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The COVID-19 pandemic has brought uncertainty to everyday medical practice. Deciding how to ration limited healthcare resources is difficult and requires the involvement of higher authorities in each country. In this article we focus on the Jordanian strategy of allocating tertiary healthcare centers exclusively for COVID-19 patients and postponing all other treatments and healthcare provision. We collected secondary data on admissions, occupancy of hospital beds, and length of stay at emergency departments and outpatient clinics, as well as surgeries conducted, between March and May 2020 at King Abdullah University Hospital in Irbid, Jordan. We also conducted a literature review to explore health resource utilization and allocation in terms of health service quality. Our findings showed a major decrease in the demand for health services at the hospital including admissions, emergency department visits, outpatient clinic visits, surgeries, and radiology during the study period. These findings indicate the enormous impact of the pandemic on the largest segment of patients in Jordan-those who depend on government health insurance-to manage their routine healthcare needs, which may affect the health status of patients. Authorities should address the COVID-19 pandemic holistically by prioritizing both COVID-19 cases and non-COVID-19 cases and should draft a framework for managing future pandemics. Moreover, planning a strategy to accommodate the number of people waiting for elective surgeries and routine healthcare should be in place to minimize the burden of this pandemic.

Aim: This study aimed to determine the compliance of healthcare workers (HCWs) with the hospital safety measures and the prevalence of hospital-acquired COVID-19 infection among them. Methodology: HCWs at King Abdullah University Hospital (KAUH) assigned for COVID-19 patients between 18 March and 10 June 2020 were tested for past infection using total anti-SARS-CoV-2 immunoglobulin assay, demographic data and compliance with safety measures were assessed using a questionnaire. Results: A total of 340 HCWs participated in the study, 260 were close direct care. Three HCWs tested positive for total anti-SARS-CoV-2 immunoglobulin. Close direct care were more compliant with personal protective guidelines than those providing direct care. Conclusion: HCWs compliance with personal protective guidelines might explain the low prevalence of COVID-19 infection in hospital settings., Lay abstract Hospitals around the globe have implemented safety measures in order to decrease the risk of spreading the virus among healthcare workers (HCWs); our aim in this study is to assess the compliance of HCWs to the safety measures introduced in our hospital and the prevalence of contracting COVID-19 among them using total anti-SARS-CoV-2 immunoglobulin assay. A total of 113 physicians and 227 nurses participated in the study; results showed a high level of compliance among HCWs working in close direct care and a relatively lower level of compliance among those providing direct care. Three of the HCWs tested positive for the total immunoglobulin assay, indicating the importance of adhering to the safety measures to decrease the risk of contracting the virus.

Purpose. To investigate the association between obesity and breast cancer clinicopathologic characteristics at presentation along with prognostic impact among Jordanian breast cancer patients. Such data are lacking in Arabian countries. Methods. In this retrospective study, 348 breast cancer patients were included. Analyses were conducted for associations between body mass index (BMI) and age at diagnosis, tumor clinicopathologic characteristics, and molecular subtypes. Eight prognostic factors were considered, and total prognostic scores were calculated. The analysis was stratified by menopausal status. Multivariate logistic stepwise regression analysis was conducted to identify predictors for breast cancer recurrence and death. Results. Mean age at diagnosis was 50.98 ± 10.96 years. Mean BMI at diagnosis was 29.52 ± 5.32 kg/m2. Mean age at diagnosis was significantly higher for overweight and obese patients compared to underweight/normal patients (P<0.001). A significant positive correlation was observed between patient age and BMI at diagnosis (r = 0.251, P<0.001). Grade of carcinoma was significantly correlated with BMI in the whole population examined (P=0.003). Obese breast cancer patients had significantly higher prognostic scores compared to nonobese cases, indicating worse prognostic features at presentation (P=0.034). Stratification of data analysis based on menopausal status revealed significant associations between obesity and each of tumor stage and grade among postmenopausal but not premenopausal patients (P=0.019 and P=0.031, respectively). Similarly, postmenopausal obese patients had significantly higher prognostic scores compared to nonobese counterparts (P=0.007), indicating worse prognosis, a finding which was also absent among premenopausal breast cancer patients. No significant association between BMI with expression status of hormone receptors, HER2, lymphovascular invasion, and molecular subtypes was found among patients. BMI was a significant predictor for disease recurrence in which obese breast cancer patients had greater odds (2-fold) to develop locoregional and distant recurrence compared to nonobese cases (P=0.011). Conclusions. Obesity was associated with advanced stage and grade of breast carcinoma at diagnosis. The impact of BMI on clinicopathologic characteristics and prognosis was confined to postmenopausal cases. Jordanian obese breast cancer patients are at greater risk of breast cancer recurrence and reduced survival compared to their nonobese counterparts.

Background The COVID-19 pandemic had many implications on healthcare services, including cellular pathology. The pandemic-related lockdown was applied in Jordan from March to May 2020. King Abdullah University Hospital (KAUH) was chosen to provide care for COVID-19 patients during that period. Since there was no experience in dealing with COVID-19 patients, the hospital maintained some essential services but canceled elective surgeries and procedures. The rationale was to prioritize care for COVID-19 patients and to provide better adherence to infection control policies and protect non-infected patients and healthcare workers. The purpose of the present study is to investigate the impact of COVID-19 pandemic restrictions on cellular pathology practice patterns at KAUH. Methods This is a retrospective observational study conducted at KAUH. All cellular pathology reports during the 2020 national lockdown were retrieved. The total numbers of specimens including types and procedures were recorded. Data were compared with the corresponding data in 2019 when there was no pandemic and when hospital and laboratory services were run in full capacity. Results 2020 lockdown period showed a 57.9% reduction in the total number of specimens received at the cellular pathology laboratory as compared to the corresponding period of 2019 (1400 versus 3322). Emergency procedures have represented 99.1% of the service during the lockdown with a remarkable diversity shift. Conclusion There was a significant drop in the number of specimens dealt with at KAUH cellular pathology laboratory during the COVID-19 pandemic-related national lockdown. We learned from this pandemic how to adapt to such circumstances by adjusting our way of working to reach the best level of staff safety while maintaining highly productive work. Implementing digital pathology platforms, working from home strategies and alternative training methodologies have emerged as an essential need., Highlights • COVID-19 pandemic-related lockdown had a major influence on healthcare services. • Pathology services and training of residents were influenced by the lockdown, too. • The pandemic taught us how to adapt to such circumstances by adjusting way of working. • Digital pathology platforms and strategies to work from home emerged as essential needs.

