A rare presentation of hydatid cyst disease at the thigh: a case report from Syria.

Introduction and importance: Hydatid cyst disease is a zoonotic disease caused by Echinococcus granulosus and is recognized as a significant health issue in many countries, particularly Mediterranean countries. Hydatid cysts in the musculoskeletal system are rare, with only a few reported cases. These usually occur as secondary cysts resulting from the hematogenous dissemination from primary sites. Case presentation: This paper reports a case of a 77-year-old man with a mass in his thigh that had been increasing dramatically in size for 4 months with no signs of local inflammation, fever, or any other symptoms. Findings from an MRI were consistent with a large abscess, so a true-cut biopsy was taken before referral. A pathological study after surgery revealed the lesion was a hydatid cyst, and a previously performed biopsy caused a rupture of the cyst. Clinical discussion: Misdiagnosing hydatid cysts, especially in non-usual areas, may lead to an unwelcome biopsy and consequences. Conclusion: This case report highlights the importance of considering hydatid cysts when encountering any enlarging mass, regardless of its location or rate of growth.

Concurrent ascending colon adenocarcinoma and colonic tuberculosis: a case report from Syria.

Introduction and importance: Tuberculosis (TB) has been one of the most devastating diseases to humanity in recent decades; although pulmonary infection is the most common, infection of any other organ is familiar as well. Colon cancer is another disease affecting the gastrointestinal (GI) system and mostly targets people over 50. Only a few studies mentioned the co-existence of cancer and TB occurring at the same place and time. Hence, the authors report a rare case of concurrent ascending colon adenocarcinoma and colonic TB. Case presentation: A 49 -year-old man presented to our clinic with constipation and abdominal pain. Two colonoscopies were performed, and two biopsies were taken; the first one showed granulomatous inflammation consistent with TB, and the second one showed low-grade adenocarcinoma. Computed tomography showed annular thickening of the ascending colon with infiltrates around the lesions. A right hemicolectomy was performed, and the final pathology confirmed adenocarcinoma grade II and extensive TB granulomas involving the colon into the serosa and the lymph nodes. Anti-TB medications were administered after surgery. Clinical discussion: Due to appropriate diagnostic methods, TB and cancer were detected at an early stage. In our treatment protocol, no adjuvant chemotherapy was applied after surgery due to the possibility of drug interaction with anti-TB medications. Conclusion: The two diseases may co-exist; thus, diagnosing them may not be the easiest, not to mention the lack of a clear treatment protocol in case of their accompany.

Boys gymnastics injuries: A 9-year retrospective review.

OBJECTIVES: Young male gymnasts are a frequently injured, yet infrequently studied population. Literature on gymnastics injuries has focused primarily on female gymnasts at elite and collegiate levels. Gymnastics equipment, rules, and training methods have continued to evolve over the past few decades so the previous data likely does not reflect current injury patterns. Our study aimed to provide a description of injury patterns for contemporary club-level, pre-collegiate male gymnasts. METHODS: This was a retrospective chart review of 163 gymnastics injuries from 84 male subjects ages 4-19 years. Subjects were seen between 2010 and 2019 in pediatric sports medicine clinics. Gymnast demographics, injury locations, injury types, and gymnastics apparatus were collected as available. RESULTS: Our cohort had a mean age of 12.5 ± 3.0 years, gymnastics participation for 8.1 ± 2.9 years, and gymnastics level of 7.4 ± 1.7. Overuse injuries (59.5%) were more common than acute injuries (40.5%). The most common injury locations were lower extremity (42.3%), followed by upper extremity (32.5%), spine/trunk (19.6%), and head/neck (5.5%). The leading injury types were strains (16.6%) and apophysitis (12.9%). The most common apparatus for injury was floor (25%) followed by vault (20%). Binomial logistic regressions revealed that higher gymnastics level (OR = 5.19, p = .031) and younger age (OR = 4.05, p = .012) were predictors of lower extremity injuries. CONCLUSION: Our data show that injuries among club-level, young male gymnasts were most frequently located in the lower extremities. This contrasts older studies of primarily elite male gymnasts where injuries were more common in upper extremities. Overuse injuries were most prevalent in our cohort, and the most frequent injury types were strains and apophysitis.

