A shocking intraoperatively diagnosis of ochronotic knee arthropathy: a case report

Introduction

Alkaptonuria is an autosomal extremely rare recessive metabolic disorder with incidence reported to occur as 1:100 000-1:250 000 live births worldwide. This rare metabolic disorder is characterized by the accumulation of homogentisic acid due to a deficiency in homogentisic acid 1,2 dioxygenase. Homogentisic acid subsequently oxidizes and accumulates in the connective tissue. The knee is the most significant peripheral joint to be affected by the disorder. The authors present the first case of ochronotic arthropathy in Syria.

Case presentation

A 46-year-old male presented with bilateral pain in the knees. the pain was affecting his day-to-day activities, and not responding to conservative management. Anteroposterior standing radiographs demonstrated extensive degenerative disease. Intraoperatively, the diagnosis was done after noticing that the quadriceps tendon and the articular cartilage of the femur, tibia, and patella were blackened during cemented total knee replacement of the knee.

Conclusion

Ochronotic arthropathy should be kept in mind in middle age patients with severe osteoarthritis to not be surprised by the rare alkaptonuria diagnosis if arthroplasty was indicated.

Basic life support awareness among medical undergraduate students in Syria, Iraq, and Jordan: a multicenter cross-sectional study

BACKGROUND AND AIMS

Basic life support (BLS) training rates vary widely worldwide, and there is a general scarcity of surveys that assess students' knowledge and awareness of BLS in middle eastern nations. This study aims to evaluate medical students' knowledge and awareness towards basic life support.

METHODS

A cross-sectional study, using an online web-based questionnaire, assessing BLS awareness and knowledge, was conducted from 3 to 30 November 2021. The study included 2114 medical students from Syria, Iraq, and Jordan. The questionnaire consisted of three sections: demographic baseline characteristics, knowledge about BLS, and ability to apply basic life support. A binominal logistic regression was done between the total score and other demographic characteristics to determine if we could predict the research sample's appropriate knowledge of BLS level.

RESULTS

There was a moderate knowledge of BLS and cardiopulmonary resuscitation (CPR) skills among participating students with an average score of 19.67 (0-34). Seventy-eight of the participants (1656) stated that they have not attended a basic life support course. There was a significant difference between the participants from different countries, where the mean score in Syria, Jordan, and Iraq was 18.3, 24.3, and 18.8, respectively (p < 0.05). Considering the level of knowledge, 18.3%, 72.8%, and 8.9% of the participants had a high, intermediate, and low level, respectively. Furthermore, students who took a BLS course had a higher level of knowledge than those who did not, with an odds ratio of 5.168 (p value < 0.0001).

CONCLUSION

The overall knowledge of medical students' basic life support knowledge is insufficient and need to be greatly improved. According to this study, previous participation in basic life support training had a positive effect on knowledge level. As a result, universities must establish basic life support programs as quickly as possible.

Newly repairing technique of deformed hand by a posterior interosseous flap in an infant: A case report

Introduction

Many non-surgical methods were performed to repair the deformities in the skeletal system to avoid severe complications post-open surgery, especially within the childhood stage or below. We aim, in this case, to present a new technique for repairing bony deformities in the childhood stage, which fewer studies have to instigate its efficacy versus open surgery.

Case presentation

We present a 14-months-old infant with wrist extravasation injury at the neonatal stage (day 1), end with a right wrist volar contraction and complete loss of brain homunculus of the right hand.

Discussion

We used a reverse posterior interosseous flap to reconstruct the soft tissue and release the flexor tendons of the hand. The flap was conducted entirely and was rapidly adapted to the recipient beds to achieve good color and texture harmonies. Within following up for 12 weeks, the patient restored hand function.

Conclusion

More global cohort studies are required to compare precisely the efficacy between surgical options and the used technique in our case for salvaging deformities in childhood.

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Many obstacles face the surgeons in children, especially among orthopedics.

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Fewer studies have reported newly non-surgical methods due to repairing the bone deformities may cause severe complications among children.

