International Journal of Clinical Research

Association of Pre-Treatment Serum Testosterone Levels with Prostate Cancer: A Prospective Study

Vishnukant Sharma — 2024-04-14

Introduction: It has been widely accepted that prostate cancer (PCa) growth is related to serum testosterone (ST). A direct correlation between pre-treatment ST level and PCa growth and progression has been reported. However, recent studies have shown that pre-treatment ST levels have a negative correlation with PCa. Thus, the literature is, at best, conflicting. In this study, we examined the pre-treatment serum total testosterone (ST) levels in PCa.

Methods: In this prospective observational study, suspected cases of PCa underwent digital rectal examination, routine blood investigation, Prostate-Specific Antigen (PSA) measurement, and prostate biopsy. Diagnosed cases of PCa without any risk factors affecting testosterone levels were included. Their pre-treatment total ST levels were measured. All patients underwent staging evaluation with either Magnetic Resonance Imaging (MRI) & Bone scan or Ga-68 Prostate Specific Membrane Antigen Positron Emission Tomography (PSMA PET). ST levels were also measured in patients with Benign Prostatic Hyperplasia (BPH) and compared with those in PCa patients. ST levels were also assessed according to Gleason Score (GS) and clinical stage in PCa.

Results: 110 cases and 54 patients with BPH were included in the study. The median ST level in PCa patients was significantly lower as compared to BPH patients [352.28 ng/dL (Interquartile Range (IQR) 224.99-563.17) vs. 448.29 ng/dL (IQR 400.97-596.42) (p =0.004)]. The median ST level in metastatic PCa was significantly lower than the localized PCa group [298.20 ng/dL vs. 452.30 ng/dL (p=0.0001)]. Moreover, the median ST level was also significantly lower in patients with Gleason Score ≥ 8 than those with Gleason Score ≤ 7 [285.92 ng/dL (149.97-560.40) vs. 425.13 ng/dL (320.43-571.46) (p=0.002)].

Conclusion: This study shows lower ST levels in patients with PCa compared to patients with BPH, thus supporting a potential association as described in previous studies. ST levels may have prognostic value since a low pre-treatment ST level is associated with a higher clinical stage and aggressive PCa.

Pleural Effusion Associated with Ulcerative Colitis: A Case Report

Rana Al Ashkar — 2024-01-07

Background: Extraintestinal manifestations associated with IBD may involve the skin, joints, hepatobiliary tract, eye, kidney, and rarely pancreas and respiratory systems; as well as risks for venous thrombosis. They may be present at diagnosis or develop later in the disease course. Pulmonary complications of IBD include airway inflammation, parenchymal lung disease, serositis, thromboembolic disease, and drug-induced lung toxicity.

Case Presentation: We report a case of a 41-year-old lady with ulcerative colitis who presented to the hospital with respiratory symptoms. Physical examination and imagery lead to the diagnosis of acute pleural effusion. Later on, the patient developed gastrointestinal symptoms. Colonoscopy and biopsy showed that she has Ulcerative Colitis. Which is a very rare presentation of EIM of IBD. The patient improved on steroids and mesalamine and pleural effusion resolved.

Conclusion: In conclusion, pulmonary involvement should be considered when pleurisy develops in UC. Early diagnosis and effective treatment are important for these patients.

Nerve Reconstruction's Revolutionary Effect on Facial Paralysis: An Editorial

Myriam Boueri — 2024-01-06

Introduction: Facial paralysis can impact a person's capacity to communicate and interact with others, as well as their physical appearance. [1] A ray of hope has been offered by the development of microsurgical methods for treating this debilitating illness. A game-changing procedure among these is nerve reconstruction using muscle grafts or merely nerves, such as the muscle gracilis. In this editorial, we explore the value of nerve repair in cases of facial paralysis and highlight the encouraging effects of microsurgical procedures.

The Major Factors Affecting Oocyte Quality in IVF Cycles: A Narrative Review

Myriam Boueri — 2023-10-16

Background: The role of assisted reproductive technologies, including in-vitro fertilization [IVF], is increasing daily because of the significant rise in subfertility cases. Among women, the most observed causes of infertility are primary ovarian insufficiency and premature ovarian failure, accounting for 25% of cases, followed by tubal damage (20%) and uterine abnormalities (10%), all contributing to the increase in IVF cases among couples. The success of IVF depends on various factors; however, the role of oocyte quality and maturation level is considered a pivotal cardinal factor for the success rates of IVF.

Methods: A thorough literature analysis was performed using the following search terms: “Oocyte Quality” and “IVF cycle.” The databases searched included PubMed, Google Scholar, MEDLINE, Cochrane Library, and ResearchGate.

Discussion: IVF success rates especially depend on oocyte quality and level of maturation. Several factors affecting these two factors include obesity, which increases O2 and H2O2 levels resulting in elevated endoplasmic reticulum [ER] stress; Polycystic Ovary Syndrome [PCOS]; age; endometriosis; cyclic nucleotides used in IVF; thalassemia major which is associated with lower ovarian reserve and increased redox activity malignancies, and anti-neoplastic drugs, which may contribute to premature ovarian insufficiency. Various treatment options were proposed to improve oocyte quality and maturation level, including growth hormone [GH] supplementation alongside ovarian supplementation, autologous mitochondrial transfer, luteal phase ovarian stimulation, administration of MI-Melatonin-Vitamin D3, Duphaston, and putrescine supplementation.

Conclusion: With the rising number of subfertility cases, the importance of Assisted Reproductive Technologies [ART] is growing. The success rate of IVF on oocyte quality and level of maturation level, and few with several factors affecting these. Though numerous treatment options have been proposed to enhance oocyte quality and maturation, not all have been deemed beneficial.

Mucormycosis as a Rare Infection in Lower Limb Necrotizing Fasciitis: A Case Report

Hilal Abdessamad — 2023-09-03

Introduction: Necrotizing fasciitis is a severe, life-threatening infection that can be fatal and rapidly progressive. It is usually caused by polymicrobial infection, monomicrobial infection by group-B streptococci (GBS) or staphylococci, or by anaerobes like Clostridium difficile that presents as a gas gangrene or rarely by fungi. Fungal infections, though found in diabetic foot ulcers, remain extremely rare agents in necrotizing fasciitis, often causing severe morbidity and higher mortality than regular bacterial infections. Though severe, these infections are not often late to diagnose and very few reports exist citing their presence. With our case report, we present another rare manifestation of Mucormycosis in a foot wound.

Case Report: We present a 57-year-old diabetic male patient who presented with a rapidly progressing very painful right foot ulcer, with high-grade fever and fatigue that did not respond to surgical intervention and treatment with broad-spectrum antibiotics. Mucormycosis species were identified in wound cultures. The patient then underwent an amputation and was treated with liposomal Amphotericin B.

Conclusion: This report aims to further highlight that virulent fungal infections, especially mucormycosis, should be considered when suspecting or diagnosing necrotizing fasciitis. An extensive review of the literature with our newly added case would serve as an eye-opener on this pathogen in the setting of difficult-to-treat necrotizing fasciitis.

Differentiating Between Mass-forming Chronic Pancreatitis and Pancreatic Ductal Adenocarcinoma: A Challenging Clinical Approach

Hadi A Zeid — 2023-06-03

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is a tumor of the pancreas that has a 5-year survival rate as low as 7.8%. In cases of chronic pancreatitis, it is sometimes challenging to rule out neoplastic changes, as mass-forming pancreatitis (MFCP) that can occur secondary to long-lasting inflammation can commonly mimic the presentation of pancreatic ductal adenocarcinoma. The clinical picture, laboratory, and radiological imaging of PDAC and MFCP may sometimes overlap, resulting in a higher incidence of misdiagnosis and unnecessary surgery.

Aim: We aim to describe the various tools available to help physicians distinguish between mass-forming chronic pancreatitis and pancreatic ductal adenocarcinoma.

Methods: A literature search was conducted on “PubMed” using the following terms: pancreatic carcinoma, mass-forming chronic pancreatitis, and pancreatic mass. Several articles discussing imaging modalities including ultrasound, CT-scan, and MRI; and laboratory markers including cancer antigen 19–9 (CA 19-9), carcinoembryonic antigen (CEA), glypican-1 (GP-1), low-density lipoprotein receptor (LDLR), and K-RAS, were reviewed.

