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Osama Alshari,1 Yazan O Al Zu’bi,2 Ahmed H Al Sharie,2 Farouk H Wafai,2 Abdelwahab J Aleshawi,2 Farah H Atawneh,3 Hasan A Obeidat,2 Majd N Daoud,2 Mohammad Z Khrais,4 Dima Albals,5 Faize Tubaishat6 1Division of Oncology, Department of Internal Medicine, Faculty of Medicine, Jordan University of Science & Technology, Irbid, Jordan; 2Faculty of Medicine, Jordan University of Science & Technology, Irbid, Jordan; 3Department of Medical Laboratory Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan; 4Department of Internal Medicine, King Hussein Cancer Foundation and Center, Amman, Jordan; 5Department of Medicinal Chemistry and Pharmacognosy, Faculty of Pharmacy, Yarmouk University, Irbid, Jordan; 6Division of Oncology, Department of Internal Medicine, Al Bashir Hospital, Amman, JordanCorrespondence: Osama AlshariDivision of Oncology, Department of Internal Medicine, Faculty of Medicine, University of Science & Technology, P. O. Box: 3030, Irbid, 22110, JordanEmail osamasalshari@gmail.comObjective: Chemotherapy-induced febrile neutropenia is a common and serious oncological emergency which carries a substantial mortality and morbidity. The main objective of this study is to evaluate the usage of absolute monocyte count (AMC) at presentation as a prognostic factor for patients with chemotherapy-induced febrile neutropenia who were subsequently treated with granulocyte colony-stimulating factor (G-CSF).Study Design: The electronic medical records of our center were used retrospectively to identify patients diagnosed with unprecedented chemotherapy-induced febrile neutropenia treated with G-CSF between January 2010 to December 2020 and diagnosed with solid and hematological malignancies. Patient’s demographics, disease characteristics and laboratory investigations were extracted. Disease progression measures were statistically compared between the study groups in the short-term period of follow-up (six days) including absolute neutrophil count (ANC), ANC difference compared to the baseline readings, hospitalization period, and mortality.Results: A total of 80 patients were identified and categorized into two groups namely monocytopenia (n = 34) and non-monocytopenia (n = 46) with an AMC cutoff point of 0.1× 109 cells/L. The monocytopenia group exhibited a worse prognosis with lower ANC values and slower improvement illustrated by the low ANC difference values at all follow up points (P-value ≤ 0.05) apart from day 5. A statistically significant lower hospitalization period was also observed in the non-monocytopenia group (P-value = 0.006). Linear regression analysis evaluated the association between AMC values at admission and ANC values at admission along with subsequent days of follow up which were found to be statistically significant (P-value ≤ 0.05). Receiver operating characteristic curves suggest a satisfactory predictability of ANC changes by AMC values at admission, days1, 2, 3, 4 and 6.Conclusion: Monocytopenia holds a worse prognosis in chemotherapy-induced febrile neutropenia patients treated with G-CSF. In addition, AMC values at presentation represents a potential risk factor that can predict short-term changes regarding ANC measures.Keywords: febrile neutropenia, granulocyte colony-stimulating factor, G-CSF, chemotherapy, absolute monocyte count, monocytopenia, absolute neutrophil count

Khalid M Abdalla,1 Mostafa A Abdelrahman,2 Abdelwahab J Aleshawi,3 Alaha S Al Taweel,1 Majid Bani-Ata,4 Khaled Obeidat5 1Department of Diagnostic Radiology and Nuclear Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; 2Department of Allied Medical Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid 22110, Jordan; 3Department of Special Surgery, Ophthalmology Division, Jordan University of Science and Technology, Irbid 22110, Jordan; 4Department of Special Surgery, Otolaryngology Division, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; 5Department of General Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, JordanCorrespondence: Khalid M AbdallaDepartment of Diagnostic Radiology and Nuclear Medicine, Faculty of Medicine, Jordan University of Science and Technology, P. O. Box: 3030, Irbid 22110, JordanTel +962 799273019Fax +962 2 7201064Email khalidmohabdalla@yahoo.comObjective: Developmental dysplasia of the hip (DDH) is an abnormal relationship between the acetabulum and the head of the femur. Plain x-ray of both hips at the age of 3 months is still in use in some countries. On plain films, classic lines and angles are evaluated to meet current guidelines for positive DDH. Among these is the acetabular angle (AA), which most did not exceed 30° in normal pelvis regardless of gender. A flat promontory gives the impression of a high AA angle, whereas a sharp promontory gives the impression of a low AA angle.Materials and Methods: All anteroposterior (AP) pelvic digital x-ray studies performed to rule out DDH were collected from the PACS systems. A novel angle was measured between a line parallel to the lateral aspect of the region of the inferior iliac spines and a line that extends along the acetabular roof to quantify the roundness of the iliac promontory. We called the former line the Miral line and the formed angle the iliac promontory angle.Results: We show that the promontory shape is significantly different between genders, and therefore it is mistaken to generalize an upper AA limit for males and females. In addition, we show that the current guideline of the upper limit of AA did not predict the incidence of DDH.Conclusion: We suggest that the current practice is introducing a high rate of false positive, especially among females, and the current guidelines on AA should be reviewed and assigned separately for males and females. This is more important for countries that did not utilize the ultrasonographic assessment for DDH.Keywords: acetabular angle, DDH, plain x-ray, head of the femur

