Al-Ahli Hospital

BackgroundAwake colorectal surgery is an alternative to general anesthesia, especially in high-risk patients with significant cardiopulmonary comorbidities. Continuous segmental spinal anesthesia offers stable intraoperative conditions while avoiding the complications of cardio depressant effects, airway manipulation and sedation. Despite its advantages, this approach remains underreported in major colorectal procedures.Case presentationWe present the case of a 73-year-old male with a history of ischemic cardiomyopathy, chronic heart failure (ejection fraction 25–30%), chronic kidney disease, and pulmonary complications, classified as American Society of Anesthesiologists (ASA) Risk Class V. The patient was admitted to a tertiary hospital in Palestine with a recurrent sigmoid volvulus, and due to the high risk associated with general anesthesia, the surgical, cardiology and anesthesia teams decided for an awake open sigmoidectomy under continuous segmental spinal anesthesia. The patient remained fully conscious and hemodynamically stable throughout the procedure. Postoperative recovery was uncomplicated apart from a superficial wound infection, which was managed conservatively. At six-month follow-up, the patient remained asymptomatic, tolerated a normal diet, had no recurrent bowel obstruction, and showed complete wound healing without late infectious or anastomotic complications.ConclusionThis case illustrates the feasibility, safety, and potential benefits of awake sigmoidectomy in fragile, multimorbid patients. To our knowledge, it represents the first reported case in Palestine. The successful outcome emphasizes the importance of advanced regional techniques and multidisciplinary collaboration in managing high-risk surgical patients, especially in settings with limited resources.

Testicular tumors are rare in children, accounting for only 1% to 2% of pediatric solid tumors. Mature teratomas (MTs) are a benign subtype that typically occur in prepubertal boys and may occasionally mimic hydroceles. We report a case of a 3-year-old boy with left testicular swelling initially suspected to be a hydrocele. Over several months, the swelling evolved into a firm, painless mass. Ultrasound and MRI revealed a multiloculated cystic lesion with internal vascularity replacing most of the testicular parenchyma. Serum tumor markers, including alpha-fetoprotein, β-human chorionic gonadotropin, and lactate dehydrogenase, were within normal limits. The patient underwent left inguinal orchiectomy, and histopathology confirmed a MT without immature or malignant elements. Postoperative recovery was uneventful. He underwent routine follow-up every 3 months for 2 years, including physical examinations, scrotal ultrasounds, and serum tumor marker assessments. Findings from the first and second follow-ups were normal, with no evidence of recurrence to date. This case underscores the importance of early imaging and tumor marker evaluation in children presenting with persistent scrotal swelling. A systematic diagnostic approach facilitates accurate diagnosis, and orchiectomy remains the standard treatment for prepubertal MTs.

The global healthcare landscape continually emphasizes the critical importance of high-quality and safe patient care, with nurses serving as the foundational providers at the point of care, significantly influencing patient outcomes. Persistent issues, including adverse events, patient dissatisfaction, and nursing workforce challenges, necessitate a comprehensive understanding of the obstacles nurses face and the strategies they employ to uphold standards. The objective of this review was to systematically synthesize existing literature to identify the principal challenges encountered by nurses and explore effective strategies for enhancing the quality and safety of care delivery. This integrative literature review, utilizing a rigorous systematic approach to collate findings from diverse international studies, revealed that major challenges include pervasive occupational burnout, suboptimal nurse-to-patient staffing ratios, communication breakdowns, and a poor organizational work environment. Key strategies identified for enhancing care quality and safety center on fostering supportive work climates, implementing robust staffing policies, utilizing professional development programs focused on precision health and safety competencies, and strengthening interprofessional collaboration. The major recommendation is for healthcare systems to implement multi-faceted, nurse-centered interventions that address both systemic and individual factors. In conclusion, addressing nurses’ challenges through strategic, evidence-based initiatives is essential for improving the nursing work environment, which directly correlates with enhanced patient care quality and safety. The implications of these findings are substantial for healthcare policymakers and organizational leadership, guiding targeted resource allocation and policy development.

ABSTRACTReferred hip pain in a child could mask Brodie's abscess of the tibia. Recognition of this unusual presentation and prompt MRI assessment are very important to avoid misdiagnosis and to appropriately guide surgical and antibiotic management.