Discussion: Despite their similar presentations, the management of MFCP and PDAC is very different. The similarity in history, clinical symptoms, and imaging findings can lead to unnecessary procedures. In this review, we examined several modalities that physicians might use to avoid any misdiagnosis.

Conclusion: Although none of these tests alone has been shown to be superior to the others, a potential suggestion might be to use a combination of these tests to allow a reliable diagnosis.

Uveitis as a Manifestation of Celiac Disease: A Population-Based Study

Antoine Boustany — 2023-06-11

Introduction: The prevalence of celiac disease (CD) in the United States population has been estimated to be 0.71%, or 1 in 141, with the prevalence in first- and second-degree relatives of those affected being 4.55% and 2.59% respectively. Due to the multitude of ways in which this disease may initially present, it is important to screen for CD to avoid the potential consequences of inadequately managed disease. Many ophthalmic conditions have also been implicated as extraintestinal manifestations of CD, including uveitis. Despite several studies and case reports suggesting a positive correlation between CD and uveitis, there has yet to be a nationwide study in the United States quantifying this relationship. Therefore, the aim of this study is to conduct a large-scale multi-center population-based study to assess whether there is a statistically significant increased risk of uveitis in individuals with celiac disease.

Methods: A validated multicenter and research platform database of more than 360 hospitals from 26 different healthcare systems across the United States consisting of data accumulated from 1999 to September 2022 was utilized to construct this study. We excluded patients with a history of autoimmune diseases, cataract surgery, or any type of eye infection. We included a subgroup of patients with a diagnosis of “uveitis” for further analysis. The risk of developing uveitis was calculated using a univariate logistic regression. A multivariate analysis was also done to account for confounding variables including African American ethnicity, male gender, sexually transmitted diseases, and celiac disease.

Results: 70,632,440 patients were screened and a cohort of 46,895,750 individuals was selected for the final analysis after accounting for inclusion and exclusion criteria were met. The incidence of uveitis in patients with celiac disease in the past 3 years was 280 per 100,000 people. The prevalence of uveitis in the US population from 1999 to September 2022 was 150 per 100,000 people (0.15%). In order to adjust for confounding variables, a multivariate regression analysis was performed and showed an increased risk of being African-American (OR: 3.20%; 95% CI: 3.14-3.26) and male (OR: 1.13%; 95% CI: 1.12-1.16); and having a diagnosis of celiac disease (OR: 3.80%; 95% CI: 3.35-4.28) and sexually transmitted diseases (OR: 4.12%; 95% CI: 3.96-4.29) in patients with uveitis.

Discussion: Recent population-based studies demonstrated that the prevalence of CD in the United States is much greater than previously thought, such that a trend of underdiagnoses is suspected to have occurred for several years. Many newly diagnosed uveitis cases, 48%, have been classified as idiopathic uveitis even after a complete workup was done. Several studies have been published in which a correlation between uveitis and CD is reported. The findings of this study further emphasize the importance of a thorough workup to evaluate for an underlying inflammatory process prior to diagnosing uveitis as idiopathic.

Conclusion: In conclusion, we established that patients with celiac disease are at increased risk of developing uveitis after excluding and controlling for any confounding variables. In further studies, it could be interesting to investigate the impact of gluten-free diet in patients with celiac disease on the risk of developing uveitis.

Effect of the Innominate Bone Horizontal Rotation on Acetabular Version: A Retrospective Radiological Study on a Middle Eastern Population

Rami Ayoubi — 2023-07-05

Background: The impact of acetabular horizontal rotation on the development of femoroacetabular impingement and subsequently osteoarthritis is well-studied in the literature. However, there is not a clear relationship between the rotation of the hemipelvis and the version of the acetabulum.

Purpose: The purpose of this study was to evaluate the influence of the rotation of the hemipelvis on the version of the acetabulum.

Methods: Through a retrospective study, three-dimensional reconstructions of high-resolution CT (computed tomography) scans of 154 patients receiving pelvic scans for non-orthopedic causes were selected from our institution’s database. The horizontal rotation of the different parts of the hemipelvis was evaluated using the following parameters: superior iliac spine angle (SIS), inferior iliac spine angle (IIS), roof edge angle (REA), equatorial edge angle (EEA) and ischiopubic angle (IPA).

Results: The results showed a significant positive correlation between the different angles of the innominate bone and the version of the acetabulum such as when the proximal innominate bone rotates, the cranial part of the acetabulum rotates in the opposite direction. Increased anteversion angles in females compared to males were also observed.

Conclusion: The observations suggest that, in an asymptomatic population, the acetabulum should not be considered a separate entity independent from the rest of the innominate bone and that the version of the acetabulum correlates with the rotation of the hemipelvis.

Permanent Pacemaker Use in Transcatheter Aortic Valve Replacement: Real World Experience from the National Inpatient Sample

Anand Muthu Krishnan — 2023-06-03

Background: Transcatheter Aortic Valve Replacement (TAVR) is associated with conduction abnormalities requiring permanent pacemaker implantation (PPMI). Data regarding predictors for PPMI following TAVR is scarce.

Methods: This is a retrospective study utilizing the 2017 National In-Patient Sample (NIS). Patients who underwent TAVR and PPMI during the same admission were identified using appropriate ICD-10 codes, as were patients with left bundle branch (LBBB), right bundle branch (RBBB), and first-degree AV delay (AVB). Patients were split into two groups based on PPMI. The groups were compared using univariate and multivariate analyses after adjusting for age, gender, race, comorbidities, insurance status, and Charlson comorbidity index (CCI). Secondary outcomes included factors influencing length of stay (LOS) and total charges incurred.

Results: In 2017, 54,175 (57.6% males) patients underwent TAVR. There were 8,067 patients with LBBB, 2,402 with RBBB, and 2,905 with AVB at baseline. A 4170 total of patients (55.2% males) required PPMI. Patients requiring PPMI were older (80.5 vs 79.6 years, p=0.001). On multivariate analyses, baseline RBBB, LBBB, hypertension (HTN), CCI 2, and CCI >/=3 predicted PPMI (aOR 4.82, p<0.001; aOR 1.63, p<0.001; aOR 1.21, p=0.013, aOR 1.53, p=0.022 and aOR 1.46, p=0.031 respectively). On multivariate analyses, patients who underwent PPMI had significantly higher LOS (aOR 2.18, p<0.001) and incurred higher total charges (USD 278,000 vs USD 204,920; p<0.001).

Conclusion: In this cohort, RBBB, LBBB, HTN, and increased CCI predicted PPMI after TAVR. Further studies are required to corroborate our findings.

Abdominal Cocoon Syndrome in a Liver Transplant Patient: A Case Report and Review of the Literature

Remy Mckey — 2023-04-17

Introduction: Cocoon syndrome is an uncommon cause of intestinal obstruction caused by the formation of a fibrous band around small intestines, thought to be caused by chronic peritoneal inflammation and associated with several conditions such as liver cirrhosis and liver transplantation.

Case Report: We present a case of a 72-year-old male patient who had liver transplantation three years ago for liver cirrhosis. He had an acute presentation of intestinal obstruction where a computed tomography (CT) scan showed dilated bowel loops and signs of intestinal ischemia, which warranted surgical laparotomy where the diagnosis of cocoon syndrome (sclerosing encapsulating peritonitis) was made and was then treated by adhesiolysis. No immediate or postoperative complications were documented and his life was back to normal.

Conclusion: Therefore, an abdominal cocoon is a challenging diagnosis and should be considered in front of intestinal obstruction, especially in those with risk factors such as liver transplantation.

Epidemiology Of Uterine Fibroid Disease In Lebanon: A Case-Control Study

2023-03-25

Background: Uterine leiomyoma (UL) are women’s most common pelvic tumors, benign in nature, growing during reproductive age, and presenting with abnormal uterine bleeding or pelvic pain and pressure. Many risk factors may contribute to UL, such as family history, obesity, and early menarche. Despite the fact that UL symptoms may improve using many medical or surgical treatments, the health-related quality of life (HRQoL) is considerably affected by their presence. Based on all of the above, we conducted this study which is to the best of our knowledge, the first of its kind in Lebanon aiming to assess the risk factors of UL among the Lebanese population and provide an overview of the diagnostic methods, treatment modalities, and HRQoL among patients.

