Microvascular Thrombosis in Celiac Disease: Is Free Flap an Option? Case Presentation and Literature Review.

Celiac disease is an autoimmune disease that occurs due to gluten intolerance. The prevalence of breast cancer among celiac disease patients is the same as in the general population. It is of note that breast cancer is the most common type of cancer in women. Following mastectomy, these patients visit plastic surgeons for breast reconstruction. Based on various factors, autologous reconstruction using abdominal-based flaps is the best option. Patients with celiac disease have a high incidence of thromboembolic disorders, which may prevent plastic surgeons from doing breast reconstruction with free flaps. We present a case of a patient with celiac disease who underwent a free flap for breast reconstruction with an uneventful course after using our routine postoperative protocol. This case report highlights that patients with celiac disease cannot be denied the option of breast reconstruction with free flaps.

Results of Modified Stenströms Technique Otoplasty and Patients' Satisfaction at King Fahad Armed Forces Hospital (KFAFH).

Background Globally, the prevalence of protruding ears is relatively frequent. Ear deformities manifest due to underdevelopment of the antihelical fold, conchal hypertrophy, and/or an obtuse conchoscaphal angle. The availability of multiple approaches proves that there isn't a single optimal accepted procedure. The Modified Stenström otoplasty technique supports the surgeon in the management of underdeveloped antihelix fold, conchal hypertrophy, and obtuse conchoscaphal angle among other deformities. We are the first to evaluate the clinical effects and measure the satisfaction rate post-otoplasty using the modified Stenström technique with a case series study. Methods Six patients were included in the study with a total of 12 ears operated on between February 2021 and July 2022. Utilizing the modified Stenström technique for bilateral protruding ears. All patients had six postoperative follow-up visits with fixed intervals; one week, three weeks, six weeks, three months, six months, and one year. During their one-year postoperative follow-up appointment, all patients completed the satisfaction survey questions. Results Six individuals were studied, three males and three females with a mean age of 23.1 (range, 7-53 years old). There were no complications or recurrences observed. Based on the responses we collected, all patients reported a high satisfaction rate at one-year postoperative follow-up. Conclusion The modified Stenström technique yields good naturally appearing ears. It is an easy and safe technique to apply. It has a short recovery period, and no hospital stay is required. All contribute to a high satisfaction rate among studied patients.

A Unique Presentation Site of Pleomorphic Adenoma in a Young Woman: A Case Report.

The expression "pleomorphic adenoma" has been used synonymously with mixed cutaneous tumors and chondroid syringomas. It originates from eccrine or apocrine skin, salivary glands, and lacrimal glands. Histologically, it comprises an epithelial-lined glandular component embedded in the cartilaginous, myxomatous, or fibrous stroma. These lesions are usually misdiagnosed because they are extremely rare. It commonly affects middle-aged men and has a slow-growing nature. The usual manifestation is a firm nodular lesion in the periorbital region, particularly at eyelid margins. A unique presentation of this tumor was described in a young woman. The tumor presented as a small, static, nontender lump located at the junction of the superior margin of the left eyebrow and forehead. After a thorough clinical assessment, she underwent a complete surgical excision of the lesion. The most probable preoperative clinical impression at that time was that of a sebaceous cyst. However, histopathological examination revealed it to be a pleomorphic adenoma, which, to our knowledge, has never been reported in the literature at this specific anatomical site. Two years after the procedure, the patient's follow-up was uneventful, and revealed no recurrence of the lesion. Although its incidence is exceptionally low, it should always be considered in the differential diagnosis of cutaneous lesions in the head, neck, and trunk. Complete surgical excision for histopathological assessment is recommended to rule out malignancy and avoid the frequent issue of local recurrence in cases of benign tumors.

Unusual Presentation of Familial Unilateral Postaxial Polydactyly With Metacarpal Delta Phalanx: A Report of a Rare Case.

The term "delta phalanx" is proposed to characterize an uncommon deformity that typically affects the middle phalanx of a finger. It has the appearance of the Greek capital letter delta, meaning it is shaped like a triangle. Because the faulty epiphysis occurs proximally to distally instead of along its usual horizontal course, the bone has a semilunar shape. Functional impairment or significant finger shortening are indications for surgery. A variety of congenital hand anomalies are linked to the delta phalanx. Few cases of middle delta phalanx in the ulnar polydactyly finger have been documented. This case study investigates an extremely uncommon occurrence of metacarpal delta phalanx in an ulnar polydactyly finger.

Is a Higher Body Mass Index a Risk Factor for Developing Antiphospholipid Antibody Syndrome?