Qusai Aljarrah,1 Mohammed Allouh,2 Amer H Hallak,3 Shamikh E Alghezawi,3 Mamoon Al-Omari,4 Mwaffaq Elheis,4 Mooath Al-Jarrah,4 Sohail Bakkar,5 Abdelwahab J Aleshawi,6 Hussam Al-Jarrah,1 Khalid S Ibrahim,7 Jan Mohammed Al Shishani,8 Aws Almukhtar9 1Department of General & Vascular Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; 2Department of Anatomy, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain 17666, United Arab Emirates; 3Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; 4Department of Diagnostic and Interventional Radiology, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; 5Department of Surgery, Faculty of Medicine, The Hashemite University, Zarqa 13133, Jordan; 6Department of Ophthalmology, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; 7Department of General & Cardiovascular Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; 8Department of Vascular Surgery, King Hussein Medical Center, Amman 11733, Jordan; 9Department of Surgery and Cancer, Imperial College London, London SW7 2BU, UKCorrespondence: Qusai AljarrahDepartment of General & Vascular Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, JordanTel +962 775593131Email qmaljarrah@just.edu.joMohammed AllouhDepartment of Anatomy, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab EmiratesTel +971 37 137 551Email m_allouh@uaeu.ac.aePurpose: Central venous lesions (CVLs) can adversely affect hemodialysis access maturation and maintenance, which in turn worsen patient morbidity and access circuit patency. In this study, we assessed several clinical variables, patient characteristics, and clinical consequences of symptomatic central vein stenosis and obstruction in patients who underwent renal replacement therapy in the form of hemodialysis.Patients and Methods: The medical records of all hemodialysis patients with clinically symptomatic CVLs who underwent digital subtraction angiography treatment at King Abdullah University Hospital between January 2017 and December 2019 were retrieved. Patient characteristics and the clinical and anatomical features of CVLs were analyzed retrospectively. Pearson’s chi-square tests of association were used to identify and assess relationships between patient characteristics and CVLs.Results: The study cohort comprised 66 patients with end-stage renal disease who developed symptomatic central vein stenosis. Of the 66 patients, 56.1% were men, and their mean age was approximately 52 years. Most (62.1%) of the patients were determined to have a history of central catheter insertion into the jugular vein. Hypertension was the most common comorbidity (78.8%, p< 0.001), followed by type 2 diabetes mellitus (47.0 %, p< 0.01). The incidence of stenosis was found to be significantly higher in the brachiocephalic vein than in other central veins (43.9%, p< 0.001). A repeated central catheter insertion in a patient was predictive of central venous occlusion (p< 0.05). Stenotic lesions were found to be associated with a significantly higher success rate than occlusive lesions (91.2%, p< 0.01).Conclusion: Multiple central venous catheters (CVCs) are found to be associated with occlusive CVLs and unfavorable recanalization outcomes. Multiple CVC should be avoided by creating a permanent vascular access in a timely fashion for patients with chronic kidney disease and by avoiding the ipsilateral insertion of CVC and AVF.Keywords: central venous lesions, brachiocephalic vein, central line catheterization, percutaneous transluminal angioplasty, fistula, hemodialysis

Shaher M Samrah, 1 Abdel-Hameed Al-Mistarehi, 2 Abdelwahab J Aleshawi, 3 Aws G Khasawneh, 4 Suleiman M Momany, 1 Baker S Momany, 3 Faris J Abu Za’nouneh, 3 Thekra Keelani, 3 Abrar Alshorman, 3 Basheer Y Khassawneh 1 1Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology (JUST), Irbid, Jordan; 2Department of Public Health and Family Medicine, Faculty of Medicine, Jordan University of Science and Technology (JUST), Irbid, Jordan; 3Faculty of Medicine, Jordan University of Science and Technology (JUST), Irbid, Jordan; 4Department of Neurosciences, Faculty of Medicine, Jordan University of Science and Technology (JUST), Irbid, JordanCorrespondence: Shaher M SamrahDepartment of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology (JUST), P.O. Box: 630001, Irbid 22110, JordanTel +962 2 7201000Fax +962 2 7201064Email samrah@just.edu.joBackground: In-hospital mandatory quarantine of asymptomatic and symptomatic COVID-19-infected individuals was part of the national control strategy used to prevent the spread of the COVID-19 outbreak in Jordan. This study aims to evaluate depression, associated stressors, and various coping methods used among adult quarantined COVID-19-infected individuals.Methods: This cross-sectional study included all COVID-19-infected individuals who were obligatorily quarantined at King Abdullah University Hospital, Irbid, Jordan from March 15 to April 20, 2020. Symptoms of depression were assessed using the 9-item Patient Health Questionnaire after 10 days of quarantine. In addition, several questions regarding the patients’ sights with the health-care system, and coping methods were added. Demographic characteristics, clinical presentation, and comorbidities were collected from the medical records.Results: Out of 91 quarantined COVID-19 patients, a total of 66 completed the survey, with a participation rate of 72.5%. The majority were relatively young; the mean ± SD age was 35.8 ± 16.2 years (range 18– 79), 59.1% were females and 47% were asymptomatic. A considerable proportion of patients (44%) reported symptoms of depression, with 21% were at high risk of major depressive disorder. Depression symptoms were significantly more common among females than males [PHQ-9 score ≥ 10: 13 (92.9%) vs 1 (7.1%), respectively; p=0.004]. The majority of patients (71.2%) reported having problems with health-care services. Insufficient involvement in making treatment decisions was the most commonly reported concern (59.1%). Patients who reported problems in maintaining privacy, reaching out to their physicians, or receiving conflicting information from the medical staff, had more symptoms of depression compared with the satisfied ones (p< 0.05). On the other hand, those who were receiving sufficient support from the family, friends, or medical staff during quarantine, were less likely to have depression symptoms (p< 0.05). Furthermore, symptoms of depression were less in patients who stayed in touch with others using phone calls, texting, or social media (p=0.024).Conclusion: Symptoms of depression were common among both symptomatic and asymptomatic quarantined COVID-19 patients. The support of family, friends, and medical staff was an essential alleviating factor. Facilitating adequate communication may promote the mental well-being of COVID-19-infected patients and help in reducing the risk of depression during the in-hospital quarantine.Keywords: COVID-19, coronavirus, SARS-CoV-2, quarantine, depression, psychological disorder

