis (21%). The majority of patients were symptomatic (72%). If symptomatic, the most common reason for retrieval was IVC penetration (94%), and the chief complaint was pain (56%). Retrieval success was 97%, with a median length of stay of 0 days. The majority of retrievals were performed through an endovascular approach (97%). There was one postprocedural complication (3%). CONCLUSIONS: Despite prolonged dwell times, IVC filter retrieval can be performed safely and effectively in carefully selected patients at a tertiary referral center.

Prescribing Habits of Providers and Risk Factors for Nonadherence to Opioid Prescribing Guidelines.

BACKGROUND: The Michigan Opioid Prescribing Engagement Network introduced guidelines in October 2017 to combat opioid overprescription following various surgical procedures. We sought to evaluate changes in opioid prescribing at our academic center and identify factors associated with nonadherence to recently implemented opioid prescribing guidelines. METHODS: This retrospective review analyzed opioid prescribing data for appendectomy, cholecystectomy, and hernia repair from January 2015 through September 2017 (pre-guidelines group) and November 2017 through December 2018 (post-guidelines group). October 2017 data were excluded to allow for guideline implementation. Opioid prescribing data were recorded as total morphine equivalents (TMEs). RESULTS: Of 1493 cases (903 pre-vs. 590 post-guidelines), the mean TME prescribed significantly decreased post-guidelines (231.9 ± 108.6 vs. 112.7 ± 73.9 mg; P < .01). More providers prescribed within recommended limits post-guidelines (2.8% vs. 44.8%; P < .01). On multivariable analysis, independent risk factors for guideline nonadherence were the American Society of Anesthesiologists class > 2 (adjusted odds ratio [AOR]:1.65, 95% confidence interval[CI] 1.09-2.49; P = .02), general surgery vs. acute care surgery service (AOR 1.89, 95% CI 1.15-3.10; P = .01), oxycodone vs. hydrocodone (AOR:1.90, 95% CI:1.06-3.41; P = .03), and nonphysician provider vs. resident prescriber (AOR:2.10, 95% CI:1.14-3.11; P < .01). CONCLUSIONS: Opioid prescribing significantly reduced after the adoption of opioid prescribing guidelines at our institution. Numerous factors associated with provider guideline nonadherence may identify actionable targets to minimize opioid overprescribing further.

Predictors of postoperative emergency department visits after laparoscopic bariatric surgery.

BACKGROUND: Postoperative emergency department (ED) visits are a quality metric for bariatric surgical programs. Predictive factors of ED visits that do not result in readmission are not clear. OBJECTIVES: We aimed to identify predictors of ED visits in patients without readmission after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). SETTING: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. METHODS: The MBSAQIP database was queried for patients who underwent LSG and LRYGB from 2015 through 2017. Patients were grouped by those who presented to the ED (ED group) and those who did not. ED visits analyzed included only those that did not result in readmission. Multivariable forward selection logistic regression was used to report adjusted odds ratios (AORs) with 95% CIs for ED visits. RESULTS: Of 276,073 patients, 257,985 (93.4%) were in the group who did not present to the ED, and 18,088 (6.6%) were in the ED group. Most underwent LSG (71.9%) versus LRYGB (28.1%). Multivariable forward logistic regression identified outpatient treatment for dehydration (AOR, 22.26; 95% CI, 21.30-23.27; P < .001) as the most predictive factor of an ED visit, followed by urinary tract infection (AOR, 7.25; 95% CI, 6.22-8.46; P < .001), wound disruption (AOR, 4.63; 95% CI, 3.09-6.96; P < .001), and surgical site infection (AOR, 3.80; 95% CI, 3.38-4.28; P < .001). CONCLUSIONS: Postoperative complications were the strongest predictors of ED visits after laparoscopic bariatric surgery. Quality improvement initiatives should target these variables to decrease postoperative ED visits.

The promise of immunotherapy in the treatment of young adults with oral tongue cancer.

Historically considered a disease of the older male resulting from cumulative tobacco and alcohol use, more recently we have witnessed a rise in the global incidence of oral tongue squamous cell carcinoma in younger adults, particularly those without any identifiable risk factor exposure. These patients appear to be at higher overall risk for locoregional treatment failure and often experience a more heterogeneous clinical course, with some afflicted with particularly aggressive, rapidly progressive disease. Recent research efforts have supported the idea that although this disease may be genomically similar in these groups, and molecular differences in the tumor immune microenvironment may account for biological differences between young and older patients, as well as patients with and without exposure to alcohol or tobacco. In this review, we seek to summarize current knowledge regarding pathogenesis of oral tongue carcinoma in the young adult patient and examine the potential role of the immune response in disease progression and as a target for novel immunotherapies.

A randomized, phase 1, placebo-controlled trial of APG-157 in oral cancer demonstrates systemic absorption and an inhibitory effect on cytokines and tumor-associated microbes.

BACKGROUND: Although curcumin's effect on head and neck cancer has been studied in vitro and in vivo, to the authors' knowledge its efficacy is limited by poor systemic absorption from oral administration. APG-157 is a botanical drug containing multiple polyphenols, including curcumin, developed under the US Food and Drug Administration's Botanical Drug Development, that delivers the active components to oromucosal tissues near the tumor target. METHODS: A double-blind, randomized, placebo-controlled, phase 1 clinical trial was conducted with APG-157 in 13 normal subjects and 12 patients with oral cancer. Two doses, 100 mg or 200 mg, were delivered transorally every hour for 3 hours. Blood and saliva were collected before and 1 hour, 2 hours, 3 hours, and 24 hours after treatment. Electrocardiograms and blood tests did not demonstrate any toxicity. RESULTS: Treatment with APG-157 resulted in circulating concentrations of curcumin and analogs peaking at 3 hours with reduced IL-1ß, IL-6, and IL-8 concentrations in the salivary supernatant fluid of patients with cancer. Salivary microbial flora analysis showed a reduction in Bacteroidetes species in cancer subjects. RNA and immunofluorescence analyses of tumor tissues of a subject demonstrated increased expression of genes associated with differentiation and T-cell recruitment to the tumor microenvironment. CONCLUSIONS: The results of the current study suggested that APG-157 could serve as a therapeutic drug in combination with immunotherapy. LAY SUMMARY: Curcumin has been shown to suppress tumor cells because of its antioxidant and anti-inflammatory properties. However, its effectiveness has been limited by poor absorption when delivered orally. Subjects with oral cancer were given oral APG-157, a botanical drug containing multiple polyphenols, including curcumin. Curcumin was found in the blood and in tumor tissues. Inflammatory markers and Bacteroides species were found to be decreased in the saliva, and immune T cells were increased in the tumor tissue. APG-157 is absorbed well, reduces inflammation, and attracts T cells to the tumor, suggesting its potential use in combination with immunotherapy drugs.