Liver segmentectomy surgery for delayed diagnosed hepatic TB, a case report from Syria.

Introduction and importance: Mycobacterium Tuberculosis infection is still one of the most common causes of morbidity and mortality worldwide. TB usually infects the lungs, but it can affect other organs. Hepatic involvement usually occurs with disseminated disease whereas isolated hepatic involvement is extremely rare. Case presentation: We present a case of a female patient who had to undergo major hepatic surgery due to delayed diagnosis of hepatic TB. It suffered from recurrent abdominal abscesses and general symptoms for a period of time. clinical Discussion: Medical therapy is the treatment of choice and surgery is justified only in specific cases. Surgical intervention may range from less complicated procedures as local excision, abscess drainage or biliary drainage to more complicated and major surgeries such as liver segmentectomy and hemihepatectomy. conclusion: Although rare, physicians should suspect and diagnose early, to give the patient the best chance to benefit from medical therapy and avoid the need for surgical intervention.

Intact and Perforated Pulmonary Hydatid Cyst: A Comparative Study from Damascus, Syria.

BACKGROUND: Hydatidosis is a major health problem around the world, especially in the Mediterranean region. Cysts can break open or develop secondary bacterial infections, altering the clinical presentation. METHODS: Patients who underwent hydatid cyst surgery at Al-Mouassat University Hospital in Damascus, Syria between January 2006 and December 2017 were evaluated. Cases involving isolated hepatic cysts were excluded. The patients were divided into those with perforated hydatid cysts (group 1) and those with intact hydatid cysts (group 2). RESULTS: This study included 224 cases: 113 in group 1 (50.4%) and 111 in group 2 (49.6%). The median chest tube duration, hospitalization time, and postoperative complication rate were higher in group 1 than in group 2 (p=0.003, p=0.002, and p=0.006, respectively). In both groups, the most common symptom was cough (present in 178 patients in total [79.5%]), while chest pain (121 patients [54%]) and dyspnea (113 patients [50.4%]) were also common. Cough, hemoptysis, fever, and expectoration of cystic contents were significantly more frequent in group 1 than in group 2 (p<0.001). CONCLUSION: The early discovery and treatment of intact pulmonary hydatid cysts reduced the hospitalization time, chest tube duration, and postoperative complication rate. Relative to intact cysts, perforated cysts are more complex and are associated with more expensive and time-consuming surgical treatment.

Pancreaticoduodenectomy in a patient with a rare celiac trunk and hepatic artery anomaly, a case report from Syria.

Pancreaticoduodenectomy is still one of the biggest and high complicated surgeries. It still has high morbidity and mortality rates. liver receives its blood supply from one hepatic artery a branch of the celiac trunk However variations of hepatic and celiac trunk are not rare. We present a case of a 60-year-old patient who underwent pancreaticoduodenectomy for ampulla tumor in which there were some rear anomalies. Angiographic CT after procedure confirmed the absence of celiac trunk, the absence of left gastric, the splenic artery arising from aorta directly and common hepatic artery arising from superior mesenteric artery. These anomalies are not considered contraindication and should not be. with good surgical experience the procedure may be done safely giving the patient his last choice to fight the disease.

Are gestures worth a thousand words? Verbal and nonverbal communication during robot-assisted surgery.