Khaldoon M Bashaireh,1 Ziad Audat,1 Ahmad M Radaideh,1 Abdelwahab J Aleshawi2 1Department of Special Surgery, Division of Orthopedics, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; 2Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, JordanCorrespondence: Khaldoon M BashairehDepartment of Special Surgery, Division of Orthopedics, Faculty of Medicine, Jordan University of Science and Technology, P. O. Box 3030, Irbid 22110, JordanTel +962799051087Fax +962 2 7201064Email bashaireh@just.edu.joObjective: In this article, we aim to revisit the synthetic graft and review the advantages and disadvantages between different types of grafts for patients who underwent anterior cruciate ligament (ACL) reconstruction in a tertiary medical institute for the new generations of surgeons.Patients and Methods: Retrospectively, we identified 115 patients who underwent arthroscopic ACL reconstruction between 2006 and 2009. We were able to retrieve 74 patients from them. The 74 patients were divided into 32 patients who underwent primary arthroscopic ACL reconstruction with hamstring and patellar tendon autograft and 42 cases with an active biosynthetic composite (ABC) ligament. The mean the follow-up period for both groups was 7 years. The following information was obtained: standard demographic information (age, sex), clinical presentation, presence of trauma, associated injuries, types of grafts (autograft versus synthetic graft) and postoperative complications. Moreover, functional and clinical outcomes in addition to the satisfaction of patients using the international knee documentation committee (IKDC) score and knee injury and osteoarthritis outcome score (KOOS) were measured.Results: We found that the natural (autograft) was better in terms of clinical and functional outcome than the synthetic one (the scores of KOOS and IKDC were better in natural grafts). Furthermore, the immediate postoperative results for the pivot and Lachman tests were better in natural grafts. On the other hand, the rate of re-rupture was similar for both groups. However, the long-term inflammatory changes and stiffness that is attributed to the immunological reactions were more in the synthetic grafts.Conclusion: This study revisited the synthetic graft and provided evidence that the natural grafts are more beneficial with less complications, as they had better immediate and long-term postoperative clinical and functional outcomes. We recommend the utilization of autograft as first choice and the synthetic not to be used given the current criteria.Keywords: anterior cruciate ligament (ACL), arthroscopy, autologous, knee

Khaled A Obeidat,1 Abdelwahab J Aleshawi,2 Mohanad M Alebbini,2 Saja N Bani Yasin2 1Department of General Surgery and Urology, Faculty of Medicine, Jordan University of Science & Technology, Irbid 22110, Jordan; 2Faculty of Medicine, Jordan University of Science & Technology, Irbid 22110, JordanCorrespondence: Khaled A ObeidatDepartment of General Surgery and Urology, Faculty of Medicine, Jordan University of Science and Technology, P. O. Box: 3030, Irbid 22110, JordanTel +962797707397Fax +962 2 7201064Email kaobeidat@just.edu.joObjective: Intra-abdominal gossypiboma may present with variable clinical presentations. The clinical picture that the patient presents with depends on the site of the retained gauze in the abdomen, with transmural migration leading to intraabdominal gauze being a rare occurrence. We systemically analyze articles and reports related to the transmural migration of gossypiboma. In addition, we report a case of ileal transmigration of gossypiboma in a 53-year-old female.Methods: A systematic literature review was conducted using Embase and Medline for articles pertaining to transmural migration of gossypiboma. Three of the authors extracted the data from the selected studies that relate to the topic. All articles included were in English language and published in peer-reviewed journals. This study was conducted according to the guidelines set out by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.Results: A total of 93 cases of intraluminal gossypiboma were found in the literature. The mean age of the patients was 40.4 years and females (77.7%) were affected more than males. The obstetric and gynecologic surgeries were the leading causative operation (41.5%). However, cholecystectomy is the most common single surgery associated with intraluminal gossypiboma. The mean time from the causative operation was 35.16 months. Most patients presented as intestinal obstruction. CT scan was the most sensitive tool to detect any non-specific finding while the endoscopic interventions were the most specific. Ileum is the most common site for intraluminal for migration. Intra-gastric location is related mostly to the hepato-biliary operations. Laparotomy with segmental resection provides a primary treatment and cure.Conclusion: Clinicians should keep the possibility of gossypiboma, including intraluminal, in their mind when a patient presents with abdominal pain, signs of infection, intestinal obstruction, or a palpable mass any time after abdominal surgery. Measures for prevention and education are the most useful tool to avoid such complications.Keywords: gossypiboma, transmural migration, intra-abdominal, retained surgical sponge, surgical complication, textiloma

Khaldoon M Bashaireh,1 Fa’ek M Aldarwish,1 Ali A Al-Omari,1 Moath A Albashaireh,1 Mai Hajjat,2 Mohammad A Al-Ebbini,3 Abdelwahab J Aleshawi3 1Department of Special Surgery, Division of Orthopedics, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; 2Princess Rahma Pediatric Hospital, Jordanian Ministry of Health, Irbid, Jordan; 3Internship, King Abdullah University Hospital, Irbid 22110, JordanCorrespondence: Khaldoon M BashairehDepartment of Special Surgery, Division of Orthopedics, Faculty of Medicine, Jordan University of Science and Technology, PO Box: 3030, Irbid 22110, JordanTel +962 799051087Fax +962 2-7201064Email bashaireh@just.edu.joObjective: The aim of this study was to investigate the impact of occupation in patients with transient osteoporosis of the hip (TOH). The study also compares two different types of management for this condition: conservative treatment and surgical drilling.Methods: This was a retrospective case series study. The medical records for patients diagnosed with TOH at our institution within the period 2012–2017 were retrieved. General demographic data, clinical features, and diagnostic modalities were obtained. In addition, management procedures and their associated prognostic factors were acquired. The effectiveness of these procedures was assessed by the number of days of sick leave, the time needed for full recovery and the number of recurrences of TOH. Also, pain responses at 24 hrs, 48 hrs, and at 1 week were estimated subjectively through a “pain score” out of 10, and objectively through the degree of improvement in daily activity. The patients had a regular follow-up at 4- to 6-week intervals.Results: In total, 15 cases of TOH, 14 men and one woman, were enrolled in the study. The mean age of the patients was 41 years (range 26–59 years). Out of the 15 cases, nine were healthcare professionals (eight physicians and one nurse). Ten patients underwent hip drilling for core decompression and five patients were treated conservatively. The time needed for full recovery was 5.8 weeks for those who underwent drilling, and 48.3 weeks for three patients receiving conservative treatment. The other two patients who were treated conservatively had not achieved full or near-full recovery at the time of reporting this study.Conclusion: Physicians may be at increased risk of developing TOH. Further studies should be conducted to examine the role of this occupation as a risk factor. In addition, hip drilling should be considered as an effective treatment modality, especially in those patients who seek a faster recovery.Keywords: hip, bone marrow edema, core decompression, healthcare professionals