Subjects & Methods: This is an epidemiologic case-control retrospective study, of 668 women of reproductive age, of different nationalities living in Lebanon, divided into 167 cases and 501 controls, conducted between January 2016 and February 2018, in Beirut, Lebanon, in Rafic Hariri University Hospital (RHUH) and Makassed General Hospital (MGH), using charts, questionnaires, and telephone calls. The statistical program Statistical Package for the Social Sciences 19 (SPSS-19) was used for data analysis. A multivariate analysis was also done. Two-sided data analysis was employed and statistical significance was considered for a p-value of ≤ 0.05.

Results: Risk factors of UL were older age (>40), early menarche, family history, oral contraceptives (OCP) use, high body mass index (BMI) (>29), and chronic diseases. Smoking and sports were protective factors. The highest effectiveness in diagnosis was attributable to pelvic ultrasonography (94.8% of cases), magnetic resonance imaging (MRI) (85.2% of cases), and hysteroscopy (77.8% of cases). Hysterectomy was the most used treatment method (83.8% of cases), followed by hysteroscopy (77.8%) and uterine artery embolization (UAE) (72.7%). Women with leiomyoma reported that their HRQoL is negatively affected by this condition.

Conclusion: This study showed many risk factors for UL, and the statistical significance of techniques for their diagnosis and treatment, in order to prevent their complications and decrease their impact on HRQoL.

Evaluation of postoperative pain in patients undergoing unilateral inguinal hernioplasty by Lichtenstein

Diogo Milioli Ferreira — 2023-03-25

Background: Lichtenstein's surgery is the most recommended technique in the treatment of unilateral inguinal hernias in men, due to its simplicity, speed, pain-free, and almost unrestricted return to physical activities. The evidence indicates that work and leisure activities can be resumed, by most patients, in three to five days after laparoscopic or conventional hernioplasties, without the risk of recurrences or complications. Nevertheless, chronic pain is the most common postoperative complication affecting about 30% of patients regardless of the surgical technique used. Predictive factors for chronic pain are young age, female gender, preoperative pain level, and postoperative pain intensity.

Aim: To evaluate the perception of postoperative pain in patients who have undergone unilateral elective inguinal hernioplasty using the Lichtenstein technique in order to define predictors of the development of chronic pain and to identify the average time to return to work and to normal physical activity.

Methods: Analysis of electronic forms applied to patients that underwent elective unilateral inguinal hernia repair by Lichtenstein at a state hospital in a small town in the interior of Brazil. The statistical analyses were processed using the software Statistical Package for Social Sciences (SPSS) version 22.0.

Results: Data from 38 participants were analyzed with an average of 41.45 (± 13.94) years. Most of them returned to work and to light physical activities 45 days after surgery. There was a positive correlation between the presence of pain 90 days after surgery and the development of chronic pain (Spearman correlation of 0,818 and p < 0.001).

Conclusion: Despite the small sample of this study, it awakens us to the consequences that Lichtenstein surgery can trigger for patients with inguinal hernia and the importance of good management and evaluation of postoperative pain in order to improve the quality of life of these patients.

Omental Necrosis and Mesenteric Ischemia Secondary to Hypercoagulability Due to COVID-19: A Case Report

Diego Guacaneme — 2023-02-05

Background: Omentum necrosis is a rare cause of acute abdomen. Its main etiologies are torsion on its axis, hypercoagulability, and intra-abdominal infections. Its clinical diagnosis is difficult since its symptoms resemble other abdominal pathologies, so diagnostic confirmation when the pain is present in the right abdomen, which occurs most frequently, is usually intraoperative Surgical treatment is more effective than conservative management in reducing hospital stays and does not require follow-up.

Case Report: We present the case of a 45-year-old male suspected to be infected with SARS-CoV-2, which potentially triggered hypercoagulability with necrosis of the greater omentum and mesenteric ischemia, requiring multiple surgical interventions.

Conclusion: It is a rare cause of acute abdomen and to the best of our knowledge, the description of the first case of necrosis of the omentum secondary to COVID-19.

The First Reported Case of Pulmonary Embolism and Deep Vein Thrombosis Associated with Intraductal Papillary Mucinous Neoplasm: A Case Report

2023-02-05

Background: Reported cases of Intraductal papillary mucinous neoplasm (IPMN) are becoming more and more frequent. The risk of hypercoagulability associated with IPMN is not clearly established in the literature as it was only reported in four cases. Therefore, we present a unique case of a patient with IPMN who subsequently developed acute pulmonary embolism (PE) and deep venous thrombosis (DVT).

Case presentation: A 70-year-old healthy female patient complained of palpitation, chest pain, and dyspnea at rest. She had normal vital signs and findings on physical examination. Laboratory tests showed an increase in the D-Dimer level of 3,730 ng/mL fibrinogen equivalent unit (FEU). Bilateral DVT ultrasound (DVT-US) of the lower extremities was positive for acute calf DVT in the right lower extremity involving the soleal vein. CT-PE chest with IV contrast was remarkable for segmental and subsegmental pulmonary arteries thrombosis. She was started on a heparin drip and then transitioned to rivaroxaban for the treatment of PE and DVT. She was discharged in stable condition with outpatient follow-up.

Conclusion: IPMN of the pancreas is an exocrine pancreatic neoplasm often detected on Computed Tomography (CT) scan or Magnetic Resonance Imaging (MRI). It is usually non-malignant but was found to be more prone to progress into cancer in contrast to the other types of pancreatic cysts. An increased risk of hypercoagulability with pre-malignant pancreatic lesions such as IPMN has not yet been well established. As far as we know, this case report is the first article presenting IPMN associated with both acute DVT and PE in a relatively healthy individual with no prior risk factor for hypercoagulability. Although there is scattered evidence suggesting an increased risk of thromboembolic events with IPMN, this unique case of DVT and PE associated with IPMN highlights the importance of close monitoring of these patients, especially those who have risk factors for thrombosis.

Diagnosis and Progression of Rectal Signet Ring Cell Carcinoma in a 15 Year Old Lebanese Boy: A Case Report

Mohammad Farhat — 2023-01-28

Introduction: Colorectal cancer (CRC) is a rare entity in children and adolescents compared to adults. In the young, it is mostly detected in the right and transverse parts of the colon. Among the variants of CRC are the uncommon Signet Ring Cell Carcinoma (SRCC) which has a late presentation and pessimistic prognosis. Patients are asymptomatic for a long time and suddenly develop changes in bowel habits or obstruction.

Case Report: A 15-year-old boy with no known health issues presented with recent rectorrhagia and weight loss. He was stable but pale with abdominal tenderness and no rectal mass on digital rectal examination (DRE). Colonoscopy unveiled a 13 centimeters segment of circumferential ulcerated blackish mucosa extending from the upper rectum to the rectosigmoid junction. Pathology studies revealed SRCC of the rectum and sigmoid. Metastatic workup showed rectosigmoid wall thickening and denoted the tumor a stage IV with ascites and intraperitoneal implants. Palliative treatment with chemotherapy was initiated, and a follow-up CT was done later to assess disease progression and response to treatment. The disease had worsened and the patient deteriorated.

Conclusion: In children, colorectal SRCC is scarce and usually presents at a late stage due to the lack of characteristic symptoms and findings. It is then usually missed by physicians and not considered in the differential thus delaying the diagnosis and rendering the prognosis poorer. To improve the outcome, pediatricians ought to keep CRC in mind when facing obstructive symptoms or refractory abdominal pain.

Untreated Atypical Left Femoral Shaft Fracture: A Case Report of Its Complication

Dany Aouad — 2023-01-28

Background: Bisphosphonate therapy is used to manage osteoporosis and decrease the risk of vertebral and hip fractures. These drugs act by suppressing osteoclast activity by inducing the inhibition of bone resorption and increasing bone mineral density. It has been shown that long-term use of bisphosphonate is correlated to a higher incidence of atypical femoral fractures.

Case report: This is a case report of an 81-year-old female, on bisphosphonate therapy for 12 years and with chronic left thigh pain for two and a half years who developed an incomplete atypical left femur fracture. What’s special about this case is that the fracture was ignored and then progressed after three months into a complete displaced spiral fracture that required surgical fixation.

