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Congenital abdominal cysts have a broad differential diagnosis. Pancreatic cysts are rare lesions that offer a diagnostic and surgical challenge to surgeons. We report on a case of a large left upper quadrant cyst detected in utero, which remained of unclear etiology despite cross-sectional imaging at birth. Intraoperative findings confirmed its pancreatic origin. In hindsight, a pre-operative elevated immunoreactive trypsinogen, performed as part of universal cystic fibrosis (CF) newborn screening, may have suggested the diagnosis.False-positive CF screening tests may be unnoticed by a surgical team assessing infants with an abdominal mass. As universal testing for cystic fibrosis increases in Canada and worldwide, physicians should review a patient's CF screening history. Elevated immunoreactive trypsinogen levels with normal sweat chloride and cystic fibrosis transmembrane conductance regulator (CFTR) detection tests may orient towards a pancreatic etiology when assessing a patient with a congenital abdominal cyst of unclear etiology.

We describe a combined sternotomy/laparotomy approach as a novel technique in central tendon diaphragmatic hernia repair. During a routine second trimester prenatal ultrasound, a 19-year-old woman was found to have a fetus with a diaphragmatic hernia. Subsequent fetal MRI at 28 weeks demonstrated a large central tendon defect through which the majority of the liver was herniated. The fetus was closely followed until her delivery at 38 weeks. The patient was intubated shortly after delivery and treated for pulmonary hypertension. A thoraco-abdominal CT scan revealed a large, mushroom-shaped herniation of the liver. By day of life 7, the patient demonstrated physiological stability. Following a multidisciplinary meeting, the decision was made to proceed to surgery. A sternotomy with an upper midline laparotomy revealed the liver herniating through a central tendon defect without any hernia sac. The liver was reduced into the abdomen without kinks in the hepatic veins. The defect was then closed using a polytetrafluoroethylene patch. She did not develop any compartment syndrome despite pre-operative concerns. Post-operatively, she was weaned to conventional mechanical ventilation after brief requirement of high-frequency oscillatory ventilation, and subsequently extubated. A combined sternotomy/laparotomy provided an excellent operative exposure and may be effective in a large congenital central tendon diaphragmatic hernia repair.

Objectives The optimal size of the health workforce for children’s surgical care around the world remains poorly defined. The goal of this study was to characterise the surgical workforce for children across Brazil, and to identify associations between the surgical workforce and measures of childhood health.Design This study is an ecological, cross-sectional analysis using data from the Brazil public health system (Sistema Único de Saúde).Settings and participants We collected data on the surgical workforce (paediatric surgeons, general surgeons, anaesthesiologists and nursing staff), perioperative mortality rate (POMR) and under-5 mortality rate (U5MR) across Brazil for 2015.Primary and secondary outcome measures We performed descriptive analyses, and identified associations between the workforce and U5MR using geospatial analysis (Getis-Ord-Gi analysis, spatial cluster analysis and linear regression models).Findings There were 39 926 general surgeons, 856 paediatric surgeons, 13 243 anaesthesiologists and 103 793 nurses across Brazil in 2015. The U5MR ranged from 11 to 26 deaths/1000 live births and the POMR ranged from 0.11–0.17 deaths/100 000 children across the country. The surgical workforce is inequitably distributed across the country, with the wealthier South and Southeast regions having a higher workforce density as well as lower U5MR than the poorer North and Northeast regions. Using linear regression, we found an inverse relationship between the surgical workforce density and U5MR. An U5MR of 15 deaths/1000 births across Brazil is associated with a workforce level of 5 paediatric surgeons, 200 surgeons, 100 anaesthesiologists or 700 nurses/100 000 children.Conclusions We found wide disparities in the surgical workforce and childhood mortality across Brazil, with both directly related to socioeconomic status. Areas of increased surgical workforce are associated with lower U5MR. Strategic investment in the surgical workforce may be required to attain optimal health outcomes for children in Brazil, particularly in rural regions.

Abstract The chance of an intrathyroidal occurrence of a parathyroid gland is about 1–3%. Among the causes of hyperparathyroidism, parathyroid cases occur in less than 1% of patients. Here we present the case of a 63 year old Saudi female suffering from an intrathryroidal parathyroid carcinoma. The suspicion coming from the clinical investigations that the removed tumor tissue may be a parathyroid carcinoma could be confirmed by histology. Additionally non-radioactive in situ hybridization to localize mRNA transcripts for Cyclin D1 and immunohistochemical localization of Cyclin D1 was performed. Although parathyroid adenoma and carcinoma have disparate natural history, it can be difficult to differentiate between the two entities. Clinical presentation, operative findings may raise suspicion, but may not be conclusive especially if there is no evidence of invasion or metastasis, especially if the gland was intrathyroidal.