Laila T Ababneh,1 Hasan Mohidat,1 Heba Abdelnabi,1 Mohammed F Kana’an,2 Nour A Tashtush,2 Omar S El-Mulki,1 Abdelwahab J Aleshawi2 1Department of Special Surgery, Division of Ophthalmology, Faculty of Medicine, Jordan University of Science & Technology, Irbid 22110, Jordan; 2Faculty of Medicine, Jordan University of Science & Technology, Irbid 22110, JordanCorrespondence: Laila T AbabnehDepartment of Special Surgery, Division of Ophthalmology, Faculty of Medicine, Jordan University of Science and Technology, P. O. Box: 3030, Irbid 22110, JordanTel +962799770699Fax +962 2 7201064Email ababneh_laila@yahoo.comBackground: Specific morbidities as blindness is a serious complication that commonly results from patients with ocular traumas and can significantly impair the patient’s social and occupational abilities. This study is conducted due to the current lack of data on ocular injuries in developing countries and places near war regions and aims to investigate and evaluate the impact of ocular trauma.Material and methods: After Institutional Review Board approval was obtained, we retrospectively identified 112 patients who were admitted due to eye trauma from January 2015 until October 2018. Information about demographics, diagnostic modalities, prognostic impact, and treatment interventions were retrieved, analyzed.Results: One-hundred and twelve patients were included in the study. The majority of patients were males. The mean age for patients was 22.2. Road traffic accident (RTA) constituted the most common cause of trauma (60.7%). Gunshots and blast injuries were observed in 12.5% of patients. Workplace injuries were infrequent (8.1%). The gunshot was significantly associated with injury to two or more eyeball structures while the RTA was significantly related to one eyeball structure injury. RTA was associated with intact globe while gunshot was significantly associated with ruptured globes. The mean duration of admission was 8.1 days. Associated truncal injury is the most important independent factor affecting the duration of admission.Conclusion: Majority of trauma cases occurred in young males involved in RTAs. The location of Jordan near the Syrian war increases the appearance of gunshot ocular trauma in specific and ocular trauma in general. Educating the public is essential if we wish to prevent eye injuries.Keywords: eyeball, lens, globe, gunshot, road traffic accident

Tagleb S Mazahreh,1 Abdelwahab J Aleshawi,1 Nabil A Al-Zoubi,1 Mohammed Z Allouh,2,3 Khaled A Jadallah,4 Rasheed Elayyan,1 Nathan M Novotny51Department of General Surgery and Urology, Faculty of Medicine, Jordan University of Science & Technology, Irbid 22110, Jordan; 2Department of Anatomy, Faculty of Medicine, Jordan University of Science & Technology, Irbid 22110, Jordan; 3Department of Anatomy, College of Medicine & Health Sciences, United Arab Emirates University, Al Ain 17666, UAE; 4Department of Internal Medicine, Faculty of Medicine, Jordan University of Science & Technology, Irbid 22110, Jordan; 5Department of Pediatric Surgery, Beaumont Children’s, Oakland University William Beaumont School of Medicine, Michigan 48073, USAAim: To evaluate the value of esophagogastroduodenoscopy (EGD) as a preoperative investigation in individuals without symptoms of Gastro-Esophageal Reflux Disease (GERD) who will undergo laparoscopic sleeve gastrectomy (LSG).Materials and methods: After Institutional Review Board approval was obtained, patients scheduled for LSG were prospectively enrolled in the study between January 2016 and March 2018. Patients with symptoms of GERD were excluded from the study. Participants were randomly allocated to two groups: individuals who underwent EGD before the surgery as a usual routine investigation (Group A), and individuals who were scheduled without preoperative EGD (Group B). Patient demographics, endoscopic findings, endoscopic biopsy results, and histopathological findings of the resected parts of the stomach after LSG were analyzed and recorded. Additionally, operative characteristics and outcomes, and follow up findings were recorded and analyzed with appropriate statistical methods.Results: A total of 219 individuals without symptoms of GERD underwent LSG were enrolled. Group A included 111 individuals (25 males and 86 females). Group B comprised 108 individuals (20 males and 88 females). The mean age and mean Body Mass Index (BMI) were similar in both groups. From Group A, 86 out of 111 individuals (77.5%) had no pathology identified on EGD, while 21 individuals (18.9%) were found to have areas of gastric erythema and biopsies showed active gastritis. All LSG operations were performed without any major complication. After one year, all individuals were assessed for the presence of symptomatic GERD and no significant difference was found between the two groups.Conclusion: Preoperative EGD may not be mandatory for asymptomatic GERD individuals undergoing LSG as post-operative complications and early follow up for GERD symptoms are not significantly different. Further prospective studies with longer follow up are needed to evaluate the role of EGD in individuals undergoing LSG.Keywords: esophagogastroduodenoscopy, GERD, obesity, laparoscopic sleeve gastrectomy

Rawan A Obeidat,1 Abdelwahab J Aleshawi,2 Hasan A Obeidat,2 Samir M Al Bashir3 1Department of Obstetrics & Gynecology, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; 2Department of General Surgery and Urology, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; 3Department of Pathology, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan Abstract: Fibromas/fibrothecomas are considered to be benign ovarian tumors. We describe a rare case of recurrent fibrothecoma with a clinically malignant course. A 42-year-old woman, with no family history of malignancy, operated multiple times for tumor that recurred three times within 4 years despite radical surgical removal. Initially, she presented with 9×7×10 cm right ovarian mass, frozen section was consistent with fibrothecoma and thus right salpingoophorectomy was performed. At the last two recurrences, she was found to have recurrent multiple abdomino-pelvic fibrothecomas and two long major operations were performed. This malignant behavior of a benign tumor is very rare. Further genetic analysis and immunohistochemistry studies are recommended to be conducted. Furthermore, new modalities of treatment should be considered, eg, high-intensity focused ultrasound and/or hormonal treatment. Keywords: recurrent fibrothecoma, ovarian tumor, radical surgery, sex cord-stromal tumors

Chat Generative Pre-Trained Transformer (ChatGPT) is an online large language model that appears to be a popular source of health information, as it can provide patients with answers in the form of human-like text, although the accuracy and safety of its responses are not evident. This study aims to evaluate the accuracy and reproducibility of ChatGPT responses to patients-based questions in ophthalmology. We collected 150 questions from the "Ask an ophthalmologist" page of the American Academy of Ophthalmology, which were reviewed and refined by two ophthalmologists for their eligibility. Each question was inputted into ChatGPT twice using the "new chat" option. The grading scale included the following: (1) comprehensive, (2) correct but inadequate, (3) some correct and some incorrect, and (4) completely incorrect. Totally, 117 questions were inputted into ChatGPT, which provided "comprehensive" responses to 70/117 (59.8%) of questions. Concerning reproducibility, it was defined as no difference in grading categories (1 and 2 vs 3 and 4) between the 2 responses for each question. ChatGPT provided reproducible responses to 91.5% of questions. This study shows moderate accuracy and reproducibility of ChatGPT responses to patients' questions in ophthalmology. ChatGPT may be-after more modifications-a supplementary health information source, which should be used as an adjunct, but not a substitute, to medical advice. The reliability of ChatGPT should undergo more investigations., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

We report a unique case of late-onsetcerebral vasospasm at 21 and again at 30 days following aneurismal subarachnoid hemorrhage.