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This article aims to highlight the utility and versatility of the flap and to show the possibility of using this flap at the age of fewer than two years old group.

Misdiagnosis of sphincter of Oddi disorder treated as familial Mediterranean fever for ten years: A case report

Introduction

Sphincter of Oddi dysfunction is a rare disease caused by sphincter of Oddi functional or mechanical abnormality. Misdiagnosis of familial Mediterranean fever is very high due to overlapping symptoms with many diseases. Our case is the first case report in the medical literature which describes the misdiagnosis of Sphincter of Oddi dysfunction as familial Mediterranean fever.

Case presentation

A 46-year-old woman presented with recurrent episodes of abdominal pain and arthralgia. The patient had familial Mediterranean fever for ten years which was diagnosed clinically without performing genetic tests. Analysis of the mutation in the MEFV gene was performed and was negative. Thereby, the diagnosis of familial Mediterranean fever was eliminated and colchisine was discontinued. Afterward, laboratory and radiological tests were performed, and the diagnosis of sphincter of Oddi disfunction was confirmed. The patient underwent biliary sphincterotomy and take sulpiride daily.

Discussion

The most common diseases were misdiagnosed with familial Mediterranean fever are appendicitis, acute rheumatic fever, gastrointestinal diseases and inflammatory arthritis. Endoscopic retrograde cholangiopancreatography with Manometry of the Sphincter of Oddi is the gold-standard test.

Conclusion

Sphincter of Oddi dysfunction may interfere with many other disorders and should be considered as a differential diagnosis for any recurrent abdominal pain. Misdiagnosis of familial Mediterranean fever is common in endemic countries due to the reliance on clinical symptoms without analysis of the mutations in the MEFV genes particularly, before 1997.

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SOD should be considered as a differential diagnosis for any recurrent abdominal pain.

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Misdiagnosis of familial Mediterranean fever is common in endemic countries.

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ERCP with Manometry of the Sphincter of Oddi is the gold-standard test.

Normal values of antistreptolysin O for adults ages 30 to 70 in Syria: A cross sectional study

Background

Group A Streptococcus is a very common pathogen which infects a large scale of people around the world causing many symptoms such as scarlet fever, sinusitis, and pneumonia. Most strains of group A and many other strains of group C and G Streptococcus bacteria secreted antigen called Streptolysin O. Anti-streptolysin O (ASO) is an antibody produced against streptolysin O that rises after 1 week of infection by streptococcus bacteria, which helps in diagnosing this type of infectious diseases. We conducted a Cross-Sectional study to determine the Upper Limit of Normal (ULN) for healthy adult in Aleppo, Syria.

Materials and methods

A sero-epidemiological cross-sectional study was conducted from September to October in 2019. ASO titers were determined on 267 healthy patients’ companions who visited Aleppo University Hospital. Geometric mean titer and Upper Limit of Normal of ASO were calculated according to sex, age and residency. Upper Limit of Normal were defined as the 80th percentile.

Results

Out of 267 participants; 126 (45.7%) were males and 150 (54.3) were females. The Upper Limit of Normal for total participants was 210.8 IU/ml. There was no significant difference (P-value > 0.05) among males (204.6 IU/ml) and females (225.8 IU/ml). In contrast to sex, there was a significant difference (P-value < 0.05) according to age groups, where the highest Upper Limit of Normal was in the 30–39 age group (256.0 IU/ml).

Conclusion

ASO test is a common, easy, cheap method, so getting enough data about it is very important in the developing countries (such as Syria). In Aleppo, Syria we found that the ULN was higher than ULN from other studies. There was no significant difference according to sex and residency. On the other hand, there was significant difference according to age groups.

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The Upper Limit of Normal for total participants was 210.8 IU/ml.

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We found that the ULN was higher than ULN from other studies.

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There was significant difference in ULN according to age groups.