BACKGROUND:  Antiphospholipid antibodies (aPLs) are antibodies directed against components of the cell membrane and can be associated with clinical features or be asymptomatic in 1-5% of the population. OBJECTIVE: The objective of this study is to investigate the frequency of aPL positivity based on body mass index (BMI). METHODS:  This is a retrospective analysis of all aPL testing done in a tertiary center between 2010 and 2020. The difference between patients with BMI <25, BMI 25-30, and BMI>30 is calculated using chi-square or Fisher's exact test as appropriate for categorical variables and a two-sample t-test for numerical variables. Unadjusted then multivariable logistic regression models were conducted to evaluate the effect of BMI on aPL positivity adjusting for age, thrombosis history, pregnancy complications history, and presence of autoimmune disease. Sex was included as an effect modifier. RESULTS:  Among 312 patients, the outcome (any positive aPL) was detected in 26 (20.8%), 13 (13.0%), and 16 (18.4%) patients with BMI groups: BMI <25, BMI 25-30, and BMI > 30, respectively. A multivariable logistic regression showed that those with BMI 25-30 had a lower risk of aPL positivity when compared to patients with BMI <25 (OR of 0.55 CI 0.25 - 1.14, p=0.116), and patients with BMI >30 also carried a lower risk compared with patients with BMI<25 (OR of 0.76, 95% CI 0.36 - 1.56, p=0.46); these results were not statistically significant. INTERPRETATION:  The results suggest that a higher BMI was not a risk factor for aPL positivity. A better understanding of the complex interactions between antiphospholipid antibodies and obesity should be further investigated.

Treatment of drop attacks: Anti-seizure drug choices of pediatric neurologists in Saudi Arabia.

OBJECTIVES: To evaluate Epileptic drop attacks (EDAs) treatment options among pediatric neurologists in Saudi Arabia (SA) and to develop a recommendation scheme for the management of EDAs in SA. Epileptic drop attacks are one of the most pharmaco-resistant epileptic seizures. The different approaches to EDA treatment are influenced by a variety of factors, including pharmaceutical availability, costs, side effects, treating physicians' experience and personal preferences. METHODS: This cross-sectional study was conducted online. A structured questionnaire that aimed to measure the therapeutic options for patients with EDA was electronically distributed to pediatric neurologists across SA. It contained 21 questions, and the data were collected in Excel sheets and analyzed. RESULTS: Our study included a cohort of 71 pediatric neurologists from SA, of which male doctors represented 60%. Most of the participating pediatric neurologists had more than 10 years of experience in the field. We found that 77% of the included pediatric neurologists used valproic acid as a first-line drug in patients with EDA. Further, in the different case scenarios provided to participants, levetiracetam, clobazam, topiramate, and rufinamide were included in the initial management protocol for EDA. CONCLUSION: The majority of pediatric neurologists in Saudi Arabia chose valproic acid and/or levetiracetam as the first line of treatment for EDA. These results highlight the need for an evidence-based clinical guidelines to treat EDA.

Incidence and Risk Factors of Infections Among Diffuse Large B-cell Lymphoma and Classical Hodgkin's Lymphoma Patients in a Tertiary Care Center in Saudi Arabia: A Retrospective Cohort Study.

INTRODUCTION:  Non-Hodgkin's lymphoma (NHL) ranked fourth among all cancer types in Saudi Arabia, as reported by the Saudi Health Council in 2015. Diffuse large B-cell lymphoma (DLBCL) is the most common histological type of NHL. On the other hand, classical Hodgkin's lymphoma (cHL) ranked sixth and had a modest tendency to affect young men more frequently. Over recent decades, DLBCL patients were treated with cyclophosphamide, doxorubicin hydrochloride, oncovin, and prednisolone (CHOP) alone. Adding rituximab (R) to the standard regimen (CHOP) shows significant improvement in overall survival. However, it also has a considerable effect on the immune system, impacting complement-mediated and antibody-dependent cellular cytotoxicity and causing an immunosuppressive state through modulating T-cell immunity via neutropenia, which can let the infection spread. AIMS AND OBJECTIVES:  This study aims to evaluate the incidence and risk factors associated with infections in DLBCL patients in comparison to patients with cHL treated with doxorubicin hydrochloride (Adriamycin), bleomycin sulfate, vinblastine sulfate, and dacarbazine (ABVD). MATERIALS AND METHODS:  This study is a retrospective case-control study that included 201 patients acquired between January 1st, 2010, and January 1st, 2020. Sixty-seven patients had a diagnosis of cHL and had received ABVD, and 134 had DLBCL and had received rituximab. Clinical data were obtained from the medical records. RESULTS:  During the study period, we enrolled 201 patients, of whom 67 had cHL, and 134 had DLBCL. DLBCL patients had a higher serum lactate dehydrogenase upon diagnosis than cHL (p = 0.005). Both groups have similar response rates with complete remission/partial remission. Compared to cHL, patients with DLBCL were more likely to have advanced disease when they first presented (stage III/IV, DLBCL: 67.3 vs. cHL: 56.5; p = 0.005). DLBCL patients had an increased risk of infection as compared to cHL patients (DLBCL: 32.1 % vs. 16.4%; p = 0.02). However, patients with a poor response to treatment had an increased risk of infection compared to patients with a favorable response regardless of the type of disease (odds ratio: 4.6; p = <0.001). When using multivariate analysis, it is revealed that unfavorable therapeutic response continues to be the only predictor raising the probability of infection in the population (odds ratio: 4.2; p = 0.003). CONCLUSIONS:  Our study explored all potential risk factors for the occurrence of infection in DLBCL patients who received R-CHOP versus cHL. The most reliable predictor of an increased risk of infection during the follow-up period was having an unfavorable response to medication. To assess these results, additional prospective research is required.