We report a case of recurrent postoperative spinal hemorrhage after lumbar disc surgery in a Glanzmann thrombasthenia patient.

We report a unique case of a huge malignant peripheral nerve sheath tumor with probable smooth muscle differentiation.

Introduction: Blunt leg trauma is common; however, it is rarely associated with significant vascular injury. This study was undertaken to determine the risk factors attributed to failure of limb salvage in acute postoperative period in blunt leg trauma with vascular injuries after revascularization., Methods: A retrospective analysis was conducted of all patients with blunt leg trauma involving bone and soft tissue associated with vascular injuries. They were studied in terms of demographic data, associated comorbidities, mechanism of trauma, associated extra leg injuries, type and nature of bone fractures, soft-tissue injuries, nerve injuries, time of ischemia, Injury Severity Score (ISS), Mangled Extremity Severity Score (MESS), injured vascular segments, modality of vascular repair, modality of bone fixation, thrombosis at the site of vascular repair, complications, limb salvage failure, and mortality., Results: Vascular injuries were identified in 45 arterial segments and 9 popliteal veins among 31 patients. The patients were 93% male, with a mean age of 31 years. The MESS ranged from 6 to 11, and the ISS ranged from 9 to 41. The main pathology of the injured vessels was contusion/thrombosis in 28 legs, which were repaired by interposition-reversed long saphenous vein graft. Seven patients developed postoperative thrombosis and underwent thrombectomy/embolectomy. Failure of limb salvage occurred in seven limbs with no mortality., Conclusions: Severe multi-segmental bone fractures, prolong ischemic time of >10 h, and MESS of ≥9 are significant predictors of limb loss in patients with blunt leg trauma in association with vascular injuries., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Emergencies, Trauma, and Shock.)

Seaweeds have attracted attention in the past decade as a biological source of highly diverse secondary metabolites with great potential in the industrial and pharmaceutical sciences. Herein, we represent a comprehensive cheminformatics study to compare the chemical diversity of seaweed metabolites based on their taxonomic source. Seaweed Metabolite Database (SWMD) was utilized in this study. The compounds were manually categorized into three datasets, namely red algae (Rhodophyta, n = 645), brown algae (Phaeophyta, n = 220), and green algae (Chlorophyta, n = 32). The compounds in each dataset were curated to generate six chemical descriptors of pharmaceutical interest for each molecule, which were later used to visualize the chemical space of these metabolites by principal component analysis. Scaffolds were generated by removing side chains and keeping the core part of each molecule. Scaffold diversity among the tested datasets was quantified using Cyclic System Retrieval Curves. Green algae metabolites in SWMD possessed the highest scaffold diversity followed by brown and red algae metabolites, respectively. Three structural binary fingerprints, including ECFP&#95;4, MACCS keys, and PubChem were computed indicating that the red algae metabolites had the highest fingerprint diversity followed by the green and brown algae metabolites respectively. Finally, Consensus Diversity Plots were generated to assess the global diversity considering both scaffold and fingerprint diversity. It was concluded that green algae metabolites in the SWMD are the most diverse regarding chemical descriptors of pharmaceutical relevance and scaffolds. While red algae possess the highest fingerprint diversity., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: To reduce the risk of cerebrospinal fluid leak, clinicians utilize a filling material placed in the sella followed by floor reconstruction with various materials, including glue sealing. Cyano-acrylic glue Glubran®2 glue is commercially available and is generally used as embolizing agent and for the prevention of cerebrospinal fluid leakage., Case Description: A 25-year-old woman underwent endoscopic endonasal transsphenoidal surgery for pituitary adenoma. After tumor resection, sellar floor reconstruction was performed by mucosal graft and Glubran®2 glue. The early post-operative period was uneventful. However, 2 months after surgery, the patient complained of headache, facial pain and greenish foul-smelling nasal discharge with solid particles dripping from the nose. Medical treatment was unsuccessful. Brain MRI showed inflammation and thickening of the sphenoidal and para-sphenoidal mucosa. The patient underwent endoscopic endonasal surgery and a solid glass-like mass surrounded by inflamed infected mucosa was seen in the inferior and lateral aspects of the sphenoid sinus. Efforts were made to erupt and de-crust the solid mass until total resection was achieved. Early post-operative period was uneventful, and a course of antibiotics was continued until total disappearance of the discharge., Conclusion: To the best of our knowledge, this is the first case reporting of acrylic glue (Glubran®2)-related sinusitis. Surgeon should be aware about similar side effects for the glue material that would complicate the surgery.

Background: Sleep quality is of paramount importance for human health. This multi-site study measures the proportion and types of self-reported sleep disorders in medical students and evaluates their association with academic performance by Grade Point Average (GPA)., Materials and Methods: A cross-sectional survey was conducted on medical students from two medical schools in Jordan during the 2018/2019 academic year. The study utilized the SLEEP-50 questionnaire to estimate the proportion of several sleep disorders and their effects on daily functioning. Below average GPAs were considered poor academic performance., Results: 1041 medical students' online surveys were analyzed from two medical schools' campuses, representing a 29.7% response rate. Their mean age was 22 ± 2.1 years (ranging from 18 to 37) and 52.6% were female. The mean body mass index was 24.2 ± 4.4 kg/m 2 . According to the SLEEP-50 questionnaire, the prevalence of sleep disorders among studied medical students ranged from 0.6% for sleep state misperception (SSM) to 23.1% for hypersomnia. Using binary logistic regression, after adjusting for gender and obesity, poor academic performance was associated with a risk for insomnia [adjusted odds ratio (OR) = 1.96, p < 0.001]; affective disorder [OR = 2.24, P < 0.001]; SSM [OR = 6.40, p = 0.045]; narcolepsy [OR = 9.54, p = 0.045]; and circadian rhythm disorders [OR = 2.03, p < 0.001]., Conclusion: Sleep disorders are common among medical students. Several sleepdisorders were associated with poor academic performance. Proper diagnosis and treatment of sleep disorders may remedy this issue., Competing Interests: Authors declare that they have no conflicts of interest., (© 2020 The Author(s).)