Background Clear Cell Sarcoma of Soft Tissue (CCSST), or melanoma of the soft part, is a rare, aggressive tumor that originates in the aponeurosis and fasciae of the distal parts of the extremities. Reports from other sites of the body are rare. Objective We are reporting an extremely rare tumor that presented as a central left-sided lung mass and found to be clear cell sarcoma of soft tissue. Methods We report a 24-year-old male patient presented with recurrent attacks of left-sided chest pain associated with cough and dyspnea. Results Imaging showed a central left-sided 8*5.5*5 cm lung mass. The age of the patient and the radiological characteristics of the lesion were suggestive of a benign pathology. After histopathological assessment of the lesion, suspicion of the malignant process was raised, mainly melanoma of soft part and PEComa. The patient underwent left-sided pneumonectomy. The postoperative histological examination, immunohistochemical findings including positive staining for S-100, HMB-45, and Melan-A, and positive FISH study for EWSR1 gene rearrangements supported the diagnosis of CCSST originating primarily in the major fissure of left the lung. Conclusion The rarity of CCSST in general and tumors originating in the lung primarily raise the challenges in hypothesizing a differential diagnosis, choosing proper investigations and treatment methods. The histological examination, immunohistochemical, and cytogenetics of the tumor are mandatory to reach the final diagnosis.

Patient: Female, 47-year-old Final Diagnosis: IgG4-related disease Symptoms: Ovarian cyst • pelvic mass Medication: — Clinical Procedure: — Specialty: Obstetrics and Gynecology • Pathology Objective: Rare disease Background: Immunoglobulin G4 (IgG4)-related disease is immune-mediated and was first proposed as a defined entity after studies on patients with autoimmune pancreatitis. Since then, it has been reported in many organs. Involvement of the ovaries is rare, and to our knowledge, only 2 cases have been reported in the literature. IgG4-related disease is associated with increased serum IgG4 levels. Organ involvement includes a lymphoplasmacytic infiltrate, fibrosis, and obliterative phlebitis, with immunohistochemistry showing IgG4-positive plasma cells. This report is of a case of IgG4-related disease involving the right ovary. Case Report: A 47-year-old woman presented with a right ovarian cyst. An ultrasound scan revealed a complex right ovarian cyst with multiple septations. The hormonal profile and tumor markers were unremarkable. Gross examination showed fragments of cyst wall. Histologic examination revealed a follicular cyst, surrounded by a dense lymphoplasmacytic infiltrate rich in eosinophils, partially obliterative phlebitis, and fibrosis. Immunohistochemically, IgG marked most of the plasma cells, of which 70% expressed IgG4, with a count >50 cells per high-power field. Subsequent testing of serum IgG4 showed that the level was elevated (330 mg/dL). A diagnosis of IgG4-related disease was made. Conclusions: Ovarian involvement by IgG4-related disease is rarely described in the literature. Our patient is likely to be the third case. We believe that cumulative findings from our case along with the 2 already reported cases increase awareness and may establish a framework for building more objective criteria to define this entity in the ovaries, similar to what has been achieved in some other organs.

Background. Notwithstanding that prostate cancer is largely studied all over the world for many decades, its etiology is not known and there is an intensive work to elucidate the cause and molecular markers for the development of this male cancer. Polymorphisms in DNA repairing genes may affect the DNA repairing capacity that in turn contributes to cancer development. This study aims to explore the polymorphisms of homologous recombination (HR) RAD51 gene (rs1801320 and rs1801321) as a possible risk factor for developing prostate cancer. Sequencing of 5'-UTR of RAD51 gene (rs1801320 and rs1801321) was studied in 80 DNA samples of prostate cancer and 50 DNA samples from a control group. Our results revealed a significant correlation between rs1801320 GC polymorphism and the presence of prostate cancer in the Jordanian population (p = 0.041, X2 = 6.377). On the other hand, the rs1801321 GT polymorphism was not associated with the presence of prostate cancer in the study population (p = 0.27, X2 = 2.6). In conclusion, our results shed a light on the possible role of RAD51 gene polymorphisms in the development of prostate cancer; however, a larger representative study is needed to elucidate a possible role of RAD51 gene polymorphisms in development and prognosis of prostate cancer.