Migraine and tension-type headache among undergraduate medical, dental and pharmaceutical students of University of Aleppo: a cross-sectional study

Introduction

Headache disorders are among the most common 10 causes of disability worldwide according to the global burden of disease survey 2010. Headache is also wildly common among universities students when compared with other populations. The purpose of this study is to assess headache prevalence among Aleppo University medical, dental and pharmaceutical undergraduate students.

Methods

A questionnaire-based cross-sectional study was conducted among medical, dental and pharmaceutical students at Aleppo University, Syria. We determined the type of headache according to the International Classification of Headache Disorder-III. The total number of participants was 2068. A χ² test was used to evaluate the association between the categorical outcomes. P<0.05 was considered significant.

Results

Out of 2068 participants, 1604 (77.6%) were medical students, 205 (9.9%) were dental students and 259 (12.5%) were pharmaceutical students. The effect on daily activities was higher in chronic tension headache (96.7%) and migraine without aura (94.6%) than migraine with aura (91.3) and episodic tension headache (85.1%). Out of 1191 who had a headache, only 188 (15.9%) had a medical consultation.

Conclusions

There was no a statistically significant difference in prevalence of tension headache and migraine according to faculties. There was a statistically significant difference in patients with migraine according to academic year, living with family and smoking. The effect on daily activities was higher in chronic tension-type headache and migraine without aura. There is a significant lack of medical consultation among students and most of them took over the counter analgesics depending on personal choice.

Hemophilia A and C in a female: The first case report in literature

INTRODUCTION

One of the relatively rare hemostatic disorders is coagulation factors' deficiency, where a single factor or multiple factors can be deficient. All hereditary coagulation factors' deficiencies are autosomal recessive, so they can manifest in both genders, but Hemophilia A and B are X-linked disorders. Therefore, females can rarely be affected. This paper reports the first case of simultaneous coagulation factors' deficiencies of FVIII and FXI in a female.

CASE PRESENTATION

A 17-year-old female came to the office due to prolonged epistaxis, with a history of severe menstrual bleeding and frequent episodes of epistaxis. In her familial history, a brother complained of epistaxis episodes. Bleeding time and prothrombin time were normal but activated partial thromboplastin time was increased. Von Willebrand disease was excluded, and she was diagnosed with hemophilia A and C.

DISCUSSION

Females can be affected with X-linked disorders such as hemophilia A and B in some rare cases: a carrier mother and affected father, skewed X chromosome inactivation, Turner syndrome, inhibiting antibodies (acquired hemophilia), or a sporadic mutation on the most activated X chromosome. On the other hand, Hemophilia C is an autosomal recessive disease. Treatment of such cases is a challenge, and the recombinant coagulation factors are the treat-of-choice.

CONCLUSION

Although Von Willebrand disease is the most common hereditary bleeding disorder in females, other rare diseases could be suspected such as Hemophilia. X-linked Hemophilia should be kept in mind as a differential diagnosis in any female patient suffering from hemorrhage.

A child with Ewing's sarcoma in scapula: A rare case report

Introduction

Ewing's sarcoma is considered to be the second most frequent primary sarcoma in children. It affects children and young adults with a male predominance. Ewing's sarcoma is usually found in the femur, humerus, ilium and tibia; and in extremely rare cases Ewing's sarcoma might affect the scapula. There are only 15 papers in PubMed database regarding scapular Ewing's sarcoma.

Case presentation

A 14-year-old male, with no significant medical or surgical history, presented with a swelling in the right scapular area for two months. The patient also experienced mild pain and fever. On physical examination, there was a tender mass and restriction in the right shoulder joint movements. MRI showed a large scapular mass with the characteristics of a sarcoma. The final diagnosis was made based on pathologic findings. Eventually, the patient was subjected to neoadjuvant chemotherapy.

Discussion

The most common tumors affecting scapula are chondrosarcoma and osteosarcoma. In a cohort study about patients diagnosed with ES between 1988 and 2018, only 29 cases were involved in the scapula. There are 12 cases of congenital ES have been reported in the medical literature, 3 of them were in the shoulder girdle. Surgery with neoadjuvant chemotherapy is considered better for total survival in ES of scapula in comparison with chemotherapy and/or radiotherapy alone.