Spiral Wrap-Around Technique in the Reverse Radial Artery Fasciocutaneous Forearm Flap for Thumb Reconstruction: A Report of An Innovative Technique.

For amputation of the thumb in any age group, microsurgical replantation is the gold standard over other osteoplastic thumb reconstruction methods as it restores the form, function, and cosmesis of the thumb better. In the osteoplastic reconstruction of the thumb, usually, a pedicled groin flap or a reverse radial artery forearm flap is used to provide the soft tissue cover, and each of these flaps has its own set of merits and demerits. The reverse radial artery forearm flap can be used as a fascial or fasciocutaneous flap in an islanded or peninsular form. Using it as a fasciocutaneous forearm flap creates a donor site secondary defect that needs skin grafting, leading to an unsightly permanent cosmetic deformity in the forearm. We report a case of a 25-year-old male patient who underwent post-traumatic near-total thumb amputation following a crush avulsion injury in whom revascularization failed, and we successfully performed osteoplastic thumb reconstruction using the same phalanges as skeletal support and the reverse radial forearm flap as soft tissue cover. We devised a novel but simple spiral wrap-around technique in the reverse pedicled fasciocutaneous flap by rearranging the dimensions, changing the length-to-width ratio to 5:1, and then wrapping this strip of flap spiraling around the bony skeleton with primary closure of the donor site.

Bizarre Parosteal Osteochondromatous Proliferation (Nora's Lesion) in the Hand: A Case Report and a Review of the Literature.

A Nora's lesion, a rare and typically non-cancerous growth originating from the parosteal osteochondromatous tissue, primarily manifests in the hands and feet. Despite its benign nature, diagnosing Nora's lesions is complex due to their tendency to exhibit aggressive features in imaging scans and the ambiguity encountered in histological examinations. This rarity is evidenced by the limited number of reported cases in medical literature since its initial discovery. Detailing a distinctive instance, we document a specific case of a Nora's lesion situated on the dorsum of the left hand, specifically above the shafts of the fourth and fifth metacarpal bones. Through a meticulous histopathological analysis, the diagnosis was confirmed, aligning precisely with imaging features. To address the lesion conclusively, a comprehensive surgical excision of the mass was performed. This particular case not only adds to the scant body of documented instances but also underscores the significance of accurate diagnosis and management. Understanding and documenting such cases are crucial in refining diagnostic approaches and optimizing treatment strategies for Nora's lesions, emphasizing the ongoing need for further research in this domain.

Impact of COVID-19 Pandemic Lockdown on the Prognosis, Morbidity, and Mortality of Patients Undergoing Elective and Emergency Abdominal Surgery: A Retrospective Cohort Study in a Tertiary Center, Saudi Arabia.

The SARS-CoV-2 pandemic's main concerns are limiting the spread of infectious diseases and upgrading the delivery of health services, infrastructure, and therapeutic provision. The goal of this retrospective cohort study was to evaluate the emergency experience and delay of elective abdominal surgical intervention at King Abdul-Aziz University Hospital from October 2019 to October 2020, with a focus on post-operative morbidity and mortality before and during the COVID-19 pandemic. This study compares two groups of patients with emergent and elective abdominal surgical procedures between two different periods; the population was divided into two groups: the control group, which included 403 surgical patients, and the lockdown group, which included 253 surgical patients. During the lockdown, surgical activity was reduced by 37.2% (p = 0.014), and patients were more likely to require reoperations and blood transfusions during or after surgery (p= 0.002, 0.021, and 0.018, respectively). During the lockdown period, the average length of stay increased from 3.43 to 5.83 days (p = 0.002), and the patients who developed complications (53.9%) were more than those in the control period (46.1%) (p = 0.001). Our tertiary teaching hospital observed a significant decline in the overall number of surgeries performed during the COVID-19 pandemic and lockdown period. During the lockdown, abdominal surgery was performed only on four patients; they were positive for COVID-19. Three of them underwent exploratory laparotomy; two of the three developed shock post-operative; one patient had colon cancer (ASA score 3), one had colon disease (ASA score 2), and two had perforated bowels (ASA scores 2 and 4, respectively). Two out of four deaths occurred after surgery. Our results showed the impact of the COVID-19 lockdown on surgical care as both 30-day mortality and total morbidity have risen considerably.