Bladder cancer is the most common cancer of the urinary tract with an estimate of 401,000 new cases diagnosed annually worldwide. In Jordan, bladder cancer accounts for 4.3% of all newly diagnosed cancer cases. Several studies have linked p53 molecular changes to tumor initiation, invasion, metastasis, and chemoresistance. In the present study, we investigated a cohort of 121 bladder cancer patients with various grades and stages of the tumor for molecular changes in p53. Overexpression of p53 was shown in 22%, 46%, 71% and 25% pTa, pT1, pT2 and pT4 cases, respectively. Additionally, p53 was overexpressed in 19%, 38% and 74% of G1, G2 and G3 cases of bladder cancer, respectively. p53 expression is not significantly associated with the stage or grade of the disease. Mutational analysis of exons 4–8 of p53 identified the following previously reported point mutations R72P (58%), P67T (9%), A159P (0.7%), D185N (28%), G199 V (0.7%), G199E (0.7%), D208N (0.7%), R283P (1.4%). Furthermore, we were able to identify two new deletion mutations located in the DNA-binding domain in two patients. The first mutation was a result of one nucleotide deletion in exon 5 causing a frameshift at codon 115 resulting in a truncated 168 amino acids long p53 protein and the second is a result of a whole codon deletion in exon 6 resulting in a p53 protein missing a valine residue at codon 218. P53 mutations were found to be significantly associated with late stage (pT2-pT4) muscle-invasive bladder tumors. Survival analysis indicates significant differences of overall survival between the patients with the p53 overexpression and those with negative p53 staining ( p = 0.0041). Additionally, were able to observe a significant difference of overall survival between p53 mutants and p53 wild-type ( p = 0.0062). The present work points to the variable spectrum of TP53 mutations and p53 expression profile in Jordanian patients with bladder cancer and reflects the importance of p53 alterations in predicting poor prognosis of bladder cancer patients.

Receptor Tyrosine Kinases (RTKs) represent a class of transmembrane receptors known to play an important role in cancer development and progression. In this study, the expression of insulin receptor (IR) and the hepatocyte growth factor receptor (c-MET) was examined in breast cancer patients. Immunohistochemistry for IR and c-MET was performed on 71 cases of invasive breast cancer and expression scores were correlated with clinicopathologic characteristics and molecular subtypes and further stratified based on a menopausal status. Expression of IR was significantly associated with the tumor grade (p = 0.017) and estrogen receptor (ER) expression (p = 0.015). There was a significant positive correlation between IR and c-MET expression scores (rho = 0.458, p &lt, 0.001). Among premenopausal cases, IR scores were significantly higher in patients with grade I/II disease (p = 0.025), ER-positive (p = 0.030), and progesterone receptor (PR)-positive carcinoma (p = 0.015). c-MET expression scores were significantly higher among premenopausal patients with ER-positive (p = 0.007) and PR-positive carcinoma (p = 0.024). IR expression scores were significantly different among molecular subtypes for all patients (p = 0.006) and among premenopausal cases (p = 0.035). c-MET expression was statistically different among molecular subtypes for premenopausal patients (p = 0.019). Survival analysis revealed that the expression status of IR and c-MET was not associated with overall survival. Our findings support a favorable prognostic value for IR and c-MET expression in premenopausal breast cancer patients.

Objective/background: Myeloproliferative neoplasms (MPNs) are heterogeneous clonal bone marrow stem cell disorders and include polycythemia vera (PV), essential thrombocythemia (ET), and idiopathic myelofibrosis (IMF) neoplasia. In 2005, the JAK2V617F mutation was identified in Philadelphia chromosome-negative patients. The aim of this study was to sequence coding exons 12 and 14 of the JAK2 gene in Jordanian patients with MPN. Methods: Both exons 12 and 14 of the JAK2 gene were amplified using polymerase chain reaction from DNA extracted from 68 blood and bone marrow samples belonging to 57 MPN patients and subjected to DNA sequencing. Results: JAK2V617F mutations were detected in 26 of 57 Jordanian patients (45%) with different MPNs. JAK2V617F was identified in 70%, 31%, and 14% of PV, ET, and IMF cases, respectively. Five men diagnosed with PV were homozygous for JAK2V617F, whereas the other 21 patients were heterozygous for the mutation. Neither the JAK2V617F mutation nor any DNA polymorphism in exon 12 or exon 14 of the JAK2 gene was detected among the 40 leukemic patients. A rare single nucleotide polymorphism, c.1860C→T (rs375442615), was detected in one patient with ET. Conclusion: This study is the first molecular investigation of the JAK2 gene in Jordan. We successfully identified the JAK2V617F mutation in Jordanian patients with Philadelphia chromosome-negative MPNs. Our results provide a basis for the early detection of this mutation and simplify the diagnostic workup for these disorders at the molecular level. Keywords: JAK2 mutations, Jordan, Myeloproliferative neoplasms, Polycythemia vera, V617F

Alveolar soft part sarcoma (ASPS), a rare soft tissue sarcoma in children and adolescents, carries a poor prognosis. ASPS is an aggressive tumor of controversial histogenesis that, unlike other soft tissue sarcomas, tends to metastasize to the brain. A 9-year-old boy presented to our outpatient clinic in April 2009 with a chief complaint of a large painless mass in the left thigh whose size had increased significantly over the past 10 months. After staging the tumor, we performed open biopsy; the diagnosis was ASPS and he underwent wide local excision. In the course of 4-year follow-up by clinical and imaging studies, there was no evidence of early tumor recurrence or metastasis. Complete surgical resection is the treatment of choice in patients with ASPS. World J Oncol. 2014;5(1):47-51 doi: http://dx.doi.org/10.14740/wjon777w

The objective was to evaluate the clinical and radiological features of peritoneal tuberculosis (PTB) that resembled advanced ovarian malignancy. A retrospective review of all patients diagnosed with PTB over a period of 10 years was made. The data included: age, presenting symptom(s), CA125 level, microbiological, histological and cytological studies of the surgical specimens. The radiological and operative findings were also reviewed. A total of 16 patients were identified. The median age was 29.5 years (range 13-65 years). The median CA125 level was 319 U/ml (range 45-1,072 U/ml). The most common symptoms were abdominal distention and pain in 13 patients. Imaging studies showed ascites in all patients. Six patients had laparotomy and 10 had laparoscopy procedure. All patients received anti-tuberculosis treatment and had complete cure. A high index of suspicion of PTB is important to avoid unnecessary extended surgery in relatively young patients with nonspecific clinical features.