Background: A high incidence of joint laxity has been reported among Asians compared with Western populations, but clear differences between more specific ethnic populations have not been established. This study aimed to determine the average knee laxity in the Malaysian and Jordanian populations., Methods: Jordanian and Malaysian medical students from our institution were invited to participate in the study. General demographic data and factors affecting joint laxity were obtained from each participant using a printed questionnaire. Both knees were examined using the anterior drawer test while in 90° of flexion. Knee laxity was measured by three separate independent investigators through a knee laxity tester., Results: One hundred and eighty-six participants (95 females) were enrolled in the study. Among them, 108 Malaysians participated. The Jordanians had significantly higher knee laxity in both knees compared with the Malaysians. The mean average right knee laxity for Jordanians was 2.98 mm vs. 2.72 mm for Malaysians (P = 0.005). Similarly, the mean average left knee laxity for Jordanians was 2.95 mm, while for Malaysians, it was 2.62 mm (P = 0.0001). Furthermore, smokers had significantly more laxity in both knees. After performing a multivariate linear regression analysis for all factors, race was the only independent factor that affected knee laxity in both knees., Conclusions: Race is directly associated with knee laxity. Jordanians tend to have more laxity in knee joints compared with Malaysians. Larger multi-center and genetic studies are recommended to establish the racial differences between different ethnic groups., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to declare., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: The lack of appropriate guidelines and justified practice in most developing countries is a serious limitation to efforts to qualify the services provided. In this paper, we evaluate and assess the clinical practice of an assisted reproductive technique of intracytoplasmic sperm injection (ICSI) in Jordan., Methods: Retrospectively, we identified women who achieved a successful pregnancy by ICSI over a period of ten years. Information related to the ICSI procedure, foetus abnormalities, maternal complications and delivery outcomes were included. A control group of normal pregnancies were incorporated., Results: In total, 291 cases were included as successful cases of ICSI with a success rate of 14.1%. For the control group, 466 pregnant women with normal pregnancies were included. No statistical difference was observed between both groups in foetus malformation. In normal pregnancy women, 42.1% delivered through caesarean section (CS) while 87.6% of ICSI patients underwent CS. Women with ICSI had significantly higher rates of multiple gestations, and their neonates were lower in birthweight. Women in the ICSI group tended to deliver females compared to the control group. Pregnancy-related hypertension was more commonly reported in the normal pregnancy group, while gestational diabetes, antepartum haemorrhage and preterm labour were more common in ICSI group., Conclusion: Services for the management of infertility are increasing in the Middle East. The clinical outcomes in Jordan is approaching that of other developed regions, although the success rate is lower than in other regions. Further studies and efforts should be carried out to maximize effective and successful practice in such low-income areas., Competing Interests: The authors declare that they have no competing interests., (© 2020 The Authors.)

Competing Interests: The authors declare that they have no competing interests.

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal., (© 2020 The Authors.)

BACKGROUND The current COVID-19 pandemic highlights the importance of the mindful use of financial and human resources. Preventing infections and preserving resources and manpower are crucial in healthcare. It is important to ensure the ability of surgeons and specialized interventionalists to function through the pandemic. Until now, no justified protocol has been reported for the anesthetic management in cesarean section (CS). CASE REPORT A 29-year-old pregnant woman, G2P1 at 37+4 weeks of gestation, was referred to our center on March 28, 2020, after she had tested positive for COVID-19. She was stable and the CS was planned after she reached term. Through spinal anesthesia, CS was conducted. The anesthesia team was protected with full personal protection equipment. The operation was carried out smoothly without complication. A female neonate was delivered and was tested to be negative for COVID-19. No medical staff cross-infection was reported. CONCLUSIONS Special precautions should be considered when pregnant women are undergoing CS. Spinal anesthesia is preferred over general anesthesia.

Peripheral neuropathy is a common neurodegenerative disease, with vastness of inducers and causalities. The acquired form peripheral neuropathy can be caused by traumatic injuries caused by nerve lacerations or compressions. Such injuries are usually followed by Wallerian degeneration, and inflammatory reaction. We present a case of a 33-year-old female with a chronic loss of the ulnar nerve function for 8 years after traumatic laceration. After that, she regained the functions of ulnar nerve after nerve stimulation by peri-ulnar nerve injection of methylprednisolone and lidocaine. The theory behind using steroids is related to the fact that the immune system could induce a secondary injury that interferes with the recovery. Many studies have shown effectiveness in using steroids alone or when combined with other substances on nerve regeneration in animal models. We believe that this is the first report of nerve recovery using local steroidal injections after a traumatic injury.

Purpose: Primary leiomyosarcoma of the pancreas (PLMSP) is rare. The clinical features and outcomes are still unclear. The present study aims to identify the clinical features, outcomes, and racial differences of PLMSP., Methods: PLMSP cases reported in Chinese, English, French, and Japanese journals were collected and reviewed. Data from these reports were summarized and analyzed statistically., Results: In addition to a female patient presented to our department with PLMS, a total of 87 cases reported in the literature were included in the present study. An equal incidence in gender was observed. The mean age was 53.8 years. Common symptoms were abdominal pain and abdominal mass. At the time of diagnosis or after a period of follow-up, 37.5% of patients had distant metastasis and 31.8% of patients had regional organs/vessels invasion. The 5-year mortality rate was 77.8%. The presence of distant metastasis and the absence of radical surgery are significantly associated with poor outcomes. Regional invasion was significantly more common in East Asians., Conclusion: PLMSP is an aggressive tumor with a poor prognosis. Radical resection can decrease the mortality of the patients. Early detection of such tumor is recommended.