Assessment of First Aid Measures to Control Epistaxis Among Health Care Providers at Tertiary Care Hospital in Saudi Arabia.

Background Epistaxis refers to bleeding from the inside of the nose or nasal cavity. It is one of the most prevalent otorhinolaryngology emergencies. It is generally treated with simple conservative measures, although it can sometimes be life-threatening. In most cases, using simple first-aid measures that involve tilting the patient's head forward to reduce the risk of blood aspiration and applying digital compression to the nasal alae and anterior septal area for 10-15 minutes will stop the nosebleeds in 90%-95% of cases. This study aims to assess health care providers' knowledge of epistaxis first-aid measures. Methods This cross-sectional study was conducted via an electronic questionnaire of multiple-choice questions. The survey was randomly sent through WhatsApp (Google Inc) to all health care providers and medical students who met the inclusion criteria. The study's inclusion criteria included emergency care providers, primary care providers, otolaryngology and head and neck surgery residents, and second-year medical students. In addition, Oto-HNS residents and medical students were included as a control. Respondents were asked to recognize where to apply nasal compression and what is the correct position of the patient's head during an epistaxis episode. Results Thirty percent of health care providers answered correctly to the site of nose compression, and 66% for the correct head position. When evaluating the answers to both questions collectively, 31% of EM consultant physicians, 18% of EM residents, 24% of FM consultant physicians, 40% of family medicine residents, 13% of ED nurses, 28% of house officers, 69% of Oto-HNS residents and 17% of the second-year medical students responded to both questions correctly. A large proportion of those who responded incorrectly to either of the questions stated they were "very confident" about their response. Conclusion Even though primary and emergency care providers see many epistaxis patients, this study found that the majority of EM consultant physicians, EM residents, ED nurses, FM consultant physicians, FM residents, and house officers surveyed in this study could not identify first-aid measures for epistaxis appropriately. Increased otolaryngology training might help primary and emergency care providers by increasing their understanding of epistaxis first-aid measures often seen in their practices.

Acceptance of COVID-19 Vaccine and Associated Factors Among Pregnant Women in Saudi Arabia.

Background: Coronavirus disease 19 (COVID-19) vaccination has been established as preventing severe and mortal COVID-19. Vaccination is critical strategy in controlling the COVID-19 pandemic, to restrict infections and reduce disease severity. Vaccination coverage will be more extensive if we can better identify vaccination barriers in the population, especially among vulnerable groups, of which one is pregnant women. The aim of this study was to determine the level of acceptance of COVID-19 vaccination and detect the factors that influence vaccine acceptance among pregnant women in Saudi Arabia. Methods: This was a cross-sectional, web-based study conducted in Western, Eastern, North, South, and Central Regions in Saudi Arabia between July and September 2021 among pregnant women, using multi-stage sampling. All pregnant women above 18 years were invited to participate in the study. Pregnant under 18 years of age and those with a contraindication to receiving COVID-19 vaccination were excluded. Binomial logistic regression (univariate and multivariate) was used to identify the influencing factors on vaccination acceptance. Results: Among the 5307 pregnant women, the acceptance level of COVID-19 vaccine was 68%. In the multivariate regression model analysis, the most common predictors of acceptance were living in North Region (P = 0.001, OR = 1.9), living in South Region (P = 0.000, OR = 3.06), and living in Central Region (P = 0.035, OR = 1.42) in comparison to living in Western Region. Gestational week (P = 0.018, OR=0.98), income more than 8000 SR (P = 0.000, OR = 0.51), education level (primary, secondary, and university; P = 0.002, 0.008, and 0.010, respectively), having had gestational diabetes mellitus (P = 0.013, OR = 1.86), being vaccinated with influenza vaccine during present pregnancy (P = 0.000, OR = 4.55, OR = 1.81), being vaccinated with tetanus vaccine during present pregnancy (P = 0.039), and believing that the COVID-19 vaccine could harm their baby (P = 0.000, OR = 0.12). Conclusion: Our study reported high acceptance of COVID-19 vaccination. The major two reasons for refusal were concerns about a lack of data on COVID-19 vaccination safety and the possibility of harming the fetus. Continued public health efforts, such as educational television programs and awareness campaigns about the safety of the COVID-19 vaccine for pregnant women, are required to raise awareness. More studies of COVID-19 vaccine safety in pregnant women would assist in overcoming these obstacles and encourage pregnant women to be vaccinated.