Aims: To identify and differentiate mycobacterium spp. in archival formalin-fixed, paraffinembedded tissue by PCR to supply additional differential diagnostic method for Mycobacterium infections, where tuberculosis had been tested for by histopathological methods but without culturing. Place and Duration of Study: Department of Medical Laboratory Sciences, Department of Pathology and Microbiology (Faculty of Medicine) and King Abdulla University Hospital, between January 2004 and July 2010. Methodology: Fifty-six extra-pulmonary specimens of formalin-fixed, paraffin-embedded tissue obtained from patients showing granulomatus inflammation and/or other histopathologic features. Specimens were analyzed by a hemi-nested PCR assay targeting the gene encoding for 16S ribosomal RNA, which is common to all mycobacteria spp. The PCR positive specimens were amplified by a touch-down PCR targeting a fragment in the insertion sequence IS6110 specific to Mycobacterium tuberculosis complex. Results were compared to acid fast bacilli stain and with histopathology of each specimen. Results: M. tuberculosis complex DNA was detected in 27 (48.2%) specimens, and nonOriginal Research Article Article British Microbiology Research Journal, 4(5): 530-539, 2014 531 tuberculous mycobacteria in four specimens, compared to 10 (18%) specimens that were positive by acid fast staining. The positive cases were observed more in the lymph nodes, and pleural specimens. Conclusions: This study is among few studies to use the touch-down PCR assay as a promising auxiliary tool for the diagnosis of extra-pulmonary tuberculosis in archival tissue specimens. It could be used in conjunction with routine laboratory tests (e.g., cultures, acid fast staining) and clinical criteria of the patient to increase the accurate diagnosis of such cases. It is also recommended that culture be routinely done for all tuberculosis suspected cases.

Background: A significant percentage of lung adenocarcinomas have a driver mutation. To date, there has been no assessment of the prevalence of such mutations in a Middle Eastern population. The present multicenter prospective study of formalin fixed paraffin embedded (FFPE) tissues from patients diagnosed with lung adenocarcinoma was performed to assess the prevalence of EGFR and ALK mutations in the Levant. Methods: Patients of Middle Eastern origin with lung adenocarcinomas at 10 sites in Lebanon, Jordan and Iraq were prospectively enrolled. Tumors were tested for EGFR by PCR and for EML4-ALK translocation by fluorescence in situ hybridization (FISH). Results: A total of 210 patients were enrolled, 139 (66.2%) males and 71 females (33.8%), with a mean age of 63.4 years. EGFR testing of 205 (97.6%) demonstrated the wild type in 173 (84.4%) and mutated forms in 32 (15.6%). Some 46.9% of EGFR positive patients were non-smokers and 62.5% were females as opposed to 22.4% and 33.8%, respectively, in the general population. As for the EML4-ALK translocation, testing in 157 (74.8%) cases gave negative results in 154 (98.1%), only 3 being positive (1.9%), 2 being females and 2 non-smokers. Conclusion: Our study established a 15.6% EGFR mutation rate in lung adenocarcinomas with ALK translocation mutations in only 1.9%, as compared to a 15-20% and 5%, respectively, in the Western literature.

In this retrospective experimental study, we assessed the immunohistochemical expression of Wilms Tumor Gene (WT1) and p53 in endometrial biopsies of patients with endometrial cancer, and correlated their expression with the final pathological findings. Sixty-two patients with primary endometrial cancer who underwent surgical treatment were investigated. Immunohistochemical expression of Wilms Tumor Gene (WT1) and p53 was assessed in curettage specimens, and the final pathology reports from hysterectomy specimens were reviewed. The expression of these markers seems to play a role in curettage specimens as they correlate with the final tumor characteristics of hysterectomy specimens. Five out of sixty-two endometrial cancer specimens (8.1%) were WT1-positive, and 21 specimens (33.9%) were P53-positive. Positive expression of WT1 and P53 was significantly associated with the non-endometrioid type (p value of 0.019 and 0.005, respectively). Positive WT1 expression was significantly associated with high grade lesions, deep myometrial invasion, and advanced stage disease. Moreover, a statistically significant inverse relationship was observed between the positivity of WT1 and P53, and the positivity of ER and PR. We think that examination for WT1 and p53 in curettage specimens might help to predict the final pathological diagnosis in patients with endometrial cancer. This might be useful for the identification of high risk groups and, therefore, of candidates for more radical surgery.

Gastric cancer (GC) is a major health problem worldwide and is one of the ten most commonly diagnosed cancers in Jordan. GC is usually diagnosed at late aggressive stages in which treatment options are limited. Recently, heat shock proteins (HSPs) found to be overexpressed in a wide range of malignancies have been considered as promising candidate biomarkers for GC. The aim of this study was to investigate pathogenic roles of a panel of cytosolic HSPs including HSP90, HSP70, HSP60 and HSP27 in GC. Immunohistochemistry was used to assess the level of expression of these proteins in archived tumor samples (N=87) representing various pathological characteristics of GC. HSP90, HSP60 and HSP27 were expressed abundantly in gastric tumors. On the other hand, HSP70 was reduced significantly and was also found to be associated with Helicobacter pylori infection in tissues collected from GC patients. Furthermore, HSP27 was found to be associated with the level of differentiation. Our findings indicate a role of HSP70 as a potential prognostic biomarker, patients harboring positive HSP70 expression displaying worse disease free survival than those with negative HSP70 expression. Differential expression of HSPs may play crucial roles in the initiation and progression of GC, and could be exploited as future therapeutic targets.