Conclusion: The benefits of bisphosphonate treatment in preventing osteoporotic fractures outweigh the risk of the occurrence of these atypical fractures. Orthopedic surgeons as well as primary care physicians must keep atypical fractures in their differential diagnosis in patients presenting with prodromal symptoms and who are on long-term bisphosphonate therapy

Therapeutic Approaches in Youth Psychiatry: The Art of Balancing Between ‘Do not Harm’ and ‘Best Possible Care’: An Editorial

Perla Ghalloub — 2022-12-11

Adolescence is one of the most critical periods of an individual’s life where the bulk of neurological, biological, and social development occur. During this stage, adolescents are forced to get out of their comfort zones such as home or school, to experience true variability and independence in their new environments. While this transition may be easy for some, it can be very cumbersome for others leading to the emergence of maladaptive behaviors and the manifestation and intensification of underlying disorders.

Analysis of Surgical Resection of Non-Melanoma Skin Cancer in The Head and Neck of Elderly Population in a Public Hospital of São Paulo

Maria Luiza Marinho Vidigal — 2022-11-20

Introduction: Skin cancer is among the most frequent neoplasms worldwide. It is divided into two major groups: non-melanoma skin cancer (NMSC) and melanoma skin cancer (MSC), with NMSC still classified into several subtypes, with the most prevalent being basal cell carcinoma subtype (BCC), followed by squamous cell carcinoma (SCC). Although NMSC does not present high mortality rates, it can involve high morbidity on the functional, aesthetic, and emotional levels. There is a divergence in the literature regarding decision-making in the cases of elderly (patients above 65 years of age) and super elderly patients (starting at 80 years of age).

Objectives: This study aims to:

1. Identify the complications of surgical resection of the NMSC of the face and neck in the elderly population.

2. Demonstrate that surgical resection can be used as a therapeutic option in the elderly population without a significantly higher risk of morbidities.

Method: This is a transversal, retrospective single-center study of quantitative nature. After the approval of the Research Ethics Committees, analysis was performed on the electronic records of 34 patients who underwent surgery at the Carapicuíba General Hospital between August 2017 and November 2019. The descriptive analysis of the results was performed employing absolute and relative frequency of the qualitative variables; mean and standard deviation were used for the quantitative variables. Analysis of group differences was done through the Fisher's Exact, Student's, or Mann-Whitney T-tests, to evaluate the factors associated with the complications of the procedure.

Results: The results showed a mean age of 85.1 years; higher prevalence in females (61.8%); higher prevalence of BCC (76.5%); higher involvement in the nasal (23.5%), periauricular (23.5%), and malar regions (17.7%); hypertension (55.9%), and diabetes mellitus (35.3%) as the main comorbidities; 8 (23.5%) patients had post-surgical complications, and 0 patients had intraoperative complications.

Conclusion: It was concluded that surgical resection was a good therapeutic method for the patients approached in the study. It is suggested that the therapeutic choice should be individualized, with the evaluation of the patient as a whole and taking into account aspects other than age group and comorbidities. Moreover, it is necessary to develop new studies and clinical trials with a more significant sample.

A Rare Axillary Cutaneous Squamous Cell Carcinoma: A Case Report and Literature Review

Pamela Carrijo Costa — 2022-11-19

Background: Non-melanoma skin cancer is the most frequent tumor in Brazil and the world. One of its forms, squamous cell carcinoma (SCC) predominantly affects the old white population in areas of high exposure to the sun. Most SCCs are indolent, evolving with a cure rate higher than 90% within five years. Rarely, metastasis occurs mainly in regional lymph nodes, but it can also happen in the lungs, liver, brain, skin, and bones.

There are currently many treatment options; based on the stratification of the neoplasm as high or low risk, an appropriate approach is defined.

Case presentation: This report presents the case of a patient with high-risk squamous cell carcinoma affecting an area not exposed to solar radiation and without any other previous triggering factor, which is quite uncommon for this type of tumor. The rarity of the case stems from the lack of scientific reports on the occurrence of SCC in the axillary region, without a history of local chronic inflammatory lesions. The Portuguese, English, and Spanish languages were used to search the database of the main scientific platforms Pubmed, Cochrane Library, Scielo, and Lilacs, with no results similar to the case reported.

Conclusion: Despite the fact that the axillary area is not sun-exposed, squamous cell skin cancer manifested as an extensive lesion that required a complex surgical resection with flap repair. Such findings highlight the importance of a thorough physical exam and work-up to diagnose lesions in their early forms which require simple resection procedures and avoid late diagnoses resulting in complex procedures. Such an approach reduces the risk of various complications like wound infection or dehiscence, flap ischemia, or necrosis, among others.

Decision-Making and Implications of Sex-Reassignment Surgery in Intersex Individuals in the Arab World: A Case Series

Alfred Chabbouh — 2022-10-02

Background: Knowledge, clinical guidelines, and medicolegal frameworks regarding intersex individuals are inexistent in the Arab world. Some medical professionals view intersexuality as a disorder of sexual development that often needs sex-reassignment surgery to correct while others view intersexuality as a natural variation along the sex spectrum. No study to date addresses the vast gap in the literature.

Methods: We contacted eleven non-governmental and civil society organizations involved in matters of sexuality and gender in the Arab world through email. Eight organizations answered but only one, Helem, had been directly involved in supporting intersex individuals and agreed to an interview. We conducted a semi-structured interview with Helem after consent was taken from intersex individuals or their legal guardians to share their experiences.

Results: We studied three cases of intersex individuals, of which two underwent sex-reassignment surgery at a young age. The surgeries were experimental in nature and had negative health consequences. Decision-making is influenced by physician factors, notably lack of knowledge, and parental factors, like stigma. Sociocultural reasons factor in the decision more than scientific evidence. Physicians, in the cases presented, dealt with intersexuality as a rare pathology requiring urgent surgical intervention. Parents of intersex individuals suffer significant psychosocial stressors.

Conclusion: Medical professionals are ill-equipped to deal with intersex individuals in the Arab world, often performing unethical and abusive practices for which they are not held accountable. Parent education and referral to intersex-knowledgeable physicians seem to deter parents from opting for SRS. Intersexuality is severely understudied and ignored in the medical field. Guidelines and medicolegal frameworks are required to address this issue.

Diagnosis of Cornual Pregnancy in the Emergency Room: A Rare Case Report

Lili-Ji Helou — 2022-09-04

Introduction: Ectopic or extrauterine pregnancy is a life-threatening medical condition in which a fertilized egg is implanted elsewhere than in the uterine cavity, commonly in the fallopian tubes. However, it can also occur in the peritoneal cavity, ovaries, and cervix. There are several etiological factors contributing to ectopic pregnancies, such as a history of pelvic inflammatory diseases, habitual abortions, and miscarriages, previous ectopic pregnancies, fertility procedures, as well as increased maternal age that has been correlated with a higher risk of carrying an ectopic pregnancy. Often, the first alerting sign in any ectopic pregnancy is a pain in the pelvic region, along with vaginal bleeding usually spotted between the 6th and 11th gestational week. Other symptoms include vomiting, nausea, tachycardia, and in severe cases hypovolemic shock due to internal bleeding induced by the rupture of the tubes. The key to diagnosing an ectopic pregnancy is transvaginal ultrasound, alongside the measurement of beta human chorionic gonadotropin hormone (beta-hCG) concentrations, which are usually found to be low in such cases. The management of ectopic pregnancy is either medical or surgical.

Case report: We are reporting the case of a 32-year-old pregnant woman, who presented to the emergency department for diffuse abdominal pain and recurrent episodes of vomiting and diarrhea of one-week duration. The patient was stable on admission, but later on, she showed a rapid shift in her vital signs. Blood tests were obtained, and pelvic ultrasound was done, followed by a Computed Tomography (CT) scan that revealed the presence of a right cornual ectopic pregnancy. A rapid surgical intervention was carried out to save the patient’s life and alleviate the pain.

Conclusion: Ectopic pregnancy is an urgent condition that needs to be treated immediately to avoid its fatal consequences. Several risk factors stand behind it, and a usual history and physical gynecological examinations are insufficient to detect it, hormone screening tests additionally to ultrasounds are highly recommended to decrease the incidence of mortality. A proper follow-up with a specialist could avoid the risk of an ectopic pregnancy as well as its undesirable outcomes.

Colocolic Hepatic Angle Intussusception due to Ascending Colon Giant Lipoma: A Case Report and a Review of Literature

2022-09-03

Background: Colon lipomas are rare benign lesions taking place mostly in the right colon with a female predomination. They are mainly submucosal and symptomatic when becoming more than 2 cm in size.

Case Report: This is the case of a 43 years old female patient presenting with bowel obstruction associated with colocolic intussusception due to a giant colonic lipoma. A segmental partial colectomy has been performed followed by a favorable postoperative course.