OBJECTIVE: To test the feasibility of short message service (SMS) usage between the clinic visits and to evaluate its effect on glycemic control in uncontrolled type 2 Diabetes Mellitus (DM) subjects. RESEARCH DESIGN AND METHODS: 34 cases with type 2 Diabetes were followed after fulfilling the inclusion criteria. The interventional group (n=12) had the same conventional approach of the control group but had two mobile numbers (physician and diabetic educator) provided for the SMS support until their next visit in 3 months. Both groups of age, BMI and the pre-study A1c were comparable. RESULTS: Both groups had a significant reduction in their A1c compared to their baseline visit. However, the interventional group had significantly greater reduction in A1c (p=0.001), 1.16% lower than controls. The service was highly satisfactory to the group. CONCLUSION: The results indicate effectiveness in lowering A1c and acceptance by the patients. Further research and large-scale studies are needed. [ABSTRACT FROM AUTHOR]

Hypothyroidism is one of the most common chronic endocrine conditions. However, as symptoms of hypothyroidism are non-specific, up to 60% of those with thyroid dysfunction are unaware of their condition. Left untreated, hypothyroidism may contribute to other chronic health conditions. In the Arabian Gulf States, hypothyroidism is thought to be common, but is underdiagnosed, and management approaches vary. An advisory board of leading Saudi endocrinologists and policy advisers was convened to discuss and formulate recommendations for the diagnosis and management of hypothyroidism in Saudi Arabia based on their clinical expertise. The final document was shared with leading endocrinologists from the other Gulf  Cooperation Council (GCC) and aconsensus report was generated and summerized in this article. While there is no consensus regarding population screening of hypothyroidism, current recommendations suggest screening patients with risk factors, including those with a history of head or neck irradiation, a family history of thyroid disease or pharmacological treatment that may affect thyroid function. Evidence from a cross-sectional study in Saudi Arabia suggests screening the elderly (> 60 years), at least in the primary care setting. In Saudi Arabia, the incidence of congenital hypothyroidism is approximately 1 in every 3450 newborns. Saudi nationwide population prevalence data are lacking, but a single-centre study estimated that the prevalence of subclinical hypothyroidism in the primary care setting was 10%. Prevalence rates were higher in other cross-sectional studies exclusively in women (13-35%). The recommendations included in this  article aim to streamline the diagnosis and clinical management of hypothyroidism in the GCC, especially in the primary care setting, with the intention of improving treatment outcomes. Further study on the incidence, prevalence and risk factors for, and clinical features of, hypothyroidism in the GCC countries is required.

The aim of the present article is to increase awareness concerning safe driving for patients with diabetes in the Gulf Cooperation Council (GCC) countries and to provide recommendations concerning the management of these patients. The cognitive, motor, and sensory skills required for driving can be adversely affected by diabetes as well as the side effects of anti-diabetic medications, particularly hypoglycemia. The prevalence of diabetes in the GCC countries is among the highest in the world. As the number of diabetic drivers in these countries continues to increase, the number at risk of having a motor vehicle accident is also expected to increase. We reviewed the available literature concerning driving and diabetes, particularly in relation to the current situation in the GGC countries. Unfortunately, very little published information is available addressing this issue in the GCC countries. Most of the GCC countries lack legislation on driving and diabetes. We have proposed recommendations to help diabetic drivers in the GCC countries as well as to provide guidance to health care professionals managing these patients., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: The A1chieve, is a multicentric (28 countries), 24-weeks, non-interventional study to evaluate the safety and effectiveness of insulin detemir, biphasic insulin aspart and insulin aspart in people with T2DM (n = 66,726) in routine clinical care across four continents., Materials and Methods: Data was collected at baseline, at 12 weeks and at 24 weeks. This short communication presents the results for patients enrolled from Manama, kingdom of Bahrain., Results: A total of 115 patients were enrolled in the study. Four different insulin analogue regimens were used in the study. Study patients had started on or were switched to biphasic insulin aspart (n = 67), insulin detemir (n = 16), insulin aspart (n = 4), basal insulin plus insulin aspart (n = 21) and other insulin combinations (n = 7). At baseline, glycaemic control was poor for both insulin naïve (mean HbA1c: 10.2%) and insulin users (mean HbA1c: 9.8%) groups. After 24 weeks of treatment, both the groups showed improvement in HbA1c (insulin naïve: -1.1%, insulin users: -1.3%). SADRs including major hypoglycaemic events did not occur in the study patients., Conclusion: Starting or switching to insulin analogues was associated with improvement in glycaemic control with a low rate of hypoglycaemia.