Extrahepatic hydatid disease has been reported in several locations, including the pelvis, and it often poses a diagnostic challenge. There are very few reported cases of primary perineal ischio-anal fossa hydatid cysts. We present a case of a 46-year-old female who had complained of painless left perianal mass for 8 months. The first clinical and radiological diagnosis was a cystic lesion of the perianal region. However, surgical and pathological examination revealed the diagnosis of hydatid disease of ischio-anal fossa. The patient underwent surgical excision. At 1-year follow-up, the patient was disease-free. Hydatid disease of the perianal area, although rare, must be kept in the differential diagnosis of pathologies of any perianal mass or lump., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Aim: In this study, we investigated and compared the effect of different types of dissector (Maryland vs Hook) on changes in liver function tests (LFTs) after laparoscopic cholecystectomy., Patients & Methods: The enrolled patients were divided into two groups. Group A patients underwent dissection by Maryland dissecting forceps, group B by Hook dissecting instrument. LFTs were measured preoperatively and at 1 day and 1 week, postoperatively., Results: For both Maryland and Hook dissection, the 1-day postoperative values for total bilirubin, alanine aminotransferase and aspartate aminotransferase were significantly higher than the preoperative values. Also, there were no statistical differences between Hook and Maryland., Conclusion: The elevation of LFTs seems to be attributed to other factors., Competing Interests: Financial & competing interests disclosure The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript., (© 2020 Tagleb Mazahreh.)

Femoral head avascular bone necrosis (AVN) is the loss of blood supply to the bone tissue of femoral head that results in cellular death. This condition causes a significant limitation in patient daily life activities and has a poor functional outcome. Long-term steroid intake was established as a cause of AVN. However, few cases reported femoral head AVN post-single steroid intra-articular injection. We review all cases of AVN that results from single intra-articular steroid injection and present a case of femoral head AVN developed in a 78-year-old male. The patient, who was not known to have any medical illness, presented complaining of mild left hip pain for 4 months with long distant ambulation and weight standing. He was diagnosed to have left hip joint osteoarthritis for which he received intra-articular steroid injection 2 months prior visiting our orthopedics center. MRI of the pelvis revealed AVN of the femoral head. He underwent total hip arthroplasty. The pathological examination confirmed the diagnosis of AVN. To best of our knowledge, this is the fifth case of AVN of femoral head AVN after single intra-articular steroid injection. We reviewed all cases of AVN of femoral head after single steroid injection. Intra-articular steroid injection can cause femoral head AVN, and the patient receiving these injections should be aware about this rare but significant complication that results in poor functional outcome and significant morbidity.

Background: Anesthesiologists prefer using general anesthesia (GA) in Parkinson's disease (PD). However, GA may mask neurological symptoms in the intraoperative period and exacerbate them postoperatively. Furthermore, the anesthetics used in GA have clear interactions with the drugs used to control PD. On the other hand, drugs used in spinal anesthesia (SA) might be safer for patients with PD. The aim of this study is to evaluate the effect of SA and GA in patients with PD who underwent hip fracture repairs., Methods: Retrospectively, we identified those patients with PD who were admitted due to hip joint fracture. The following information were obtained: demographics, preoperative assessment information of the patients, type of anesthesia, and types of fractures and orthopedic procedures. In addition, intraoperative and postoperative complications were studied. The patients were divided based on the type of anesthesia received and were compared., Results: Ten (8 males) patients with PD who underwent hip fracture surgery included in the study. Six patients received SA and 4 patients received GA. The mean age was 73.2 years. The preoperative assessment was not significant for all patients. Postoperatively, within the inpatient period, 3 out of 4 patients received GA developed complications (two atelectasis and urinary tract infection) while no patient developed complication from the SA group. Postoperative outpatient complications within one-month included 3 out of 4 cases in the GA group and only one complication in the SA group. The mean hospitalization period was 9 days for patients received GA and 5.8 days for patients received SA., Conclusion: This study reported less perioperative complications in the SA. Accordingly, further investigations and rp-randomized controlled trials evaluating various anesthetic techniques or drugs are needed., Competing Interests: The authors declare that they have no competing interests in this work., (© 2020 Bani Hani et al.)

Background: Currently, guidelines from around the world endorse measurement of coronary artery calcium (CAC) to improve clinical risk prediction in appropriately selected asymptomatic and stable symptomatic individuals. A CAC score of zero may discourage from further testing as coronary computed tomography angiography (CCTA). We investigate the presence of malignant coronary artery anomalies (CAA)s among stable symptomatic patients with zero CAC., Methods: A total of 281 individuals' information was obtained. These individuals had low to intermediate pre-test probability of coronary artery disease, complained of stable typical or atypical chest pain, were not known to have CAD, and had CAC scan score of zero. After investigating the CCTA, Angelini's classification system for CAA was utilized in adapted form to determine the presence, the class and type of the CAA., Results: The CAAs were detected in 16 (5.7 %) patients on CCTA, 15 (8.1 %) of them were below 45 years. The mean age for patients with CAAs was 31.8. According to Angelini classification system, most of the detected CAAs were malignant such as the origination of the coronary artery from the opposite sinus with arterial course between the aortic and pulmonary trunks and the intramural muscular bridge course., Conclusion: It is preferable to perform CCTA in young patients with cardiac symptoms, especially in Asian and Middle Eastern countries even of the CAC score is zero., Competing Interests: There are no conflicts of interest to declare., (© 2019 Published by Elsevier Ltd.)

Obesity is a growing public health problem worldwide. Bariatric surgical procedures achieve the most sustainable and efficacious outcomes in the treatment of morbid obesity. However, little is known about the underlying molecular pathways modulated by these surgical interventions. Since leptin resistance is implicated in the pathogenesis of obesity, we herein report the effects of laparoscopic sleeve gastrectomy (LSG) on the serum levels of leptin and leptin receptor, in addition to its overall effect on leptin resistance. This was an interventional and follow-up clinical study. In the first part, patients attending the general surgery outpatient clinics at our university hospital were first stratified according to their Body-Mass Index (BMI) into cases (n = 38) with BMI ≥ 35 who were scheduled to undergo LSG, and controls (n = 75) with a normal BMI. Serum leptin and leptin receptor levels were measured by sandwich ELISA technique. A leptin resistance index was estimated by adjusting leptin to BMI ratio to leptin receptor concentration. In the second part of the study, cases who underwent LSG were followed up one year postoperatively to assess their BMI and serum leptin and leptin receptor levels. Leptin to BMI ratio was significantly higher, while serum leptin receptor was significantly lower, in obese patients compared to controls. This translated into a significantly higher leptin resistance index in obese patients. LSG resulted in a significant reduction of BMI, leptin to BMI ratio, and leptin resistance index, as it significantly increased leptin receptor levels. In conclusion, LSG showed significant decrease in leptin resistance in obese patients after one year. Further studies are needed to determine the clinical impact of this finding on LSG outcomes., Competing Interests: The authors declare no conflict of interest. Further, the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results”.