BackgroundSLE is a chronic autoimmune illness that affects several systems. Gastrointestinal abnormalities, although uncommon, can be dangerous and frequently go undiagnosed due to vague symptoms. Lupus enteritis and peritonitis are serious consequences. Lupus enteritis affects up to 9.7% of SLE patients and causes stomach discomfort, nausea, and diarrhea. It frequently involves intestinal vasculitis, which results in gut wall thickening and, in extreme instances, ischemia or perforation. Lupus peritonitis is very uncommon. Differentiating them from other causes of stomach discomfort is critical. This case emphasizes the diagnostic problems, imaging results, and the significance of early, focused therapy for better outcomes.Case presentationA 38-year-old lady from Hebron, Palestine, reported 3 days of increasing, colicky abdominal discomfort, bloody vomiting, and black feces. She had a three-year history of migrating polyarthralgia, photosensitivity, alopecia, and two first-trimester losses. Her cousins’ family history indicated rheumatoid arthritis and hypothyroidism. Upon examination, she seemed pale and unwell, with stomach discomfort and right basal lung crepitations. Laboratory results revealed microcytic anemia, lymphopenia, hypokalemia, hypophosphatemia, increased ESR and CRP, and a positive Coombs test. High levels of ANA, anti-dsDNA, and anti-Sm antibodies proved systemic lupus erythematosus (SLE). The imaging indicated a pulmonary embolism, pleural effusion, and thickening of the jejunal wall. Methylprednisolone and anticoagulant treatment were started. Gastroscopy indicated hemorrhagic gastritis, and paracentesis revealed exudative ascitic fluid due to ascites worsening. The patient was given cyclophosphamide with mesna, which showed improvement. The patient improved on treatment with prednisolone, hydroxychloroquine, and a proton pump inhibitor after discharge. Follow-up showed continued recovery without recurrence of symptoms.ConclusionSystemic lupus erythematosus (SLE) is an autoimmune illness that causes uncommon gastrointestinal symptoms such as lupus enteritis and peritonitis. This case demonstrates their simultaneous occurrence, underscoring the need to include SLE in the workup for gastrointestinal symptoms. Proper diagnosis by laboratories, imaging, and gastroscopy is critical since early intervention dramatically improves patient outcomes.Clinical trial numberNot applicable.

Retinal folds are an uncommon but impactful complication following rhegmatogenous retinal detachment (RRD) surgery with gas instillation.We report on a 56-year-old male who developed a persistent macular edema with intra-and subretinal fluid due to leakage from a retinal fold.A combined approach using intravitreal Faricimab and laser retinopexy led to full anatomical and functional recovery, avoiding major revision surgery.

Rationale:Euglycemic diabetic ketoacidosis (EuDKA) is a rare variant of diabetic ketoacidosis (DKA), characterized by normal or near-normal glucose levels despite severe metabolic acidosis and ketosis. This condition poses a diagnostic challenge as it mimics DKA without the hallmark hyperglycemia. Recent studies have suggested an association between EuDKA and newer antidiabetic medications, including dipeptidyl peptidase-4 (DPP-4) inhibitors.Patient concern:A 57-year-old male with a history of type 2 diabetes, hypertension, ischemic heart disease, and rheumatoid arthritis developed EuDKA following a traumatic brain injury. Despite a blood glucose of 134 mg/dL, he exhibited classic features of DKA, including severe metabolic acidosis, low bicarbonate levels, an elevated anion gap, and positive urinary ketones.Diagnosis:Despite the blood glucose level being within normal range, the patient’s clinical presentation, including severe acidosis (pH 7.16), low bicarbonate (2.8 mmol/L), elevated anion gap (24.9 mmol/L), and urinary ketones, pointed to EuDKA. The patient’s use of Sitagliptin, a DPP-4 inhibitor, was identified as a likely precipitating factor.Interventions:Timely interventions, including fluid resuscitation, insulin therapy, and electrolyte correction, were promptly administered to manage the patient’s metabolic abnormalities.Outcome:After receiving intensive treatment, the patient made a full recovery with normalization of metabolic parameters and no long-term complications.Lessons:This case emphasizes the importance of maintaining a high index of suspicion for EuDKA in trauma patients, particularly those on DPP-4 inhibitors. Early recognition and prompt intervention are crucial to preventing complications and ensuring positive outcomes. Further research is needed to explore the mechanisms linking DPP-4 inhibitors with EuDKA, especially in the context of metabolic stress like traumatic brain injury.

Neuroendocrine neoplasms of the lung include neuroendocrine carcinomas and neuroendocrine tumors (NETs). NETs are also known as carcinoid tumors (CaTs), which are categorized as typical carcinoid and atypical carcinoid (AC). Pulmonary CaTs often metastasize to various sites, including regional lymph nodes, lungs, liver, and bone; however, metastasis to the brain is relatively rare. It is even rarer for patients with CaTs to present with signs of brain metastasis initially. We report the case of a 50-year-old female patient who initially presented with neurological symptoms and magnetic resonance imaging findings suggestive of multiple sclerosis. Despite initial treatment for multiple sclerosis, further evaluation uncovered a rare case of bronchopulmonary AC tumor metastasis to the brain. This case highlights the importance of considering metastatic disease in patients presenting with atypical neurological symptoms, especially when initial management fails to yield expected outcomes. Our literature review revealed 7 cases of CaTs initially presenting with brain metastases, with our patient being the youngest among all published cases.