The diffuse large B-cell lymphoma (DLBCL) encompasses two major groups of tumors with uneven survival outcomes--germinal center B-cell (GCB) and non-germinal center B-cell (non-GCB). In the present study, we investigated the expression of GCB markers (BCL-6 and CD10) and non-GCB markers (CD138 and MUM-1) in an effort to evaluate their prognostic value. Paraffin-embedded tumor biopsies of 46 Jordanian DLBCL patients were analyzed, retrospectively, by immunohistochemistry to investigate the expression of BCL-6, CD10, CD138 and MUM-1. In addition, survival curves were calculated with reference to marker expression, age, sex and nodal involvement. Positive expression of BCL-6, CD10, CD138 and MUM-1 was shown in 78%, 61%, 39% and 91% of the cases, respectively, that of BCL-6 being associated with better overall survival (p = 0.02), whereas positive CD138 was linked with poor overall survival (p = 0.01). The expression of CD10 and MUM-1 had no impact on the overall survival. Among the clinical characteristics studied, diagnosis at an early age, nodal involvement and maleness were associated with a higher overall survival for DLBCL patients. Our results underline the importance of BCL-6 as a marker of better prognosis and CD138 as a marker of poor prognosis for DLBCL patients.

Aim of this study was to investigate the incidence of Epstein–Barr virus (EBV) in patients diagnosed with undifferentiated nasopharyngeal carcinoma (UNPC) from the Northern Province of Jordan. All cases diagnosed with UNPC at King Abdullah University Hospital, Irbid, Jordan, between the years 1991 and 2009 inclusive were examined. Clinical data including age, gender, mode of presentation, site of biopsy were retrieved from pathology reports. In situ hybridization for (EBV)—EBERs was performed on cases with available paraffin blocks. Correlation between the different clinical variables and results of in situ hybridization was performed. There were 49 cases diagnosed with UNPC, only 39 specimens were available and studied. The median age of presentation was 41 years (range 9–70 years). Bimodal age distribution was noted, the first peak between 15 and 19 years of age and second between 60 and 64 years of age. Males were slightly more commonly affected than females. Cervical lymph node enlargement was the most common mode of presentation, followed by nasal obstruction. Biopsies were obtained primarily from the posterior nasal space, followed by cervical lymph node. Positive staining for EBERs by in situ hybridization was seen in 92.3% of the cases examined. There was no difference in detection rate between males and females or adults and pediatrics. All cases obtained from posterior nasal space were positive. The three negative cases were from biopsies obtained from cervical lymph nodes, which was statistically significant (P value

AimsTo build an automated decision support system to assist pathologists in grading gastric atrophy according to the updated Sydney system.MethodsA database of 143 biopsies was used to train and examine the proposed system. A panel of three experienced pathologists reached a consensus regarding the grading of the studied biopsies using the visual scale of the updated Sydney system. Digital imaging techniques were utilised to extract a set of discriminating morphological features that describe each atrophy grade sufficiently and uniquely. A probabilistic neural networks structure was used to build a grading system. To evaluate the performance of the proposed system, 66% of the biopsies (94 biopsy images) were used for training purposes and 34% (49 biopsy images) were used for testing and validation purposes.ResultsDuring the training phase, a 98.9% precision was achieved, whereas during testing, a precision of 95.9% was achieved. The overall precision achieved was 97.9%.ConclusionsA fully automated decision support system to grade gastric atrophy according to the updated Sydney system is proposed. The system utilises advanced image processing techniques and probabilistic neural networks in conducting the assessment. The proposed system eliminates inter- and intra-observer variations with high reproducibility.

This study was designed to compare the efficacy of intraventricular (IV), intramyocardial (IM) or combined IV and IM injections of human adipose tissue-derived stem cells (hADSCs) administered either immediately, 5, or 10 days after induction of acute myocardial infarction (AMI) in a nude rat model. Acute myocardial infarction was induced in 99, adult (250–350 g BW), male nude rats strain Crl:NIH-Fox1RNU. Rats received either no cells (group I, n = 15) or 2 million, hADSCs as follows: group II (n = 19) IV injection immediately after AMI; group III (n = 18) IV injection 5 days after AMI; group IV (n = 15) IV injection 5 days and IM injection 10 days after AMI; group V (n = 17) IV injection immediately after AMI and IM injection 10 days after AMI and group VI (n = 15) IM injection 10 days after AMI. Tissue sections from hearts were studied using H&E and immunohistochemistry. In the control group, there was a tendency toward granulation tissue formation, active phagocytosis, and variable angiogenesis when evaluated at 10 days, early fibrosis when evaluated at 30 days, and established fibrosis when evaluated at 60 days. However, hADSC-treated groups showed a tendency toward cardiomyocyte regeneration and prominent angiogenesis when evaluated at 10 days and smaller infarction size when evaluated at 30 and 60 days. The present study showed a significantly decreased amount of scar tissue following myocardial infarction and enhanced regenerative capacity of myocardial cells following a single, intraventricular injection of 2 million hADSCs immediately after AMI.

Here we report that paclitaxel induces variable degrees of apoptosis in human colorectal cancer cells. Paclitaxel induces multiple arms of the endoplasmic reticulum stress response, including upregulation of the 78-kDa glucose-regulatory protein (GRP78) and eukaryotic initiation factor alpha phosphorylation. Inhibition of the MEK/ERK pathway sensitized colorectal cancer cells to paclitaxel-induced apoptosis. A similar result was obtained by the inhibition of GRP78 using small interfering RNA molecules. Knockdown of MEK resulted in a significant downregulation of paclitaxel-induced upregulation of GRP78 indicating that activation of GRP78 is a downstream event of MEK/ERK pathway activation. These results indicate that GRP78 might be a novel mechanism underlying the resistance of colorectal cancer cells to microtubule-targeting drugs. A combination of compounds capable of suppressing GRP78 might be a golden approach for improving the effectiveness of taxanes.