Communication breakdowns in the operating room (OR) have been linked to errors during surgery. Robot-assisted surgery (RAS), a new surgical technology, can lead to new challenges in communication owing to the remote location of the surgeon away from the patient and bedside assistants. Nevertheless, few studies have studied communication strategies during RAS. In this study, 11 robot-assisted radical prostatectomies were recorded and the interaction events between the surgeon and two bedside surgical team members were categorized by modality (verbal/nonverbal), topic, and pair (sender and receiver). Both verbal and nonverbal modalities were used by all pairs. The percentage of nonverbal interactions differed significantly by pair: 66% for the Surgeon-Physician Assistant, 50% for the Physician Assistant-Scrub Nurse, and 25% for the Surgeon-Scrub Nurse, indicating different communication strategies across pairs. In addition, there was a significant dependence between topic and the percentages of verbal and nonverbal events for all pairs. Strategies to improve team communication during RAS should take into account the use of verbal and nonverbal communication means and the variation in interaction strategies based on the topic of communication.

The environmental health nexuses within the Strategic Roadmap: regional work priorities for the WHO Eastern Mediterranean Region (Editorial).

The Eastern Mediterranean Region (EMR) is a diverse region in terms of income, development, health and environmental conditions. The environment and ecosystems are under serious pressures with adverse impacts on human health and well-being. Environmental Health (EH) is an area of growing importance for EMR, and environmental risk factors such as air, water and soil pollution, chemical exposures, climate change and radiation, contribute to more than 100 diseases and injuries, and environmental hazards are responsible for about 22% of the total burden of disease in the Region.

False-positive radioiodine accumulation in a huge pelvic mass after thyroidectomy for papillary carcinoma, a case report from Syria.

Iodine has always been connected to thyroid gland, and the fact that thyroid tissue traps, organificates and stores iodine more than other tissues is well known, hence the use of radioiodine as a diagnostic and therapeutic tool for thyroid disorders. However, false-positive cases do occur. We present a case of a 34-year-old patient who underwent total thyroidectomy for papillary carcinoma. Results of follow up TSH, thyroglobulin and thyroglobulin antibody tests after surgery lead to two rounds of radioactive iodine. After that, a radioiodine whole-body scan showed high uptake in the pelvis above bladder. Computed tomography scan showed a pelvic heterogeneous mass with some calcifications. Surgical removal and subsequent pathology confirmed the absence of metastasis. The final pathological diagnosis was serous cystadenoma, endometriosis cyst and leiomyoma. As the real cause behind false-positive iodine uptake by these tissues has yet to be determined, careful assessment should be considered in any suspicious case.

Perioperative Liver Function after Hepatectomy in a Tertiary University Hospital in Damascus

Background: Liver resection is the only viable therapeutic treatment option for several neoplastic entities of the liver. Although, the number of resectable patients is increasing in Syria, liver failure is still a major complication affecting mortality and morbidity rates. Methods: Between 2009 and 2016, 104 patients undergoing liver resection in Damascus University Faculty of Medicine were retrospectively analyzed. Liver function tests were conducted before surgery (ps) and in the perioperative period (po) and comparisons were performed with division into anatomic VS non-anatomic or malignant VS non-malignant groups. Results: Liver synthetic, excretory and detoxifying functions deteriorated after liver resection (INR ps 'presurgery'=1.129 po 'perioperative'=1.426 P<0.001, TP ps=7.426 po=5.581 P<0.001, ALB ps=4.204 po=3.242 P<0.001, T-Bill ps=0.061 po=0.136 P<0.001) and liver cell necrosis increased after resection (ALT ps=27.597 po=200.221 P<0.001, AST ps=33.395 po=190.553 P<0.001). There was no significant difference in liver functions when we compared anatomic VS non-anatomic groups or malignant VS non-malignant groups, but liver cell necrosis was higher with malignancies (ALT malignant group=236.475 non-malignant group=89.5 P=0.002, AST malignant group=222.644 non-malignant group=101.125 P=0.001). Conclusion: Although liver resection affects liver function significantly, no differences in outcomes were found between anatomic VS non anatomic or malignant VS non-malignant groups.

Castleman's disease with TAFRO syndrome: a case report from Syria.

