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BACKGROUND Most thyroid nodules are fortunately benign; however, up to 15% of thyroid nodules turn out to be malignant. Follicular thyroid cancer is the second most common type of thyroid malignancy, originating from the follicular cells lined by cuboidal epithelium, with a peak incidence between the ages of 40 and 60 years. The feature that differentiates follicular carcinoma from adenoma is the presence of capsular invasion. While distant metastases occur in 10% to 15% of patients with follicular thyroid cancer, only 2% to 13% of patients with thyroid cancer develop bone metastases. Metastasis to the knee in thyroid cancer is extremely rare. This report describes a rare case of limping and knee pain as presenting symptoms of metastasis of follicular thyroid cancer to the knee joint observed during clinical practice and addresses its implications. CASE REPORT A 60-year-old woman presented with right knee swelling, disabling pain, and difficulty with walking in the last 3 months. Magnetic resonance imaging showed a large mass, and a computed tomography scan-guided biopsy confirmed it to be a distant metastasis of follicular thyroid cancer. The patient underwent total knee replacement and thyroidectomy and was postoperatively treated with radioactive iodine therapy. She was in good condition at her 1-year follow-up, with no recurring pathology. CONCLUSIONS This case reports on the metastasis of follicular thyroid cancer to the knee, which is exceedingly rare. However, it should be considered in the differential diagnoses of lytic bone lesions, as early diagnosis and management yield a more favorable prognosis for patients.

SUMMARY: Obesity and fatty liver steatosis are already considered metabolic risk factors which may aggravate the severity of COVID-19. This study aims to investigate the correlation between COVID-19 severity, obesity, and liver steatosis and fibrosis. 230 consecutive patients with laboratory-confirmed COVID-19 aged between 15 and 84? years, admitted to a hospital devoted to COVID-19 patients, were enrolled in the study. COVID-19 severity was classified as severe versus non-severe based on admission to ICU. Obesity was assessed by Body Mass Index (BMI). CT-scan was used to check for the liver steatosis. Fibrosis-4 score was calculated. The study was conducted in March-May 2020. Obesity strongly and positively correlated with severe COVID-19 illness r: 0.760 (P

Introduction The burden of stroke can be substantially studied by establishing the functional consequences of stroke and its predictors on the population, economy and to guide rehabilitation efforts. This study aims to determine the subtypes, risk factors, and epidemiology of stroke in Jordan. Methods: A retrospective cohort study design was carried out to determine the risk factors and subtypes of stroke during 2017–2018. The study sample included 176 ischemic stroke patients of the King Abdullah University Hospital. Data was collected through medical records, which was then statistically analysed through frequencies and percentages. Results: Total 176 cases were identified out of which 101 (57.38%) were males and 75 (42.61%) were females and male to female ratio was 1.9:1. Hypertension was the commonest risk factor identified (50.56%), followed by diabetes mellitus (19.88%), hyperlipidaemia (15.34%), coronary artery disease (6.25%), atrial fibrillation (4.54%), and past history of stroke (1.13%). Risk factors such as hypertension (p = 0.007), diabetes (p = 0.000), coronary artery disease (p = 0.000) were significantly associated with subtypes of ischemic strokes. Conclusion: The study concludes that mean age of men was higher as compared to women in small vessel occlusion. The risk of ischemic stroke in patients with dyslipidaemia, diabetes mellitus, and hypertension was higher in middle-aged and old patients., Highlights • A Snapshot of Ischemic Stroke Risk Factors, Sub-Types, and its Epidemiology. • Risk of ischemic stroke is with dyslipidaemia, diabetes mellitus, and hypertension. • Control and treatment of hypertension and dyslipidaemia should be prioritized. • Risk of ischemic stroke is higher among middle and old aged patients.