Conclusion: Giant colon lipomas presenting with intussusception is a rare finding. Surgery is the major treatment but, unfortunately, there is no clear consensus on the recommended procedure in the literature.

Risk Factors for Invasive Fungal Disease in Pediatric Oncology

Adam Maamar Roumani — 2022-09-02

Background: Invasive fungal infections are a major cause of death in pediatric oncology, especially among patients under chemotherapy. This study aims to identify risk factors for invasive fungal infections in pediatric oncology.

Methods: We conducted a monocentric retrospective case-control multi-cohort study on a population of 30 patients with malignant hemopathies or solid cancers under chemotherapy, admitted in the Pediatric Oncology unit of Nafissa Hammoud Hospital in Algiers, amongst which 24 patients were controls, and 6 patients were cases.

Results: In a total of 30 patients (53.3 % male), 13 patients developed a fever, from which 6 patients were identified as invasive fungal infection cases according to the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and Infectious Diseases Mycoses Study Group (EORTC/MSG) guidelines, with an incidence of 20 %. The mean age was 7.47 years old at the admission date. Four statistically significant risk factors were identified (p-value < 0.05, CI 95 %): mucositis with an odds ratio (OR) at 10 (1,34 – 74,51), the most aggressive chemotherapy protocol according to the ITR2 with an OR at 115 (6,10 – 2165,95), severe prolonged neutropenia with an OR at 7,6 (1,07 – 54,09) and severe prolonged lymphopenia with an OR at 25 (2,27 – 275,71).

Conclusion: Many conditions were identified as risk factors for invasive fungal infections in pediatric oncology, especially severe lymphopenia and aggressive chemotherapy. These patients may have to receive close monitoring or even antifungal prophylaxis.

Streptococcus Intermedius Brain and Liver Abscesses After Dental Manipulation: a Case Report

Jony Dib — 2022-08-26

Background: Brain abscesses are intracerebral infections with pus accumulation that can be fatal in most cases without appropriate treatment. The most common cause of brain abscesses are infections with streptococci and staphylococci. Streptococcus anginosus is a group of streptococci that are part of the normal flora of the oropharynx and are rarely the cause of severe bacterial infections.

Case Report: Our patient is a 64-year-old man who underwent a dental procedure, and presented a few days later with a high-grade fever and decreased level of consciousness. He was found to have multiple brain abscesses and a liver abscess, and blood cultures revealed Streptococcus intermidius, which belongs to the Streptococcus anginosus group. The patient received appropriate treatment and recovered completely.

Conclusion: Dental procedures, even simple tooth brushing, can cause bacteremia leading to multiple abscesses in different parts of the body, especially if a germ of the Streptococcus anginosus group has been detected in the blood culture.

The Impact of COVID-19 Pandemic, Financial Wellness, and Online Teaching on Schoolteachers’ Mental Health: A Cross-Sectional Study in Lebanon

Tarek Baroud — 2022-08-26

Background: Teaching is a mentally and physically draining occupation, and due to the SARS-CoV-2 pandemic, the education system shifted to online platforms, which made it even harder. Lebanon is a developing country that is not well prepared for such a daunting outbreak. In addition to its tremendous economic crisis, it will be even harder for teachers to maintain mental stability. The aftermaths of this crisis could, perhaps, impact all the fundamental systems within the country including education

Aim: This study aims to assess stress, anxiety, and depression levels among Lebanese schoolteachers based on the COVID-19 outbreak, the Lebanese economic crisis, and online education.

Methods: A cross-sectional study was carried out, enrolling 300 schoolteachers currently working in Lebanon. An online survey was used, assessing sociodemographic factors, teaching status, financial wellness, fear of COVID-19, and mental health. The IFDFW scale is used to assess financial distress, DASS-21 to assess psychological distress, and the COVID-19 fear scale to measure fear.

Results: Results showed that 23% of teachers had severe depression, 25% had severe anxiety, and 16% had severe stress. Depression was correlated to both fear of COVID-19 and financial wellness (p<0.0001 for both). Anxiety and stress were correlated with online teaching (p<0.05), fear of COVID-19 (p<0.001), and financial wellness (p<0.001).

Conclusion: Lebanese teachers showed severe levels of anxiety and stress as a consequence of online teaching, associated as well with depression when correlated with fear of COVID-19 and financial wellness. It is urgent to take measures to keep the Lebanese educational system productive, and dynamic, and prevent the storm of the stressful environment from worsening.

Keywords: Anxiety, Depression, Stress, Online teaching, Pandemic, Economic crisis

Clinical Correlation Between Pre and Post ERCP Laboratory Values

Johny Salem — 2022-08-21

Background: Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic modality to a primarily therapeutic procedure for pancreatic as well as biliary disorders. However, several complications were described post-procedure such as pancreatitis, perforation, cholangitis, post-sphincterotomy bleeding, etc. Data concerning variation in laboratory values before and after ERCP and its clinical significance with respect to endoscopic findings and possible complications is lacking in the literature.

Aim: To analyze the clinical significance of laboratory values in patients before and after ERCP.

Methods: From a total of 723 patients, 363 with different sets of findings on ERCP were eligible to be included in the study and were divided into 8 different groups. Serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), Gamma-glutamyl transferase (GGT), Alkaline phosphatase (ALKP), bilirubin, amylase, lipase, c-reactive protein (CRP), white blood count (WBC), neutrophil, lymphocyte, monocyte, eosinophils, basophils, platelets counts and creatinine were determined preoperatively as well as postoperatively in these patients.

Results: AST and direct bilirubin showed a significant difference in all patients between pre and post-ERCP (p-value<0.01 and p-value<0.05, respectively). Liver tests were significantly higher in the malignant obstruction group than in the bile duct stones group (P <0.05) and decrease more significantly (P <0.05) after the procedure. A significant increase in lipase (p-value<0.05) among all groups was found, and interestingly, the lymphocytic count showed a significant decrease (p-value<0.01).

Conclusion: In conclusion, (1) ERCP significantly decreases AST, direct bilirubin, lymphocytes, and monocytes count post procedure among all stratified groups of obstructive etiology thus proving its therapeutic value for biliary system obstructions. (2) Higher baseline disturbances in laboratory values at T0, especially in liver function tests such as ALT, AST, GGT, and ALKP as well as a bigger decrease in lymphocyte count at T1 are noted to be linked with malignant obstructions (tumor group), rather than benign obstructions (stone, sludge, stone+ sludge, and stricture). (3) Finally, stone and stricture groups are at the highest risk of post-ERCP pancreatitis owing to those groups having the highest pancreatic enzyme levels post ERCP, and thus should be the best candidates for a pre-ERCP pharmacologic prophylaxis (such as diclofenac, etc) and post ERCP close monitoring.

Buccal Mucosal Metastasis of Renal Cell Carcinoma: A Case Report and Review of Literature

Lithika Lavanya M — 2022-08-20

Background: Intraoral metastasis of RCCs are unusual, especially when it comes to buccal mucosal metastases, which are extremely rare, accounting for less than 1% of metastatic RCC. The buccal mucosal metastatic lesion from RCC poses a challenge in diagnosis and treatment. Due to their scarcity, there doesn’t exist any literature primarily concentrating on them.

Case Report: In this work, we describe the case of a 58-year-old man affected and operated on for renal cell cancer, brought to our care for the appearance of a buccal mucosal ulcer. Pathological analysis revealed a metastasis compatible with clear-cell carcinoma. Its renal origin was confirmed by immunohistochemical technique. The patient was evaluated and managed after post multidisciplinary tumor board discussion with palliative radiotherapy for local disease.

Conclusion: There should be no hurry in starting treatment for a buccal mucosal lesion, and it should be histopathologically evaluated keeping in mind a differential of metastasis from the distant primary. Multidisciplinary tumor board discussion plays an important role in such rare scenarios.

Hepatic Vein Thrombosis in a COVID-19 Patient with Hereditary Thrombophilia: A Case Report

Georges Chedid — 2022-08-20

Background: COVID-19 is an infection secondary to the novel SARS-COV-2 virus with a well-established increased risk for thrombotic events. However, the interaction between COVID-19 and other patient-specific hereditary or acquired thrombophilias remains a poorly explored area.