Introduction:Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis primarily affecting medium-sized vessels. It has several clinical manifestations, including renal, gastrointestinal, cutaneous, neurologic, and general symptoms, but it is not associated with pulmonary manifestations. PAN mainly affects individuals aged 40–60 years, with a male predominance. Although the underlying cause of this disease remains unclear, several triggers can be associated with it such as hepatitis B virus. Diagnosis typically requires an organ biopsy or angiography revealing microaneurysms or stenotic lesions. The overall prognosis can improve with early diagnosis and administration of immunosuppressants. However, it remains a potentially life-threatening diagnosis with a mortality rate of 24.6% at 5 years for severe cases. We presented a rare case of PAN with severe renal and gastrointestinal involvement at presentation.Case presentation:A 21-year-old male presented with sudden severe right flank pain radiating to the back. He was noted to have reticular purple skin lesions on his abdomen and lower legs. Clinical and laboratory findings indicated that he had a hemorrhagic shock. A contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis revealed a ruptured, partially thrombosed pseudoaneurysm of an accessory right renal artery with acute retroperitoneal hemorrhage, splenic infarcts, and two lower mesenteric artery aneurysms. Selective coil embolization of the ruptured artery was successfully conducted. Notably, the patient reports a 1-year history of intermittent abdominal pain, bilateral foot pain, and livedo reticularis, alongside left testicular pain managed with varicocelectomy. During the hospital stay, the patient developed progressive bilateral lower limb weakness that nerve conduction studies revealed it as mononeuritis multiplex. These combined findings were pointing toward PAN diagnosis. Therefore, the patient was started on pulse steroid and cyclophosphamide therapy. However, his abdominal pain worsened requiring surgical exploration with extensive bowel resection, after which plasmapheresis was commenced.Discussion:After our patient presented with life-threatening retroperitoneal bleeding, CT scan revealed that an accessory renal artery had ruptured, and also revealed the hidden cause of his chronic, recurrent, self-resolving attacks of severe abdominal pain, which were investigated multiple times by endoscopy without appropriate diagnosis. The final diagnosis of PAN was supported by the presence of livedo reticularis, testicular ischemia, chronic abdominal pain, and mononeuritis multiplex, fulfilling four diagnostic criteria of the American College of Rheumatology for PAN. Renal involvement in PAN can be in up to 75% of cases. However, rupture of accessory renal artery aneurysms is infrequent and it was the first presenting symptom of our patient. Similarly, GI complications are observed in 50% of patients, which can progress to life-threatening ischemia and gangrene, as seen in this case. Treatment involved corticosteroids and cyclophosphamide as an induction therapy based on the 2011 revised Five-Factor Score (FFS). The addition of plasma exchange therapy in this patient was due to the catastrophic complications of PAN. Eventually, the patient became clinically stable with an expected 5-year survival rate of 65.0% according to his FFS ≥2. Therefore, careful follow-up is necessary.Conclusion:Even though vascular aneurysms in PAN have a long history, they are more often linked to gradual development rather than to catastrophic events. Acute rupture resulting in hemorrhagic shock is rarely the initial sign of PAN. Rare reports of renal artery rupture in PAN highlight the significance of having a high level of clinical suspicion in young patients with unexplained vascular events. Early diagnosis and rapid management, including immunosuppressive therapy and plasmapheresis, are crucial in preventing severe outcomes. Despite a poor prognosis associated with severe disease features, careful management can stabilize the patient, although long-term follow-up remains essential.

Introduction:Hereditary hyperekplexia (HKPX) is a rare neurogenetic disorder caused by mutations in glycine signaling genes, such as GLRB. We report two neonates with autosomal recessive HKPX2 due to a novel GLRB mutation (c.1414C>T, p.Arg472*).Cases description:Case 1, a 1-month-old female, presented with severe startle responses and tonic episodes, normal EEG, and no developmental delays. Case 2, a 2-week-old male, showed similar symptoms but with generalized rhythmic ictal fast activity on EEG. Both had consanguineous parents and unremarkable brain MRIs. Whole exome sequencing identified the same homozygous GLRB mutation in both cases. Treatment with Clonazepam and Levetiracetam significantly improved symptoms.Discussion:This is the first report of the c.1414C>T (p.Arg472*) mutation in GLRB, expanding the genetic spectrum of HKPX2. The differing EEG findings highlight the disorder’s phenotypic variability. Early diagnosis and treatment are crucial to prevent complications like hypoxia and SIDS.Conclusion:This article reports a novel GLRB mutation in two neonates with autosomal recessive HKPX2, presenting with divergent EEG findings.