Nidal A. Younes

Underlay mesh repair for spontaneous lumbar hernia.

INTRODUCTION Lumbar hernia is a rare condition with fewer than 300 cases reported in the literature. It arises through posterolateral abdominal wall defects, named the inferior triangle (Petit) and superior triangle (Grynfelt). It can be congenital or acquired, primary or secondary, peritoneal or extraperitoneal, reducible or complicated. PRESENTATION OF CASE We report a 63 year old female patient who presented to our hospital with a reducible right superior lumbar hernia. She underwent repair with underlay mesh after inversion of the sac and had a smooth postoperative course. DISCUSSION In contrast to the classical procedure the underlay mesh modification saved us from enlarging the defect, and was quick and associated with minimal tissue injury. CONCLUSION Underlay mesh repair for spontaneous lumbar hernia is feasible when the defect is small.

Simultaneous Medullary and Papillary Thyroid Carcinoma with Lymph Node Metastasis in the Same Patient: Case Report and Review of the Literature

We report a rare case of simultaneous medullary thyroid carcinoma on the left thyroid lobe with lymph node metastasis and papillary thyroid cancer on the right thyroid lobe. The 55-year-old woman was diagnosed with medullary thyroid carcinoma after left hemithyroidectomy for goitre. Completion thyroidectomy, central neck dissection and left modified neck dissection revealed the presence of papillary carcinoma on the right side. The extreme rarity and interesting pathological features are discussed and we raise the question of whether the finding of another thyroid cancer on the opposite side was coincidental or from possible activation of a common tumorigenic pathway for both follicular and parafollicular thyroid cells.

Evaluation of VTE Prophylaxis in an Educational Hospital Comparison Between the Institutional Guideline (Caprini 2006) and the ACCP Guideline (Ninth Edition)

Venous thromboembolism (VTE) is the most common preventable cause of hospital death; the burden of VTE includes the management of the acute event (deep vein thrombosis [DVT]/pulmonary embolism) and the chronic subsequents such as postthrombotic syndrome and recurrent DVT. All experts agree that despite the abundance of knowledge available on VTE and how to prevent it, it is still underused, and since the first step in prophylaxis is to identify those who are at high risk of VTE, several risk assessment models have been developed to identify these patients and provide appropriate prophylaxis. In our study, the institutional guideline in a tertiary educational hospital is the Caprini score (2006), a comparison was conducted between the institutional guideline and the American College of Chest Physicians guideline (ACCP ninth edition [ACCP-9]) in terms of the degree of agreement of the actual prophylaxis with the institutional guideline and the ACCP-9 and the differences in risk levels. The concordance with the ACCP-9 guideline was higher than with the institutional guideline, specifically in those patients receiving prophylaxis, and there was an overestimation of the risk levels in the institutional guideline, especially in medical patients. The replacement of the existing Caprini-2006 with the ACCP-9 is prudent, since it agrees with the physicians’ clinical judgment and may result in reduced use of pharmacologic prophylaxis which could lead to lower costs and fewer adverse effects.

Islet transplantation: the quest for an ideal source.

The progress of islet transplantation as a new therapy for patients with diabetes mellitus depends directly upon the development of efficient and practical immunoisolation methods for the supply of sufficient quantities of islet cells. Without these methods, large scale clinical application of this therapy would be impossible. Two eras of advances can be identified in the development of islet transplantation. The first was an era of experimental animal and human research that centered on islet isolation procedures and transplantation in different species as evidence that transplanted islets have the capability to reverse diabetes. The second was the era of the Edmonton protocol, when the focus became the standardization of isolation procedures and introduction of new immunosuppressive drugs to maintain human allograft transplantation. The quest for an alternative source for islets (xenographs, stem cells and cell cultures) to overcome the shortage of human islets was an important issue during these eras. This paper reviews the history of islet transplantation and the current procedures in human allotransplantation, as well as different types of immunoisolation methods. It explores novel approaches to enhancing transplantation site vascularity and islet cell function, whereby future immunoisolation technology could offer additional therapeutic advantages to human islet allotransplantation.

The Cricothyroid Space: a Guide for Successful Thyroidectomy

OBJECTIVE The frequent complications of thyroid surgery are mostly related to the anatomy of the region. This stimulated us to look for a starting point that makes exploration of the region easier and consequently reduces complications. We aimed to explore and define the anatomy of the cricothyroid [CT] region from cadaveric dissection and to present the outcome of 73 consecutive thyroidectomies starting from a space in the CT region. METHODS Dissection in the thyroid gland region and creating a space in the CT region was performed on five cadavers [10 spaces], followed by 73 consecutive thyroidectomies through a standard approach beginning from the CT space. RESULTS In all cadavers, a space was easily created in the CT region. Vessels, nerves and the parathyroid glands were identified. Standard thyroidectomy starting from the CT space was performed on 73 patients. The external laryngeal nerve was seen in 40% of the cases. The recurrent laryngeal nerve was identified and preserved in all patients. Six patients had temporary hypocalcaemia and eight had a temporary voice change. None of the patients had permanent hypoparathyroidism or recurrent laryngeal nerve palsy. CONCLUSION The CT space is an avascular space medial to the thyroid lobe and is a good starting point for thyroidectomy that allows easy and safe exploration of the region.