Conclusion

Ewing sarcoma is extremely rare in the scapula and should be considered as a differential diagnosis for any patient with scapular tumor.

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The most common tumors affecting scapula are chondrosarcoma and osteosarcoma.

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In extremely rare cases, Ewing’s sarcoma (ES) might affect the scapula.

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Surgery with neoadjuvant chemotherapy is considered better for total survival.

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ES should be considered in each child presents with a swelling over scapular region.

Syrian medical, dental and pharmaceutical publication in the last decade: A bibliometric analysis

BACKGROUND

Scientific research has an essential role in building up the basics of public health and clinical care. As a developing country, Syria has a limited contribution to scientific research. Besides, the current Syrian crisis has inflicted severe damage to the infrastructure of the country, which, in turn, negatively affected the scientific sphere. This study examines the scientific publishing in Syria from 2011 until 2020. It aims to define the real and deep reasons for the slow-down in publication to get over them, push Syria to keep track of the latest updates, and take its place in scientific research.

METHODS

We conducted a bibliometric analysis of articles published in (PubMed and Scopus) Databases from 1/1/2011 until 26/12/2020, using the following search terms (("Syrian Arab Republic") OR (Syria) OR (Syrian)) limiting the search to (Affiliation) fields.

RESULTS

Syrian medical, dental and pharmaceutical institutions published 1403 papers from 2011 until 2020. There were only 55 papers in 2011, and a peak with 180 papers in 2018. Besides, publications in the last 4 years were 1.135 times more than publications in the last 6 years.

CONCLUSION

We noticed a peak in quantity of Syrian medical, dental and pharmaceutical publications in the last decade. Accordingly, we recommend enhancing research skills, paying more attention to the quality of researches, and holding research workshops and Evidence Based conferences to enhance the scientific endeavor.

Unusual case of classic testicular seminoma in a 90-year-old patient: a case report

BACKGROUND

Seminoma is the most common subtype of testicular cancer and occurs most commonly in patients aged 30-49 years, but decreases to a very low level in men in their 60s or older.

CASE PRESENTATION

A 90-year-old Syrian man with a 6-year history of an increase in size of his right scrotum, presented to the urological clinic and, on clinical examination, the findings suggested testicular tumor. After orchiectomy and histology results based on microscopic and immunohistochemical examinations, a pure seminoma was diagnosed, so we describe in this case report the second-oldest patient with classical seminoma in the medical literature.

CONCLUSION

This case report has been written to focus on the probability of any type of testicular tumor occurring at any age or decade; urologists should consider seminoma as a differential diagnosis with any testicular swelling even in elderly patients.

Uncommon musculoskeletal femoral hydatid cyst disturbs a female for a year: Case report

“Hydatid cyst” which also known as cystic Echinococcosis is a parasitic infestation caused by the larval stage of Echinococcus granulosus. The liver and lungs are the most sites to occur. Incidence in muscles is exceptionally rare.

We report a case of a 36-year-old female presented with an uncomfortable mass in the upper medial of her right thigh without any presence of other symptoms. She lived in a rural area in Manbij, which is an endemic area of hydatid cysts in Syria. She was a shepherdess; therefore she had direct contact with sheep and dogs. Ultrasound examination showed a cyst located between adductor longus muscle and gracilis muscle closed to the deep femoral artery. The patient was treated with pharmaceutical therapy for a week before cystectomy, which was done under general anesthesia. The cyst was dissected between the fibers of adductor longus muscle from the lateral side and fibers of the gracilis muscle from the medial side. The cyst with all its layers was resected.

Musculoskeletal Echinococcosis is a rare disease, because of intramuscular growth of cysts is restricted by muscle's contractility, the muscles are undesirable habitat for Echinococcus granulosus and because of the hepatic barrier role. Many cysts are revealed by complications such as nerve compressions, infections simulating an acute abscess or a malignant tumor.