Case Presentation: We herein report a case of a 23-year-old Caucasian female with known risk factors for coagulopathy (smoking, oral contraceptives, anti-phospholipid (aPL) antibodies, heterozygous Factor V Leiden mutation, and homozygous methylenetetrahydrofolate reductase (MTHFR) mutation) who developed a Budd-Chiari syndrome after testing positive for COVID-19. To our knowledge, this is the first report of a case of splanchnic vein thrombosis in a COVID-19 patient with the above risk factors.

Conclusion: Such a presentation underscores the additional increased thrombotic risk attributed to COVID-19 infections in the setting of underlying hereditary or acquired thrombophilias.

Patient Characteristics, Clinical Courses, Fatality Rates, Predictors of Severe Diseases, and Deaths in Intensive Care Unit: A Lebanese Retrospective Cohort of COVID-19 Patients

Mohamad Hachem — 2022-08-15

Background: The novel coronavirus 2019 (COVID-19) pandemic is straining Intensive Care Units’ (ICU) capacities worldwide. It was demonstrated that the ICU mortality rate from Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is higher than from other viral pneumonia.

Aim: The goal of this research is to determine ICU COVID-19 patient characteristics, clinical courses, fatality rates, as well as risk factors for severe diseases and mortality in Lebanon, a country known to suffer from a deficiency in ICU capacity as well as a high COVID-19 infection rate.

Methods: We conducted a retrospective monocentric cohort study that enrolled COVID-19 patients admitted to the ICU at Baabda Governmental Hospital, between January 1, 2021, and March 31, 2021. Demographics, clinical, radiological, laboratory characteristics, treatments, and medical and infectious complications were gathered and compared between survivor and non-survivor groups, as well as between mild/moderate and severe/septic groups. Parameters were then entered in a multivariate regression analysis to identify predictors of death and disease severity.

Results: A total of 191 patients were included in our study. The fatality rate reached 35.6% in our population with a median ICU length of stay of 8 days. Non-survivors were more likely older (p<0.001), active smokers (p=0.008), and in severe or septic stage at admission (p<0.001). Elevated levels of neutrophils (p=0.013), ferritin (p=0.002), lactate dehydrogenase (p<0.001), and C-reactive protein (p=0.008) were more frequently encountered in non-survivors. The latter were more commonly intubated (p<0.001) and suffered from complications such as ventilator-associated pneumonia, sepsis, cytokine storm, myocardial infarction, and pulmonary embolism (p<0.001). Multivariate analysis showed that older age, intubation, and severe/ septic stage at admission were associated with an increased risk of death.

Conclusion: Older COVID-19 patients who were intubated, and those who were in severe or septic stages at ICU admission

Listeria Necrotizing Cellulitis: A Case Report

Emilio Abi Rached — 2022-07-14

Background: L. monocytogenes typically affects pregnant women, neonates, or immunocompromised individuals, with a wide clinical spectrum that includes Central Nervous System (CNS) infections, endocarditis, and very rarely, localized infections such as necrotizing fasciitis . Although L. monocytogenes is the main pathogenic species, there are a total of 21 described species including L. grayi. L. grayi is not a well recognized human pathogen, despite a few case reports of infection in organ transplant patients. Listeria-associated soft tissue infections are exceedingly rare and are typically seen in immunocompromised individuals, with the usual culprit being Listeria monocytogenes.

Case Report: We report the case of A 33-year-old previously healthy male, presented to the Emergency Department (ED) with left leg swelling, erythema, and fever. After multiple courses of treatment, we were able to isolate the L.grayi from the intraoperative specimen, confirmed the diagnosis of L.grayi associated cellulitis in a healthy young non-immunocompromised patient.

Conclusion: This is to the best of our knowledge the first case of Listeria Grayi associated soft tissue infection in a previously healthy young man 3 months after recovery from COVID-19 infection.

The Simultaneous Occurrence of Acute Appendicitis and Bowel Perforation in Taenia Infection: A Case Report

Mohammad Farhat — 2022-08-01

Background: Appendicitis is most likely due to obstruction of the appendiceal lumen. Parasitosis is an unusual cause of obstruction and in specific, Taenia Saginata is a very rare cause of appendicitis, even more so of small bowel perforation. Teiniosis is usually an asymptomatic process but a greater load or migration of the adult form may complicate some cases. The simultaneous occurrence of acute appendicitis and ileal perforation in the same setting has not been reported in the literature.

Case Presentation: A 60-year-old Lebanese female patient presented to the emergency department with right lower quadrant pain radiating to the left lower abdomen. The patient reported associated fever, chills, and anorexia prior to presentation. On physical examination, she was afebrile and normotensive, abdominal examination revealed diffuse lower abdominal tenderness. A blood workup revealed an elevated c-reactive protein (CRP) value with a normal white blood count (WBC). Computed tomography (CT) scan done with intravenous (IV) and per os (PO) contrast disclosed a leak of PO contrast in the absence of pneumoperitoneum implying a contained perforated appendicitis or colitis. The patient underwent urgent laparoscopic exploration. Intraoperatively patient had gangrenous appendicitis and an inflamed right fallopian tube, as well as small bowel perforation and the presence of a tapeworm. The tapeworm was removed and the patient ended up having an appendectomy, right salpingectomy, and oophorectomy, with the closure of ileal perforation. Her hospital stay was uneventful and she was discharged on ciprofloxacin, mebendazole, and metronidazole. Soon after her discharge from the hospital, the patient resumed her normal daily activities. Histopathological studies revealed mixed inflammatory infiltrates and the worm to be Taenia Saginata.

Conclusion: Patients with teniosis are mostly asymptomatic. In symptomatic patients, the course is usually mild except for some rare occasions including appendicitis or bowel perforation. The diagnosis of Taenia Saginata infection in such cases should be considered in endemic areas such as the Middle East and North Africa (MENA) region where eating raw meat is habitual.

Manuka Honey Versus Wet to Dry Dressing for Wound Closure Time After Open Pilonidal Sinus Surgery

Houssam Khodor Abtar — 2022-08-01

Background: Sacrococcygeal pilonidal sinus disease is a very common chronic inflammation of the natal cleft that presents frequently as an abscess. Management requires the eradication of the sinus tract and postoperative wound care. Manuka honey (Medihoney) was used in acute and chronic wounds. In our study, we sought to investigate the clinical effectiveness of Manuka honey in decreasing wound healing time post excision.

Material and Methods: We describe patients’ characteristics using traditional descriptive statistics. We compared the study endpoint (wound closure time) in patients who received Medihoney versus those who did not by Kaplan-Meier analysis.

Results: A total of 119 patients underwent pilonidal cyst surgery between the years 2017 and 2018. The median time for healing in the Medihoney group was 40 days compared with 39 days in the control group. After adjusting for age, BMI, wound length, wound volume, smoking and operative time, the time to healing in the Medihoney group was significantly less compared to the group not receiving the treatment (Hazard Ratio 1.56, 95% Confidence interval 1.02- 2.49, p= 0.041).

Conclusion: Postoperative use of Manuka honey showed a significant decrease in wound healing time when compared to gauze fabric dressings. Further research would be beneficial to explore optimal treatment protocols for this dressing technique.

Forestalling Anti-Ergonomics in Plastic Surgery: Challenging the Modus Operandi?

2022-07-31

Despite formidable advances throughout surgical disciplines spanning decades, plastic surgeons, especially microsurgeons, have most certainly ignored the memo to sufficiently recognize the alarming prevalence of musculoskeletal disorders (MSDs), a consequence of anti-ergonomic postures assumed during intricate procedures (eg. microsurgery), capable of physical limitations which can lead to early retirement. Collective ignorance of the aforementioned predicament is reflected in the plastic surgery literature wherein epidemiologically rigorous studies remain non-existent. Anecdotal reports evidencing the crippling effect of anti-ergonomic postures along with rigorous operative practices in plastic surgery procedures that have exaggerated operative durations suggest increased predisposition to occupational disorders like cervical disk disease, distal interphalangeal arthrosis, ligamentous injury, pulmonary embolism secondary to deep vein thrombosis and tendinitis. Remarkably, evidence in the literature highlights the commencement of musculoskeletal discomfort as early as in residency, even though previous studies have documented 35.4 years as the initiation point of musculoskeletal symptoms.

Barriers and Facilitators for Setting Upper Limb Reconstruction Services.