Prevalence of Foot Ulcers, Foot at Risk and Associated Risk Factors Among Jordanian Diabetics

OBJECTIVE To examine the prevalence of foot ulcers, foot at risk, and the associated risk factors among Jordanian diabetics. METHODS A cross-sectional design was applied on 1000 diabetes patients (both type-1 and type-2) aged >20 years. The participants were selected systematically from among every second patient visiting the diabetes clinics at National Center for Diabetes, Endocrinology, and Genetics (NCDEG) in Amman, Jordan. The participants were interviewed, examined, and then their medical records were reviewed. The factors including sensory neuropathy, vibratory neuropathy, painful neuropathy, vascular insufficiency, retinopathy, and dermatological changes were recorded for all patients. Foot at risk was identified based on the risk category classification and foot ulcers were evaluated based on the Wagners classification system. RESULTS A total of 53 (5.3%) patients had foot ulcers, 17 (1.7%) had undergone amputations, and 172 (17.2%) had foot at risk. A total of 62 patients were identified in the risk category-1, 82 in the risk category-2, and 28 in the risk category-3. Loss of protective sensation was detected in 174 (17.4%) patients, loss of vibratory sensation in 162 (16.2%) patients, absence of posterior tibial pulse in 115 (11.5%) patients, absence of dorsalis pedis pulse in 97 (9.7%) patients, and claudication in 72 (7.2%) patients. Loss of protective sensation (p < 0.000), loss of vibratory sensation (p < 0.039), and vascular insufficiency (p = 0.02) were found to be significantly higher in diabetic patients with foot ulcers than in those without foot ulcers. CONCLUSION The prevalence of foot ulcer in Jordan was 5.3%, while foot at risk was prevalent in 17.2% patients. Patients with loss of protective sensation, loss of vibratory sensation, and vascular insufficiency of the lower limbs were found to be at a higher risk for the development of foot ulceration.

Detection of combined genomic variants in a Jordanian family with familial non-autoimmune hyperthyroidism

Five patients, four brothers and their paternal aunt, presented with a history of overt hyperthyroidism and goiter. Hyperthyroidism in this family was remarkable for its poor response to carbimazole (30–50 mg/d). The thyroid ultrasound showed a diffusely enlarged gland in all the affected members, and thyroid stimulating antibodies (TSAB) were negative. Screening for germline mutations in thyroid stimulating hormone (TSH) receptor (TSHR) gene was performed by direct sequencing of genomic DNA extracted from peripheral blood leukocytes of all family members. The sequence analysis of all TSHR gene exons and intron borders revealed two genomic variants. The first was a single nucleotide polymorphism (SNP) within exon seven (Asn187Asn), whereas the other was located in intron seven (IVS7+68T>G). All affected members, two asymptomatic brothers with sub-clinical hyperthyroidism, and their father were heterozygous for those two genomic variants. Anti-thyroid drug treatment for several months successfully relieved symptoms in one subject, whereas the remaining patients required total thyroidectomy to control their disease. This is the first Jordanian family with familial non-autoimmune hyperthyroidism, with mutations affecting the TSHR gene.

The discovery of the Zollinger‐Ellison syndrome

Over the years, great strides have been made in the diagnosis and care of patients with gastrinoma and with the ZE syndrome. As the 40th anniversary of the description of this tumor approaches, we remain indebted to Professors Zollinger and Ellison for their outstanding work. They will long be remembered and revered as outstanding surgical scholars of our time.

Role of the clinical pharmacist in improving the appropriateness of venous thromboembolism prophylaxis in hospitalised patients in Jordan

Venous thromboembolism (VTE) is one of the most important preventable causes of death in hospitalised patients. The role of the clinical pharmacist in Jordan is still at its beginnings in this field; this study explored the contribution of the clinical pharmacist to improving the frequency of appropriate VTE prophylaxis.

Ascending Infection of Foot Tendons in Diabetic Patients

Bone and soft tissue infection in the foot of diabetic patients is a well-described issue in the literature. A sound anatomical knowledge of the foot anatomy and compartments is mandatory to understand the mechanisms of infection spread. We describe four cases of diabetic foot infection complicated by long ascending infection. All did not respond initially to antibiotic treatment and the usual surgical debridement and were cured only after excision of the infected tendons. We highlight a rare but serious complication of the diabetic foot disease not commonly seen by the surgical community. We hope that this report raises the awareness of this condition so that a prompt diagnosis is made and appropriate treatment started, thereby reducing the risk of major lower limb amputations.