SUMMARY: Thorough knowledge of splenic artery course and morphology may help clinician to provide better practice. This Study aims at finding out if there was a relationship between splenic artery tortuosity index and age, sex, Body Mass Index (BMI) and abdominal cavity diameters. Routine abdominal Computerized Tomography (CT) scan images were retrospectively analyzed for 219 patients. Splenic artery tortuosity index was calculated. Abdominal cavity diameters were measured. Age, sex, and BMI were recorded. Splenic artery straight length (x) mean was 9.41 cm (SD 1.33). Splenic artery tortuous length mean was 15.15 cm (SD 3.31). Splenic artery tortuosity index mean was 1.63 (SD 0.36). Pearson correlation coefficient for Splenic artery tortuosity index vs. age was: 0.02 (P value 0.80). Splenic artery tortuosity index for females vs. males were 1.70 vs. 1.57 (P value 0.01). Pearson correlation coefficient for Splenic artery tortuosity index vs. BMI was 0.02 (P value 0.75). Pearson correlation coefficient for Splenic artery tortuosity index vs. abdominal cavity diameters were: Anterior-Posterior (AP) diameter -0.01 (P value 0.88) and transverse diameter 0.00 (P value 0.98). There may be a relationship between splenic artery tortuosity and female sex, but not with age, BMI and abdominal cavity diameters (AP and Transverse).

Background One of the most feared complications of endoscopic retrograde cholangiopancreatography (ERCP) is duodenal perforation. We aim to discuss the incidence and risk factors of ERCP induced perforation in light of pertinent literature and review therapeutic options of different perforation types. Methods In this case-control study, we reviewed the charts of all patients with ERCP-induced duodenal perforation between January 2016 and June 2020 and compared them to a control group without perforation. Data regarding patients’ demographics, comorbidities, indication for endoscopy, ERCP findings, presumed risk factors for complicated procedures, clinical presentation of perforation, radiologic findings, time to diagnosis and perforation type according to the Stapfer classification were collected. Treatment approach, additional interventions, length of hospital stay (LOS), morbidity and mortality were also documented. Results A total of 996 ERCP procedures were performed, 13 patients were diagnosed with ERCP-induced perforation (EIP). The most common indication for ERCP was obstructive jaundice. The most significant risk factor of duodenal perforation was failure or difficult cannulation (P = .003). 5 patients were treated surgically, the majority of them had type I perforation, whereas type IV was the most common in those treated conservatively. ICU admission rates and LOS in the ICU were higher among the surgical patients. The overall mortality rate was 15% with a slightly higher rate in the surgical group. Conclusion ERCP-induced duodenal perforation carries significant morbidity and mortality. Conservative management yields favorable outcomes in selected patients compared to the surgical approach.

Kikuchi–Fujimoto disease (KFD) is a rare benign and self-limiting syndrome. We aim to review cases of KFD at our institution as a rare illness in the Arab ethnic descent and to analyse reports from most countries in the East Mediterranean zone. This is a retrospective study in which the histopathology database was searched for the diagnosis of KFD. A full review of KFD patients’ medical records was done. Data regarding demographic features, clinical presentation, laboratory findings, comorbidities, and management protocols were obtained. Published KFD cases from east Mediterranean countries were discussed and compared to other parts of the world. Out of 1968 lymph node biopsies studied, 11 (0.6%) cases of KFD were identified. The mean age of patients with KFD was 32 years (4–59). 73% (8/11) were females. The disease was self-limiting in 5 patients (45%); corticosteroid therapy was needed in 4 patients (34%). One patient was treated with methotrexate and one with antibiotics. One patient died as a consequence of lymphoma. Jordanians and Mediterranean populations, especially those of Arab ethnic background, seem to have low rates of KFD. The genetic susceptibility theory may help to explain the significantly higher disease prevalence among East Asians. Early diagnosis of KFD—although challenging—is essential to reduce the morbidity related to this illness.

Patient: Male, 23 Final Diagnosis: May-Thurner syndrome Symptoms: Claudication Medication: — Clinical Procedure: Venous stenting Specialty: Interventional Radiology • Vascular Surgery Objective: Congenital defects/diseases Background: May-Thurner syndrome (MTS) is a condition characterized by compression of the left common iliac vein (LCFV) between the right common iliac artery (RCIA) and the lumbar vertebrae. This anatomical entrapment typically affects young women and is mostly asymptomatic. High index of suspicion is required in cases of recurrent left-sided deep vein thrombosis (DVT) and severe leg pain. We describe a case of MTS in a young male patient with a left-sided superior vena cava (LSSVC) that was successfully managed by an endovascular approach. To the best of our knowledge, the coexistence of MTS and LSSVC anomaly has not been reported previously. Case Report: A 31-year-old man presented with a history of left-sided iliofemoral deep vein thrombosis and disabling venous claudication of 2 years’ duration. Duplex ultrasound and computed tomography venogram (CTV) revealed evidence of MTS with chronic subtotal occlusion of the left common iliac vein (LCIV) with extensive venous collaterals. Venogram via the left femoral vein puncture confirmed the aforementioned findings. Retrograde recanalization of the occluded segment was attempted without success. Therefore, an antegrade approach via the right internal jugular vein was performed to facilitate recanalization. Surprisingly, venography revealed an LSSVC. The occluded CIV was successfully stented and the patient had complete resolution of his symptoms at 22-month follow-up. Conclusions: MTS is a potentially treatable and often-overlooked pathology. In the era of expanded endovascular management of MTS, recognition of this coincidence is essential to prevent unwarranted mishaps during endovascular management when the jugular approach is used.