Castleman's disease is a rare disorder, yet a rarer newly described syndrome called TAFRO syndrome was discovered to accompany it. TAFRO represents the constellation of symptoms (Thrombocytopenia, Anasarca, MyeloFibrosis, Renal failure, Organomegaly). Most cases were described in Japan. We present the first case of TAFRO syndrome in Syria. A 58-year-old Caucasian male with no relevant history presented with fatigue, oliguria, decreased platelets, increased creatinine level, hepatosplenomegaly, ascites, pitting edema and lymph node enlargement. Possible differential diagnoses were excluded by laboratory, radiologic and cytologic tests including TB, malignancy and autoimmune diseases. A biopsy of a supraclavicular lymph node confirmed Castleman disease. Our patient had Catleman's disease, and presented with only four diagnostic criteria for TAFRO syndrome (Myelofibrosis was absent) in addition to other minor characteristics (microcytic anemia, negative HIV and HHV-8 infections.) which make the presentation consistent with TAFRO syndrome described in the Japanese cases. The criteria for diagnosing TAFRO syndrome are still changing, and the pathophysiology behind it is unclear. We recommend further research to understand this syndrome taking into account that its prevalence might be worldwide.

Technical mentorship during robot-assisted surgery: a cognitive analysis.

OBJECTIVE: To investigate cognitive and mental workload assessments, which may play a critical role in defining successful mentorship. MATERIALS AND METHODS: The 'Mind Maps' project aimed at evaluating cognitive function with regard to surgeon's expertise and trainee's skills. The study included electroencephalogram (EEG) recordings of a mentor observing trainee surgeons in 20 procedures involving extended lymph node dissection (eLND) or urethrovesical anastomosis (UVA), with simultaneous assessment of trainees using the National Aeronautics and Space Administration Task Load index (NASA-TLX) questionnaire. We also compared the brain activity of the mentor during this study with his own brain activity while actually performing the same surgical steps from previous procedures populated in the 'Mind Maps' project. RESULTS: During eLND and UVA, when the mentor thought the trainee's mental demand and effort were low based on his NASA-TLX questionnaire (not satisfied with his performance), his EEG-based mental workload increased (reflecting more concern and attention). The mentor was mentally engaged and concerned while he was engrossed in observing the surgery. This was further supported by the finding that there was no significant difference in the mental demands and workload between observing and operating for the expert surgeon. CONCLUSIONS: This study objectively evaluated the cognitive engagement of a surgical mentor teaching technical skills during surgery. The study provides a deeper understanding of how surgical teaching actually works and opens new horizons for assessment and teaching of surgery. Further research is needed to study the feasibility of this novel concept in assessment and guidance of surgical performance.

Ambulatory movements, team dynamics and interactions during robot-assisted surgery.

OBJECTIVE: To analyse ambulatory movements and team dynamics during robot-assisted surgery (RAS), and to investigate whether congestion of the physical space associated with robotic technology led to workflow challenges or predisposed to errors and adverse events. METHODS: With institutional review board approval, we retrospectively reviewed 10 recorded robot-assisted radical prostatectomies in a single operating room (OR). The OR was divided into eight zones, and all movements were tracked and described in terms of start and end zones, duration, personnel and purpose. Movements were further classified into avoidable (can be eliminated/improved) and unavoidable (necessary for completion of the procedure). RESULTS: The mean operating time was 166 min, of which ambulation constituted 27 min (16%). A total of 2 896 ambulatory movements were identified (mean: 290 ambulatory movements/procedure). Most of the movements were procedure-related (31%), and were performed by the circulating nurse. We identified 11 main pathways in the OR; the heaviest traffic was between the circulating nurse zone, transit zone and supply-1 zone. A total of 50% of ambulatory movements were found to be avoidable. CONCLUSION: More than half of the movements during RAS can be eliminated with an improved OR setting. More studies are needed to design an evidence-based OR layout that enhances access, workflow and patient safety.