To report a successful delivery of a healthy infant fathered by an infertile 46, XY true hermaphrodite who suffered from a seminoma.Case reportIVF unit in University hospital.Male 41 years (true hermaphrodite), his wife 35 years.Laboratory, pathology tests and ultrasound tests.The above patient treated and cured from seminoma, the couple had in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) using frozen testicular sperm and had a healthy baby.This is the first case report of a successful delivery of a healthy infant fathered by an infertile 46, XY true hermaphrodite who suffered from a seminoma. Once treated and cured, the couple had IVF and ICSI using frozen testicular sperm and had a healthy baby.

The aim of this study is to establish a basis for automated assessment of gastric atrophy according to the Updated Sydney System. We sought to minimize inter- and intra-observer variations in the application of the Sydney System. A total of 160 biopsies were examined by three pathologists and graded using the visual scale of the Updated Sydney System. A consensus was reached on 135 biopsies. Digital images were captured for the studied biopsies. Image processing techniques were used to extract four morphological features that uniquely discriminate each atrophy grade. The features are related to gland density and shape. To validate the reproducibility of these features, the K-Means clustering technique was used. We were able to grade the atrophy with an overall precision of 95.6%. Furthermore, the proposed features were able to distinguish four discrete grades without any significant overlap. This has not been achieved by previous studies.

Background: Semiquantitative staging of liver fibrosis is a highly subjective procedure and may lead to an uncertainty in judgment regarding the degree of severity and hence the progression of the disease. Aim: In this work, we present an automated quantification system (AQS) for evaluating the degree of severity of fibrosis in liver biopsies based on Ishak et al.'s classification. Accordingly, liver fibrosis is classified into six classes depending on its severity and progression. The described system is of special value in accurately assessing the prognosis of chronic liver disease. Methods: In our method, we tried to approximate the architecture of the fibrosis in the subject sample using texture features and shape representation of the fibrosis structural expansion with an overall accuracy of about 98%. Results and conclusion: The presented AQS is considered to be a novel approach in the domain of automatic liver fibrosis quantification. It is a true quantification and intelligent approach that attempts to utilize the current semiquantitative methods of liver fibrosis assessment to turn them into real quantitative ones with significant reduction in variability and subjectivity. We propose that our method can be adopted by a panel of expert liver pathologists and software to be developed and used on a wide scale.

Aim: To evaluate the diagnostic value of the 10 systematic transrectal ultrasound-guided (TRUS) prostate biopsy compared with the sextant biopsy technique for patients with suspected prostate cancer. Methods: One hundred and fifty-two patients with suspected prostate cancer were included in the study. Patients were entered in the study because they presented with high levels of prostate specific antigen (PSA) (over 4 ng/mL) and/or had undergone an abnormal digital rectal examination (DRE). In addition to sextant prostate biopsy cores, four more biopsies were obtained from the lateral peripheral zone with additional cores from each suspicious area revealed by transrectal ultrasound. Sextant, lateral peripheral zone and suspicious area biopsy cores were submitted separately to the pathological department. Results: Cancer detection rates were 27.6 % (42/152) and 19.7 % (30/152) for the 10-core and sextant core biopsy protocols, respectively. Adding the lateral peripheral zone (PZ) to the sextant prostate biopsy showed a 28.6 % (12/42) increase in the cancer detection rate in patients with positive prostate cancer (P < 0.01). The cancer detection rate in patients who presented with elevated PSA was 29.3 % (34/116). When serum PSA was 4–10 ng/mL TRUS-guided biopsy detected cancer in 20.6 %, while the detection rate was 32.4 % and 47.0 % when serum PSA was 10–20 ng/mL and above 20 ng/mL, respectively. Conclusion: The 10 systematic TRUS-guided prostate biopsy improves the detection rate of prostate cancer by 28.6 % when compared with the sextant biopsy technique alone, without increase in the morbidity. We therefore recommend the 10-core biopsy protocol to be the preferred method for early detection of prostate cancer. (Asian J Androl 2005 Jun; 7:165–169)

Idiopathic granulomatous mastitis is a rare disease of the breast. Clinically and radiologically it may mimic breast carcinoma. Awareness of surgeons, pathologists, and radiologists is essential to avoid unnecessary mastectomies. Data regarding 24 patients with histologically confirmed idiopathic granulomatous mastitis treated at our center over 8 years were analyzed. The mean age of patients was 34.3 years. Breast lump was the most common presentation. The right breast was affected in 16 cases. Four patients were pregnant at the time of presentation. Lactation within 6 months of presentation was documented in four patients. Two patients used contraceptives pills. A clinical suspicion of malignancy was present in 17 cases. Mammography was performed in 16 patients and showed focal asymmetrical dense lesions in 9, well-circumscribed opacity in 4, spiculated lesion in 1, and was normal in 2. Fine-needle aspiration was performed in 17 patients, of which 2 were reported as malignant. Wide local excision was the mainstay of treatment. One patient underwent mastectomy upon clinical, mammographic, and repeated cytologic findings consistent with malignancy, and the final histology confirmed idiopathic granulomatous mastitis with no evidence of malignancy. Four patients developed recurrence after a mean follow-up of 31.2 months. A greater awareness of the rare entity of idiopathic granulomatous mastitis is mandatory to avoid unnecessary mastectomies. Clinical, radiologic, and even cytologic findings are sometimes confused with malignancy. To the best of our knowledge, our patient who developed the disease at the age of 11 years is the youngest reported case.