Luigi Troisi — 2022-07-30

Microsurgical limb reconstruction is a complex surgical technique that aims to preserve an extremity that has been affected by acquired conditions, such as trauma or cancer. It involves the transfer of free tissue flaps, which are micro-surgically revascularized in the recipient site to reconstruct a variety of defects. This can be not only technically demanding for the surgeon leading this type of procedure but also requires a well-set-up perioperative team and service. This article aims to present the experience of the first author setting up a new microsurgical service.

Awareness, Perception and Behaviors Related to Electronic Cigarettes in Lebanon: A Survey Study

2022-07-01

Background: Electronic cigarettes (E-cigarettes) are gaining momentum worldwide. They are looked at as an effective way to cease smoking with reduced harm. Since Lebanon is a country with a high smoking prevalence, it is of interest then to analyze the current and expanding role of E-cigarettes among the Lebanese population.

Aim: The objective of our study was to evaluate the awareness, perception, and behaviors related to E-cigarettes in Lebanon.

Methods: A cross-sectional survey of Lebanese pedestrians chosen from random sectors of Beirut was recruited in our sample study. A self-administered questionnaire was distributed to examine their awareness, perception, and behaviors related to E-cigarettes. SPSS was used for analysis. The main outcome was to assess the awareness of E-cigarettes in the Lebanese population and evaluate their perception as an effective smoking cessation tool.

Results: Of the 364 respondents, 53% were males, 84% were aware of E-cigarettes, and 16% never-tried them. E-cigarettes helped 56% of users to cut down on tobacco smoking, and among all respondents, 60% believed that it is less harmful than tobacco cigarettes. Moreover, 30% perceived it as an effective way to quit smoking. The majority of participants (61%) who tried it were between 18 and 25 years of age, and 36% of them were nonsmokers.

Conclusion: Our study is the first in Lebanon to assess the awareness, perception, and behaviors related to E-cigarettes. The majority of our population was aware of E-cigarettes, and some perceived them as a less harmful replacement compared to tobacco smoking. Additionally, non-smokers may be attracted to E-cigarette smoking which may lead to developing a new attraction and gateway for smoking. Therefore, awareness about E-cigarette's correct use, benefits, and harms need to be highlighted among the public, particularly the young generation in Lebanon.

Avascular Necrosis of the Femoral Head After Recurrent Traumatic Posterior Hip Dislocation in a 10-Year-Old Girl: A Case Report

Raymond Massaad — 2022-06-28

Background: Traumatic hip dislocation (THD) is a rare pathology in the pediatric population. The severity of the trauma, mismanagement, or late treatment of such pathology can lead to complications, including avascular necrosis (AVN) of the femoral head. We hereby report a case of recurrent traumatic posterior hip dislocation that eventually lead to AVN of the femoral head in a 10-year-old girl.

Case presentation: A 10-year-old girl presented to the Emergency Department complaining of left hip pain one day following a fall from a standing position. On physical examination, the left hip was held in the position of flexion, adduction, and internal rotation, with complete loss of range of motion of the left hip joint. Radiographic imaging was done and showed: a posterior dislocation of the left hip, enlargement of the growth cartilage of the left femoral epiphysis, and hypertransparency of the anterosuperior corner of the left femoral neck, and increased bone density of the upper left femoral epiphysis, suggesting previous hip dislocations. Open reduction with arthrotomy and posterior capsulorrhaphy was performed 36 hours post-injury, followed by hip immobilization by a spica cast. Two months after surgery, the cast was removed. On examination, the left hip was stable with good mobility, and weight-bearing was authorized. Follow-up was done three months post-injury. The patient had no complaints, but radiographic images showed signs of avascular necrosis (AVN) on the left femoral head.

Conclusion: Our case emphasizes the importance of early diagnosis and management of a THD in pediatrics, to prevent serious complications such as AVN.

Varicella Zoster Reactivation Post COVID-19 Vaccination: Two Case Reports

Hilal Abdessamad — 2022-06-27

Background: After initiation of COVID-19 vaccination, many side effects were described (Itching, swelling, pain, redness, induration, coughing, fatigue, fever, diarrhea, nausea, headache, vomiting, pruritus, myalgias, arthralgias, anorexia, malaise). Whether traditional, vector-based, or mRNA-based, all COVID-19 vaccines have had many mild and severe adverse events. In this article, we describe two cases of Varicella-Zoster Virus (VZV) reactivation one day after receiving Pfizer’s mRNA-based vaccine first dose, and another one month after the second dose. Both patients were not immunodeficient and not on immunomodulator therapy. To our knowledge, few similar cases have been described in the literature before, and thus it would be an important addition to guide future expectations and management in morbid patients receiving the mRNA vaccine for COVID-19.

Case presentation: Case one is a 74-year-old male who presented with zoster reactivation one day after receiving the first mRNA COVID-19 vaccine. He was treated successfully with valacyclovir. The second case is an 83-year-old lady who presented with facial zoster reactivation one month post the second dose of the mentioned vaccine and was also treated with oral valacyclovir.

Conclusion: The patients were not immunodeficient and not on immunomodulatory therapy, which is a major difference from the other reported cases, which are already few in the literature. To our knowledge, very few similar cases have been described in the literature before. Reporting more of such rare side effects would be of utmost importance to establish a full side effect profile of mRNA vaccines and to better understand such clinical finding. It is worth noting, however, that despite the risks that accompany these vaccines, the benefits far outweigh them.

Musculoskeletal Tuberculosis Involving Ribs, Spine, and Pelvis in a 17-year-old Girl: A Case Report

Lina Hammoud — 2022-06-16

Background: We present a case of progressive back pain associated with weight loss and low-grade fever in a 17-year-old patient previously diagnosed with spinal tuberculosis (TB) also known as tuberculous spondylitis or Pott’s disease.

Case presentation: Upon the patient's presentation to the clinic, a differential diagnosis including infectious and non-infectious causes such as extra-pulmonary tuberculosis, septic arthritis, malignancy, rheumatologic diseases, and physical abuse was made. Her preliminary workup was suggestive of granulomatous disease. A positive tuberculin skin test (TST), and a polymerase chain reaction (PCR) test of the tissue with mycobacterium tuberculosis deoxyribonucleic acid (MTB DNA), confirmed the diagnosis of musculoskeletal TB.

Conclusion: The patient was treated with anti-TB regimen and Pyridoxine to avoid peripheral neuropathy associated with isoniazid use. Her clinical follow-up showed improvement with a proper response to treatment and no sequelae.

Vitamin D Deficiency Mimicking Pseudohypoparathyroidism Type II in an Adolescent Boy: A Case Report

Andrew Shieh — 2022-06-16

Background: Vitamin D deficiency in children is common and usually characterized by hypocalcemia, hypophosphatemia, and elevated serum parathyroid hormone level. However, vitamin D deficiency can be associated with parathyroid hormone resistance in the kidneys which may cause hyperphosphatemia instead, mimicking thus pseudohypoparathyroidism type II. The exact pathogenesis for parathyroid hormone resistance remains unclear, and the distinction between the two conditions remains difficult. We describe the case of an adolescent who presented with seizures and was found to have biochemical features consistent with pseudohypoparathyroidism, likely related to vitamin D deficiency.

Case Report: A 13-year-old previously healthy adolescent presented with seizures. He experienced back pain during the previous month prior to the presentation. He did not have features of Albright hereditary osteodystrophy. His laboratory studies were significant for hypocalcemia, hyperphosphatemia, elevated serum alkaline phosphatase level, elevated parathyroid hormone level, and a deficient vitamin D level. Magnetic resonance imaging of the spine revealed multiple compression fractures. The child was treated with intravenous calcium and vitamin D administration with rapid improvement and his seizures resolved.

Conclusion: Hypocalcemia from vitamin D deficiency can mimic pseudohypoparathyroidism type II. The principles of treatment for hypocalcemia in both conditions are similar and patients require timely intervention with close follow-up to ensure the resolution of symptoms. Patients with resolution of symptoms after adequate treatment may not require further evaluation for other types of pseudohypoparathyroidism.

Hemothorax Occurring After Central Venous Catheter Removal: A Case Report

Jony Dib — 2022-06-04

Background: Central venous catheterizations are used frequently in critical care unit. The procedure is associated with various complications ranging from mechanical ones during insertion and the possibility of vessel laceration and dissection to infections, not to forget haemothorax and pneumothorax that may require chest tube insertion. However, some complications may also origin from its removal.