Patient: Female, 44-year-old Final Diagnosis: Pancreatic adenocarcinoma Symptoms: Abdominal pain Medication:— Clinical Procedure: Neoplasm Specialty: Surgery Objective: Unusual clinical course Background: Inferior vena cava (IVC) filters are indicated for patients with recurrent venous thrombosis despite proper anticoagulation or whenever anticoagulation is contraindicated. IVC filter deployment is an invasive procedure with various complications. One example is IVC filter limb fracture and migration, which is associated with significant morbidity and/or mortality. Extravascular migration toward pancreas may induce pancreatitis. Patients with chronic pancreatitis are known to have an increased risk of pancreatic malignancy. Case Report: We report an extremely rare case of IVC filter fractured limb in 44-year-old woman, which had migrated into the pancreatic tail and manifested as chronic distal pancreatitis. A pancreatic adenocarcinoma was found by biopsy at the pancreas tail. It is likely that a foreign body promoted this metaplasia and neoplastic transformation. Conclusions: Early detection and retrieval of a displaced foreign body in organs, such as the pancreas, seem to be essential to reduce risk of subsequent complications, including chronic inflammation and possibly neoplasia.

Background Obesity and fatty liver steatosis are already considered metabolic risk factors that may aggravate the severity of COVID-19. This study aims to investigate the correlation between COVID-19 severity, body mass index, and hepatic steatosis. MethodsConsecutive patients with laboratory-confirmed COVID-19, admitted to a hospital devoted to COVID-19 patients, were enrolled in the study. COVID-19 severity was classified as severe versus non-severe based on the condition at time of admission to ICU. Obesity was assessed by Body Mass Index (BMI). CT-scan of the patient liver was used to check for the hepatic steatosis. Fibrosis-4 score was calculated.Results230 patients were enrolled in this study. Obesity strongly and positively correlated with severe COVID-19 illness. Hepatic steatosis had rather less of a correlation with COVID-19 severity. Multivariable-adjusted association between hepatic steatosis or obesity, or both (as exposure) and COVID-19 severity (as the outcome) revealed an increased risk of severe COVID-19 illness with obesity, with hepatic steatosis, and with hepatic steatosis among obese patients. ConclusionsBMI remained the most noticeable factor that strongly correlated with COVID-19 severity. Obesity even in the absence of hepatic steatosis greatly increased the risk of severe COVID-19. This association remained significant after adjusting for likely confounders. The presence of liver steatosis even in non-obese patients increased the risk of severe COVID-19 but to a much lesser degree compared to obesity. The risk of steatosis to COVID-19 severity was greater in those with than those without obesity. This association also remained significant after adjusting for likely confounders

Patient: Male, 70-year-old Final Diagnosis: Embolization of vascular closure device Symptoms: Claudication Medication: — Clinical Procedure: Angioplasty Specialty: Radiology Objective: Unusual clinical course Background: This report describes the endovascular management of a Celt ACD® vascular closure device (VCD) lodged in the superficial femoral artery (SFA), 1 year after its deployment. There is a paucity of evidence in the existing literature regarding the management of complications related to embolized VCD discovered months or years after its deployment. Case Report: A 70-year-old male patient, who was a heavy smoker, presented with right lower-limb intermittent claudication of 2 months’ duration. He underwent a successful left retrograde iliac artery and left SFA angioplasty 1 year ago. The right femoral pulse was normal, whereas the right popliteal pulse was absent. The right ankle-brachial index was 0.64. Doppler ultrasound showed evidence of mid-right SFA occlusion. Angiogram showed an embolized Celt ACD VCD in the right SFA causing segmental occlusion. An endovascular attempt to retrieve the embolized VCD via a snare failed, as the VCD got deeply embedded in the vessel wall. After successful balloon angioplasty, a stent was placed into the SFA with excellent angiographic and clinical outcomes. Conclusions: This case demonstrates the risk of dislodgement of the VCD and its distal embolization with a risk of late ischemia. Endovascular retrieval may be unsuccessful for chronically embolized VCD. Therefore, stent angioplasty is an acceptable option.