Background Sources of reports about laparoscopic and percutaneous treatment of liver hydatid cysts are limited to just a few countries. To address the reason behind this, we carried out a survey of 30 surgeons in northern Jordan. Methods A questionnaire was distributed to collect data regarding the surgical technique preferred by each surgeon. Further information was collected from those not adopting minimal-access techniques to determine their reasons for not doing so. Results Only 3 surgeons (10%) considered laparoscopy as the first line of treatment. Of the 27 surgeons who did not consider percutaneous or laparoscopic treatment, fear of anaphylaxis and/or dissemination was the main reason given by 21 surgeons (78%) for not using minimal access techniques. Conclusions The seemingly exaggerated traditional fear of anaphylaxis seems to discourage surgeons from more widely adopting minimal access techniques for the treatment of hydatid cyst.

Aim. The relationship of tumour T-lymphocytic subset infiltration and recurrence in patients undergoing potentially curative resection for colorectal cancer has not been clearly defined. Methods. Tumour sections from patients who had undergone potentially curative resection for colorectal cancer were stained and counted for CD4+ and CD8+ T-lymphocytes. Results. Twenty-three patients developed recurrence during the follow-up period. Patients were grouped according to whether or not they developed recurrence. The groups were similar in age, sex, site of tumour, Dukes stage and the numbers of patients receiving adjuvant therapy. The total percentage volume of labelled CD4+ T-lymphocytes in the tumour was significantly lower in the patients who recurred (p

Epidemiological data about malignant tumours of the oral cavity among Jordanians and Arabs is lacking. The purpose of this study is to obtain the incidence rates of oral malignant tumours in the population of the North of Jordan and to describe their main characteristics over a period of 11 years, 1991–2001 inclusive. A retrospective study of all primary malignant tumours of the oral cavity at the regional histopathology departments for the period 1991–2001 was performed. 125 patients had histologically diagnosed primary malignant tumours, 80 (64%) were men and 45 (36%) were women, with male:female ratio of 1.77:1, and a mean age of 62.5 years for both sexes. Between 1991 and 2001, the incidence of oral malignant tumours at all anatomic sites showed little change. Squamous cell carcinomas were the most frequent histological type accounting for more than 84% of oral malignant tumours. Other histological types included: sarcomas (5.6%), adenocarcinomas (5.6%) and lymphomas (4%). The mouth (42.4%) was the most common site affected, followed by the lip (33.6%) and tongue (24%). In comparison with other international studies, there was a low incidence of mouth and tongue malignancies in the North of Jordan. Lip malignancies were the second most common tumours of the oral cavity in North of Jordan and in global terms showed mild incidence rates. Cigarette smoking, exposure to solar radiation and possible dietary factors play a major role in the aetiology of oral malignancy in Jordan.

Background and Aim: To highlight the epidemiological, clinical, and pathological features of gallbladder cancer in Jordan as a model for the Middle East. Only scattered reports are available from this region. Methods: The histopathological reports and the hospital records for all cholecystectomies performed at Princess Basma Teaching Hospital between 1994–2000 were retrospectively reviewed to identify all patients with gallbladder carcinoma. All the histological slides for the cancer group were reviewed and reclassified by a single pathologist. Results: Of 4502 cholecystectomies performed, 33 cases (0.73%) of gallbladder carcinoma were found. The mean age was 61.4 years (range 39–80 years). The male : female ratio was 1 : 3.7. Biliary colic and/or acute cholecystitis were the main presentations. Gallstones were present in 88% (29/33) of the patients. The spectrum of histological subtypes was similar to other series. Only three cases were diagnosed preoperatively, making the incidence of incidental gallbladder cancer 0.66% (30/4502). Simple cholecystectomy was performed for 13 patients. The remaining 20 patients underwent cholecystectomy and portal lymphadenectomy with (five cases) or without (15 cases) extrahepatic resection of the bile ducts. The mean follow up was 22 months (SD ± 18.95 months; range 1–96 months). The 2-year survival rates for stages I, II, III, and IV were 100%, 42.9%, 10.8%, and 0%, respectively (P = 0.0013). Conclusions: The importance of a high index of suspicion when dealing with cholelithiasis in elderly patients, particularly with large sized stones, cannot be over-emphasized. Proper gross inspection in the theater should be a routine procedure performed by all surgeons. Routine ultrasound for suspected gallbladder stones should always be performed under the supervision of senior radiologists.

Malignant rhabdoid tumor (MRT) of the liver is a rare malignancy with grave prognosis. This entity should be considered in the differential diagnosis of any aggressive liver tumor with low levels of alpha fetoprotein. We report 2 cases of hepatic MRT presenting in infancy. In these 2 cases, we show that loss of INI1 facilitates making the correct diagnosis of primary hepatic MRT utilizing BAF 47 (INI1 gene product) immunostains. Difficulty encountered in making this rare diagnosis, including the need for repeated biopsies, can be avoided if MRT is considered in the differential diagnosis early on and BAF 47 immunohistochemistry is ordered.

Osteoid osteoma is a primary benign bone tumour with characteristic imaging and pathological features. In about 10% of the cases it involves the spine, especially the posterior elements. We report a pathologically proven case of osteoid osteoma of the odontoid process of the second cervical vertebra associated with atlanto-axial fusion. The case was diagnosed pre-operatively using plain radiography, multiplanar helical CT, contrast-enhanced MRI and radioisotope bone scanning.

Sir,Medulloblastoma is an infratentorial primitive neuroectodermal tumour most frequently seen in children.1-2 It accounts for up to 20% of all primary intracranial neoplasms in this age group.3 Me...