Case Report: This is a case of a 72-year-old patient with multiple comorbidities admitted to the Intensive Care Unit (ICU) for respiratory distress. A central line was inserted because a peripheral line was hard to establish, and as a consequence of catheter removal, he had a massive right-sided hemothorax.

Conclusion: Central venous line removal could cause fatal complications such as massive hemothorax that should be looked for. We emphasize monitoring of patients after catheter removal because the uncommon nature of this complication can lead to diagnosis delay and even misdiagnosis.

Rudimentary Horn Adenomyosis in A 20-Year-Old Patient With Unicornuate Uterus: A Case Report

Elio Junior Feghali — 2022-06-04

Background: A unicornuate uterus with a rudimentary horn is a rare Mullerian anomaly with few cases reported in the literature. The symptoms vary depending on the functionality of the endometrial cavity and the presence of an obstruction. Adenomyosis is a disease defined as areas of endometrial glands and stroma present within the myometrium. Reports describing adenomyosis in relation to the Mullerian anomalies are scarce.

Case Report: We present a 20-year-old middle eastern woman admitted for chronic pelvic pain and abdominal distension. Pelvic ultrasound revealed a unicornuate uterus with an adjacent mass of 10 x 8 cm. An MRI (Magnetic Resonance Imaging) was performed, and a left unicornuate uterus was demonstrated. On the right side, a large non-communicating rudimentary horn with features suggesting diffuse adenomyosis was found. Laparoscopic removal of the horn was performed successfully, and the extraction of the specimen was made by a power morcellation containment system. The patient was discharged uneventfully the second day after the surgery, and the pathology result confirmed the presence of diffuse adenomyosis.

Conclusion: Non-communicating rudimentary horn is a rare finding manifesting as different symptoms in young women. The enlargement of the horn can have obstructive consequences on an active endometrium, and this would lead to the formation of a hematometra and the distension of the cavity, and sometimes adenomyosis.

Cardiac Sarcoidosis Managed by Biventricular Pacing: A Case Report

Samih Khoury — 2022-06-04

Background: Cardiac sarcoidosis (CS) is a rare pathology that affects the middle-aged population. Its diagnosis, as well as its treatment, can be quite challenging, especially dealing with device management. We hereby discuss a case of CS, managed by a biventricular pacemaker in a 43-year-old man.

Case Report: A 43-year-old male presented to the emergency department with a 15-day history of chronic cough and worsening dyspnea. On examination, he was found to be bradycardic in the context of a third-degree heart block on ECG as well as bilateral hilar lymphadenopathy on chest radiography. Based on these findings, cardiac sarcoidosis was suspected. A temporary right internal jugular transvenous pacemaker was implanted in the right ventricle and empiric corticosteroid management was commenced. Lung tissue biopsies were obtained via bronchoscopy and were positive for granulomas consistent with a diagnosis of sarcoidosis. Even though the patient showed a partial positive response to corticosteroid treatment, he required a permanent pacemaker. A dual-chamber implantable cardioverter-defibrillator (ICD) was implanted and the patient was discharged on prednisone. His follow-up plan consisted of serial echocardiography and consideration of a new coronary sinus lead in the event of left ventricular dysfunction in the future.

Conclusion: Cardiac rhythm management in the context of CS is often difficult, with decisions that need to be made between a pacemaker, a defibrillator, or a cardiac resynchronization device. The idea that biventricular pacing has a preventative role against heart failure in patients with normal left ventricular ejection fraction and CS deserves more attention and discussion.

A Special Technique to Remove a Jammed Cephalic Screw from an Intramedullary Nail: A Case Report

Raymond Massaad — 2022-05-15

Background: The complexity of implant removal is a well-known problem in the field of orthopedics. It is encountered mainly during the removal of plates and screws and understood by the phenomenon of seizing or cold-welding, formerly known in mechanics. In this case study, we describe a complex experience during a gamma nail removal in a 21-year-old male patient, explained by the same phenomenon of seizing or cold-welding. The case is rather unusual and rare, with no similar reports in the literature, and required a special technique of extraction.

Case Report: A 21-year-old male presented to our clinic with a 5-months history of right groin pain radiating to the anterior thigh. The patient was a victim of a car accident three years ago that resulted in right femoral neck and shaft fractures, which were managed by open reduction and internal fixation by a long gamma nail with distal locking. After proper examination, the team decided to remove the implant. There was difficulty loosening the cephalic screw as it was welded to the nail. For this reason, we opted for a technique that involved making a transverse slit at the level of the anterior part of the nail which is in contact with the cephalic screw. It was followed by a hammer blow at the level of the cephalic screw, allowing it to loosen and thus allowing the screws along the femoral nail to be removed successfully.

Conclusion: Our report describes a rare case of a cephalic screw cold-welded/seized into the intramedullary nail, which can be an unexpected and serious complication during intramedullary nail removal. However, our technique described in this case can be an effective way to treat such a complication.

Artificial Intelligence: A New Era in Cardiology

Robert Abed — 2022-04-29

Very few fields have evolved as Cardiology has. The last four centuries have brought extraordinary discoveries, achievements, inventions, and innovations, and we are now on the verge of witnessing the beginning of a new chapter of Cardiology that will unlock diagnostic and therapeutic interventions that are today considered impossible. Why? Artificial Intelligence (AI).

Iatrogenic Tracheal Injury During Endotracheal Tube Exchange in a COVID-19 Patient: A Case Report

Connie P. Nguyen — 2022-04-26

The coronavirus disease 2019 (COVID-19) pandemic has increased the need for prolonged intubation and mechanical ventilation. Though a rare complication of mechanical intubation, tracheoesophageal fistulas (TEFs) are severe and life-threatening. We present a patient with COVID-19 pneumonia who developed an iatrogenic TEF suspected to have been acquired during traumatic reintubation. After optimizing her for surgery, management of the TEF included tracheostomy tube placement at the distal end of the tracheal injury and placement of a stent over the defect. CT scan later showed migration of the stent into the esophagus that required removal. Despite receiving supportive therapy, the patients’ status declined and the patient shortly expired. By increasing demand for prolonged mechanical ventilation, complicating intubations amid fears of transmission, and potentially causing inflammatory tracheal damage, COVID-19 creates heightened obstacles to intubation that may put patients at risk of acquiring tracheal injuries. Increased awareness of possible tracheal injuries should be made by considering the many risk factors.

CMV Colitis Mimicking Crohn’s Disease in a Patient with CLL: A Case Report

Eddy Fares — 2022-04-26

Background: Cytomegalovirus (CMV) infections are common, especially in immunocompromised patients. These infections are usually asymptomatic but can become symptomatic in immunocompromised individuals, with colitis being the second most common presentation of end-organ disease. CMV colitis can mimic Inflammatory Bowel Disease (IBD) or cause an IBD flare, thus making the diagnosis challenging.

Case Report: We describe the case of a 69-year-old male known to have Chronic Lymphocytic Leukemia (CLL) maintained in remission on venetoclax, a BCL-2 inhibitor. The patient was recently started on mesalamine and steroids after a Crohn’s Disease (CD) diagnosis three weeks before presentation. The patient presented with bloody diarrhea and abdominal pain. His workup included a colonoscopy that showed skip lesions (diffuse ulcerated lesions separated by areas of normal mucosa), a characteristic of CD. Ileal and colonic biopsies were sent for Polymerase Chain Reaction (PCR) of CMV and turned out positive. Therefore, the patient was diagnosed with CD with superimposed CMV colitis. We started the patient on ganciclovir. Three months later, a repeat colonoscopy revealed complete resolution of mucosal ulcerations, practically changing the diagnosis to an isolated CMV colitis mimicking CD.

Conclusion: An isolated CMV colitis can mimic CD, and physicians must consider this entity in their differential diagnosis. This case is additionally remarkable because CLL and the use of a BCL-2 inhibitor usually have a protective role against CMV disease, but this was not the case for our patient.

The Importance of Research for the Aspiring Young Scientists

Ricardo Villela — 2022-03-21

For many years, research served as the primary pillar behind the growth of medical sciences and provided the scientific community with the tools needed to expand their discoveries. According to a recent survey, students are now unable to follow research tracks owing to financial difficulties, obstacles in finding opportunities, or a lack of enthusiasm in research due to insufficient exposure to medical research in their medical schools. This becomes a worrisome fact since medical school curricula are not giving much importance to research in the training of future medical generations. This editorial tackles these challenges and how to face them.