Our aim was to investigate the variation in the vertebral levels of the origins of the celiac artery, superior and inferior mesenteric arteries, paired renal arteries, and common iliac arteries. We conducted a retrospective imaging study in a large public secondary hospital on a nonrandom sample of 227 participants. We consecutively included adult patients who had undergone computed tomography angiography of the abdomen and excluded patients with a history of any vertebral abnormality or whose images revealed evidence of a vertebral abnormality or a congenital anomaly of any of the branches of the abdominal aorta. The primary outcome was the frequency distribution of the vertebral levels of the landmarks. The secondary outcomes were the intercorrelations of the vertebral levels of the landmarks and their relationships with age, sex, weight, height, and body mass index. The celiac artery originated at T11/T12-L1/L2, followed by the superior mesenteric artery at T12-L2, the paired renal arteries at T12/L1-L2/L3, the inferior mesenteric artery at L2-L4, and the common iliac arteries at L3-L5. The vertebral levels of the landmarks were positively intercorrelated and stronger between proximate pairs. In addition, the vertebral levels of the landmarks were related to age, but not sex, weight, height, or body mass index. The intercorrelations suggest that a considerable proportion of the variation is accounted for by 'trickle-down' variation; variation in the vertebral level of a proximal landmark results in variation in the vertebral level of the immediate distal landmark. The overarching parameter remains unidentified.

SUMMARY: Anatomy is considered the core of surgery. Surgeons often complain about deficiencies in their junior doctor's level of knowledge in anatomy. The study aim was to compare opinions of final year medical students and consultant surgeons regarding current methods of teaching anatomy and which methods should be utilized to enhance medical student's anatomy knowledge. Two questionnaires were developed: one for consultant surgeons and the other one was for medical students. These questionnaires surveyed consultant surgeons and senior medical students regarding their views on various aspects of undergraduate anatomy teaching including: increasing time for anatomy teaching, anatomy knowledge level, surgeons participation in teaching, best methods of teaching and examination of anatomy, areas of strength and weakness among students, and adequacy of current teaching to understand radiology images, laparoscopic and endoscopic views. The response rate for consultants and students was 62.6 %. Surgeons who encouraged increasing the time for undergraduate anatomy teaching were 77.1 %. A significant percentage of surgeons and students thought that their junior surgeons / student level of anatomical knowledge was poor (63.4 % and 46.6 % respectively). Additionally, over two thirds of surgeons and students thought that surgeons participation in anatomy teaching in the first 3 years in medical schools may be useful (68.0 % and 69.0 % respectively). Cadaveric teaching was selected as best method of anatomy teaching by 81.0 % surgeons and 79.6 % students. Only 33.1 % surgeons and 35.4 % student thought that our current anatomy teaching was adequate to understand radiologic, laparoscopic and endoscopic views. Surgeons and students were in agreement regarding students' reduced levels of anatomy knowledge. One particular aspect of such deprivation was students' inability to interpret radiological pictures, laparoscopic and endoscopic views. Increasing time dedicated for anatomy teaching, involving surgeons in the process of anatomy teaching and redirecting the focus on cadaveric dissection may be beneficial.

Background The growth of the liver and spleen is a dynamic process in children, and is related to the somatic parameters of the child, and may be affected by many diseases in children. It is of paramount importance to have standard reference values for the size of these organs for diagnostic and prognostic purposes. The aim of our study was to provide practical and reliable normal reference values for the size of the liver and spleen in children and to correlate the values with age, height, and weight. Methods Three hundred fifteen children (142 boys and 173 girls) were prospectively examined by ultrasound due to problems unrelated to the liver or spleen. All of the subjects had normal sonographic appearance of their organs. The ages of the subjects ranged from newborns to 14 years. The liver and spleen size was correlated with age, height, and weight. The spleen size was compared with previous internationally published data. Results There was no statistical significant difference in the size of the liver and spleen between boys and girls (P>0.05). There was steady increase in the size of the liver and spleen, with good correlation with age and all the somatic parameters. The spleen size was in close proximity to those previously reported in the literature. Conclusions Standard spleen and liver size reference values were obtained by ultrasound for Jordanian children and were in concordance with international values.