Intrathyroidal parathyroid carcinoma is an exceedingly rare cause of primary hyperparathyroidism with difficulties in the diagnosis and management. We report a case of hypercalcemia from intrathyroidal parathyroid carcinoma in a 63-year-old Saudi female. She was diagnosed 2 years earlier with osteoporosis in a primary care clinic and was on alendronate since then. This year she was noted to have hypercalcemia, but in retrospect she had more than 10 years history of multiple medical problems related to hypercalcemia. Parathyroid 99mTc-SestaMIBI scintigraphy revealed parathyroid adenoma in the left inferior parathyroid gland. She had successful video-assisted parathyroidectomy that relieved most of her symptoms. The extreme rarity of such a case, the interesting clinical presentation and review of the literature are discussed.

Objective: To determine the prevalence of autoantibodies to IA-2 (IA-2Ab) and glutamic acid decarboxylase (GADAb) in type 2 diabetes, their relationship to disease duration, and their importance in management decisions., Methods: We undertook a study of 101 patients with type 2 diabetes (defined as nonketotic hyperglycemia at diagnosis) of varied duration (median, 4 years). Results were compared with those from 36 patients with type 1 diabetes also of varied duration (median, 2 years). IA-2Ab and GADAb were measured by radioligand-binding assays with use of in vitro-synthesized, 35S-labeled antigens., Results: Of the 101 patients with type 2 diabetes, 20 (20%) were positive for GADAb; only 4 of these 20 were positive for IA-2Ab. In comparison, 75% of patients with type 1 diabetes were positive for GADAb, IA-2Ab, or both (P<0.0001). The coincidence of IA-2Ab positivity in GADAb-positive patients with type 2 diabetes was significantly lower than in patients with type 1 diabetes (20% versus 73%, respectively; P = 0.002). All four IA-2Ab- and GADAb-positive patients with type 2 diabetes required insulin and were younger than those positive for GADAb alone (P = 0.018). GADAb positivity in patients with type 2 diabetes was highly associated with insulin requirement (P = 0.004), with an odds ratio of 5.8 in predicting insulin dependence. Among patients with type 2 diabetes receiving insulin therapy, disease duration was significantly shorter (P = 0.025) and body mass index was significantly lower (P<0.001) in GADAb-positive versus GADAb-negative patients. In contrast to type 1 diabetes, in which GADAb values were negatively correlated with disease duration (r = -0.34; P = 0.044), no significant correlation with disease duration was observed in type 2 diabetes (r = -0.166; P = 0.48)., Conclusion: Irrespective of duration of disease, measurement of IA-2Ab and GADAb can help to identify those patients with type 2 diabetes most likely to require insulin therapy.

Background: Hyperhomocysteinemia is an independent risk factor for coronary, peripheral, and cerebrovascular disease. Elevated plasma homocysteine levels were described in a preliminary report on primary hypothyroidism., Objective: To determine whether restoration of euthyroidism by L-thyroxine replacement therapy would reduce or normalize plasma homocysteine levels., Design: Prospective cohort study., Setting: Outpatient endocrinology department of a tertiary center., Patients: 14 patients (10 women and 4 men; 25 to 77 years of age): 4 with newly diagnosed chronic (Hashimoto) hypothyroidism and 10 who had been rendered acutely hypothyroid (thyroid-stimulating hormone level > 25 mU/L) by total thyroidectomy for thyroid carcinoma., Measurements: Total plasma homocysteine levels were measured at baseline and 3 to 9 months later, after euthyroidism had been attained by L-thyroxine replacement therapy., Results: Median baseline plasma homocysteine levels in both sexes (women, 11.65 micromol/L [range, 7.2 to 26.5 micromol/L]; men, 15.1 micromol/L [range, 14.1 to 16.3 micromol/L]) were higher (P = 0.002) than those in healthy female (n = 35) and male (n = 36) volunteers (women, 7.52 micromol/L [range, 4.3 to 14.0 micromol/L]; men, 8.72 micromol/L [range, 5.94 to 14.98 micromol/L]). Eight patients (57%) had baseline plasma homocysteine levels that exceeded the upper limit of sex-specific reference ranges. Upon attainment of euthyroidism, all patients had a diminution in plasma homocysteine levels. The median overall change of -5.5 micromol/L (range, -15.4 to -1.8 micromol/L) corresponds to a difference of -44% (range, -58% to -13%) (P < 0.001). Homocysteine levels returned to normal in 7 of the 8 patients with elevated pretreatment values., Conclusions: Hypothyroidism may be a treatable cause of hyperhomocysteinemia, and elevated plasma homocysteine levels may be an independent risk factor for the accelerated atherosclerosis seen in primary hypothyroidism.