Postpartum hemorrhage (PPH) is an obstetric emergencythat can follow vaginal or cesarean delivery. It is a majorcause of shock, renal failure, acute respiratory distress syn-drome, coagulopathy and Sheehan’s syndrome. PPH is oneof the top Wve causes of maternal mortality in both high-income and low-income countries, with a much lower abso-lute risk of death in the former [1].The true incidence of PPH is unknown, but a reasonableestimate is 1–5% of deliveries. Figures vary according tothe criteria used to deWne the disorder [1]. The most com-mon deWnition of PPH is an estimated blood loss of 500 mlafter vaginal birth or 1,000 ml after cesarean delivery [2],yet accurate measurement of blood loss is rarely possible orpracticable. PPH can also be de Wned as 10% change in hae-matocrit from admission assessment to postpartum data, orthe need to administer a transfusion of red blood cells [3].PPH is classiWed as primary or secondary. Primary PPHoccurs within 24 h after delivery, and secondary PPHoccurs 24 h to 6 weeks after delivery.Bleeding after delivery is controlled by a combination ofcontraction of the myometrium, which constricts the bloodvessels supplying the placental bed, and local decidual hae-mostatic factors, including tissue factor, type-1 plasmino-gen activator inhibitor and systemic coagulation factors [ 4].DeWcient contraction of the myometrium is manifestedclinically as uterine atony. Defective decidual homeostasisis associated with inadequate decidualization or bleedingdiatheses.

To assess the immuno-histochemical expression of various markers in, endometrial biopsies of patients with endometrial cancer, and to correlate their expression with the final pathologic findings. Sixty-two patients with primary endometrial cancer who underwent surgical treatment were included in this study. Immuno-histochemical expression of estrogen receptor (ER), progesterone receptor (PR), p53, bcl-2, Her-2/neu and Ki-67 were assessed in curettage specimens, and review of the final pathology report from hysterectomy specimens was carried out. The expression of these markers in curettage was correlated with the final tumor characteristics obtained on hysterectomy specimens. Both ER and PR were significantly more expressed in endometrioid type (EC) than non- endometrioid type (NEC) (P value of 0.004 and 0.012). On the contrary, P53, Her-2 and Ki-67 showed higher positivity in NEC than EC (P value of 0.005, 0.025 and 0.002). Positive expression of ER and PR was significantly associated with low grade tumors and superficial myometrial invasion, whereas positive expression of Her-2 and Ki-67 was significantly associated with higher grade lesions, and deep myometrial invasion. Moreover, a statistically significant inverse relationship was observed between the positivity of P53, Her-2 and Ki-67 and the positivity of ER, PR. We found that determination of immuno-histochemical markers in curettage specimens might be helpful in predicting the final pathologic findings in patients with endometrial cancer. This might be helpful in planning the extensivity of the surgery.

Background The human multi-drug resistance gene (MDR1), which encodes the major trans-membrane transporter P-glycoprotein (P-gp), was found to be associated with susceptibility to cancer and response to chemotherapy. The C3435T Polymorphism of MDR1 gene was correlated with expression levels and functions of P-gp. Here, we studied the association between MDR1 C3435T polymorphism and susceptibility to Hodgkin lymphoma (HL) and patient's response to ABVD chemotherapy regimen. Methods a total of 130 paraffin embedded tissue samples collected from HL patients were analyzed to identify the C3435T polymorphism. As a control group, 120 healthy subjects were enrolled in the study. The C3435T Polymorphism was genotyped by polymerase chain reaction and restriction fragment length polymorphism (PCR-RFLP) method. Data analysis was carried out using the statistical package SPSS version 17 to compute all descriptive statistics. Chi-square and Fisher exact tests were used to evaluate the genotype distribution and allele frequencies of the studied polymorphism. Results these studies revealed that the frequency of T allele was significantly higher in HL patients compared to the controls (P < 0.05). In addition, the frequency of CT and TT genotypes were also significantly higher in HL patients compared to the controls (P < 0.05). No association between C3435T polymorphism and response to ABVD was detected among HL patients (P > 0.05). Conclusions these results suggest that MDR1 C3435T polymorphism might play a role in HL occurrence; however this polymorphism is not correlated with the clinical response to ABVD.

Anemia is a common finding in lymphoma. There are few data available regarding the erythropoietin (EPO) levels in conjunction with ferritin in lymphoma patients. We prospectively evaluated 55 patients diagnosed with malignant lymphoma during the period between November 2006 and March 2008 at the King Abdullah University Teaching Hospital, Jordan. Our data showed that 74.4% of lymphoma patients were anemic. Furthermore, serum EPO and ferritin levels were higher in lymphoma patients compared with the healthy controls (P=0.001). The observed versus predicted EPO ratio showed also significantly higher levels in anemic lymphoma patients compared to healthy controls (p=0.03). There was an improvement in the Hb level in lymphoma patients who were treated with at least 3-cycles of chemotherapy as compared with newly-diagnosed patients. An adequate increase of EPO levels was observed in anemic lymphoma patients and notably associated with higher ferritin levels and improvement of Hb (p

Anemia is a common finding in lymphoma. There are few data available regarding the erythropoietin (EPO) levels in conjunction with ferritin in lymphoma patients. We prospectively evaluated 55 patients diagnosed with malignant lymphoma during the period between November 2006 and March 2008 at King Abdullah University Teaching Hospital, Jordan. Our data showed that 74.4% of lymphoma patients were anemic. Furthermore, serum EPO and ferritin levels were higher in lymphoma patients compared with the healthy controls (P=0.001). The observed versus predicted EPO ratio showed also significantly higher levels in anemic lymphoma patients compared to healthy controls (p=0.03). There was an improvement in Hb level in lymphoma patients who were treated with at least 3-cycles of chemotherapy as compared with newly-diagnosed patients. An adequate increase of EPO levels was observed in anemic lymphoma patients and notably associated with higher ferritin levels and improvement of Hb (p

The authors report a case of 4-year-old boy with primary spinal extradural hydatid cyst of the thoracic spine. The location is extremely rare. However, the case is unique because the patient is the youngest reported in the English language medical literature. Surgical excision is the gold standard therapy.