Epidermoid cysts are asymptomatic, slowly enlarging, firm to fluctuant, dome-shaped lesions. Epidermoid cysts frequently appear on the trunk, neck, face, and scrotum, behind the ears and in the palmoplantar region. We review all the cases of epidermoid cyst of the knee and present a case of non-traumatic-induced epidermal cyst in the popliteal fossa of a 66-year-old male with 10-year history of right knee swelling, which appeared firstly as a small mass 2 × 2 cm in the popliteal aspect of the knee. The mass was increasing gradually in size until 2 years ago when it increased suddenly to gain the dimensions of 4 × 6 cm. MRI of the right knee revealed a well-defined cystic lesion in the subcutaneous tissue measuring about 7 × 5 × 5 cm containing internal debris and septations. He underwent complete surgical excision of the mass. The pathological results revealed an epidermal inclusion cyst. To the best of our knowledge, this is the second description for epidermal inclusion cyst involving the popliteal fossa. We were able to retrieve three cases of epidermal cyst of the knee from the literature since its first description in 2004. Including our case, we had a total of four cases of epidermal cyst of the knee. Three males and one female constituted the patients' sample. The mean age for the patients is 55. The epidermal cyst occurred equally in both knees. The popliteal fossa was the location for two epidermal cysts. Similarly, the prepatellar region was the location for another two cysts.

Biliary tract cancers (BTC) represent an aggressive disease with a dismal prognosis. Gemcitabine in combination with cisplatin is the standard first-line palliative treatment for advanced BTC. There is no established treatment following progression on gemcitabine-cisplatin. In this article, we present two cases for individuals with advanced BTC who were treated with pembrolizumab and the tumors have completely resolved., Competing Interests: The authors report no conflicts of interest in this work.

Background: Jejunal diverticula are the rarest of all small bowel diverticula. Most patients with jejunal diverticula are asymptomatic. Major complications include diverticulitis, gastrointestinal hemorrhage, intestinal obstruction and perforation. The hemorrhage has been attributed to diverticulitis with ulceration, diverticulosis associated with trauma and irritation disorder. However, only six cases reported the arteriovenous malformations within jejunal diverticulosis to be the cause of hemorrhage., Case Presentation: We present a case of arteriovenous malformations within jejunal diverticulosis in a 68-year-old male presented with lower gastrointestinal bleeding. After admission and stabilization, upper and lower endoscopies were performed without demonstrating the bleeding site. They only revealed clotted and red blood throughout the colon. Technetium-labeled red blood cell bleeding scan, endoscopic capsule, and selective angiography were performed to localize the site of bleeding without significant findings. As the clinical status of the patient deteriorated, exploratory laparotomy was performed urgently. Extensive jejunal saccular pouches were found 10 cm distal to duodenojejunal junction extending 1.6 m distally. Segmental resection was performed with side to side primary anastomosis. Microscopic examination of the specimen revealed many diverticula. He was followed up 2 years after that without complications., Conclusion: We report yet the seventh case jejunal diverticulosis with the presence of angiodysplasia, in hope of expanding the knowledge of a rare occurrence and increasing the demand for further research about the etiology, clinical impact and treatment of such anomalies coexistence. This case also highlights the importance of considering the diagnosis of AVMs within jejunal diverticulosis in the presence of uncontrollable blood loss in the pre- or intra- operatively diagnosed jejunal diverticulosis and the urgent need for surgical intervention. In addition, the diagnostic tests should be performed close to the bleeding episode.

Background: The unicornuate uterus is caused by abnormal or failed development of one Müllerian duct. Unicornuate uteri with functioning non-communicating rudimentary horns are susceptible to many gynaecologic and obstetric complications such as hematometra, endometriosis and ectopic pregnancy and thus surgical resection is usually recommended.., Case Presentation: We report a rare case of a unicornuate right uterus with rudimentary non-communicating (functional) cavitary left horn (class U4a) in a 17-year-old girl who was diagnosed with VACTERL association. She was presented to our centre with 3 years history of secondary sever dysmenorrhea. Pelvic magnetic resonance imaging revealed a normal uterus on the right side, a 7 × 8 cm left endometrioma, a tortuous dilated fluid-filled structure in the left hemipelvis, mostly represented left-sided hematosalpinx, and a well-defined lesion with thick enhancing wall in the left hemipelvis measuring 6.7 × 5.7 × 5.6 cm with a similar enhancement to the uterus in the right. She underwent laparotomy that showed a right unicornuate uterus with a normal cervix and a rudimentary non-communicating distended left horn. In addition, there was a left endometrioma and left hematosalpinx. Resection of the left communicating horn, left salpingectomy and left ovarian cystectomy were performed. The right tube and both ovaries were preserved. At 9-months follow up, the patient had a regular period and the pain subsided completely., Conclusion: We report yet the second case of VACTERL association and unicornuate uterus with non-communicating functional rudimentary horn, in hope of expanding the knowledge of a rare occurrence. This case also highlights the importance of considering the diagnosis of Müllerian duct anomalies in patients with a history of other anomalies, and/or history of early-age secondary dysmenorrhea.

Introduction: Primary renal Ewing's sarcoma is a rare tumor with dismal prognosis. The main treatment modality of treatment is surgical excision with adjuvant or neoadjuvant chemotherapy., Case Presentation: We present a case of primary renal EWS in 27-year-old male. He presented to our center complaining of three days history of severe left flank pain associated with nausea and vomiting. Computerized tomography (CT) revealed a 10 × 7 × 6.5 cm left lower pole renal mass. Left radical nephrectomy was performed and revealed a tumor with uniform round to oval nuclei cells. The cells stained strongly positive for CD 99. The diagnosis was established as primary renal Ewing's sarcoma. The patient refused the chemotherapy. Fortunately, he was free of the disease on regular clinical and radiological follow-up, the last follow up was 30 months post-nephrectomy., Conclusion: This case highlights the importance of proper surgical treatment and its role in the managing this type of malignancy especially in localized disease at presentation., (Copyright © 2019 The Author(s). Published by Elsevier Ltd.. All rights reserved.)