Hydatid cyst present as mass of soft tissue, particularly in endemic areas, as a result of contaminated water. MRI considered the best technique in the diagnosis.

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Incidence of Hydatid cyst in muscles is exceptionally rare.

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MRI considered the best technique in the diagnosis.

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Confirming the final preoperative diagnosis of muscle hydatid cysts is important.

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Hydatid cyst should consider as a differential diagnosis for masses of soft tissue.

A rare complication of gallstones ended with spontaneous cholecystocutaneus fistula in an old man: A case report

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Cholecystocutaneous fistula is an extremely rare complication for gallstones.

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The diagnosis is not easy because symptoms are nonspecific.

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Computed tomography considers the gold standard in diagnosing this case.

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First procedure was laparoscopic, but greater omentum adherent to the gallbladder.

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So we turned to open technique to perform cholecystectomy and resection the fistula.

Introduction

Cholecystocutaneous fistula is an extremely rare complication of gallstones. The majority of the fistulae localize into the right upper quadrant of the abdomen. Diagnosis is not easy because the symptoms are nonspecific. External biliary fistula is more common in females between the 5th-7th decades because in this age group the frequency of cholecystitis is increased.

Case presentation

A 65-year-old man presented with a swelling in the right hypochondrium. He had not complained of any serious symptoms. Laboratory investigations were normal. Both abdominal ultrasound and Multislice computed tomography (MSCT) showed that the gallbladder contained stones, in addition to a cystic mass in the abdominal wall. The previous findings suggested that there was an abscess. So, the patient underwent laparoscopic procedure, and we found a fistula between the gallbladder and the abdominal wall causing the abscess. The greater omentum was adherent to the inflamed gallbladder. So that we transformed into open procedure to perform cholecystectomy and resect the fistula.

Discussion

Biliary fistulae have two types, external and internal. The most common type is internal. External biliary fistulae emerge like a complication of cholecystolithiasis in general. Spontaneous cholecystocutaneous fistulae occur due to acute inflammation caused by cholecystitis or chronic gallstones disease. The most common clinical manifestation is an abscess in the abdominal wall that discharges bile to the outside.

Conclusion

Computed tomography is considered the gold standard in diagnosing a spontaneous cholecystocutaneous fistula, and it should be considered as a differential diagnosis for any abscess that is evident in the abdominal wall.

Trichobezoar in a young girl caused by ingestion of bristles brush for more than a decade: A case report

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Ingestion of hair and bristle brush led to unique type of trichobezoars.

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Trichobezoars led to gastric outlet obstruction.

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The diagnosis is made by abdominal X-ray, computed tomography scan and endoscopic examination.

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Surgical intervention is performed for the majority of patients.

Introduction

Trichobezoar is a rare cause of bowel obstruction. In general, Trichobezoars are composed of hair and usually found incidentally in patients undergoing upper gastrointestinal endoscopy or imaging. Patients diagnosed with Trichobezoar may have psychiatric disorders.

Discussion

Trichobezoars cause nonspecific symptoms like asymptomatic abdominal mass, vomiting, nausea, and anorexia. Diagnosis of Trichobezoar is made by endoscopic examination and radiological methods. Therapeutic options for trichobeazoar are chemical dissolution, endoscopic removal or surgery.

Case presentation

Here we present a case of an 18-year-old girl who has a unique type of Trichobezoars caused by ingestion of hair and bristle clothes brush for 14 years. She presented to the surgical clinic complaining of vomiting, anorexia and epigastric mass. Abdominal computed tomography scanner showed nonattached intragastric mass which was consistent with trichobezoar. The patient was managed by surgical removal of the intragastric mass.

Conclusion

Trichobezoar is caused by chronic ingestion of hair; it is commonly seen in young females who may have psychological disorders, such as trichophagia and trichotillomania. Common symptoms are abdominal pain, nausea, vomiting, and weight loss. Surgical intervention is performed for the majority of the patients.