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The acromioclavicular (AC) joint is crucial for shoulder function. Injuries, often in young males, result from trauma or degeneration. Treatment ranges from conservative to surgical. The Ligament Advanced Reinforcement System (LARS) technique was noted for restoring stability and function. In this review, we evaluate the LARS technique for AC joint reconstruction, focusing on clinical outcomes and complications. A literature search was done in May 2024 across PubMed, Scopus, Google Scholar, and Cochrane Library using keywords such as "acromioclavicular joint," "reconstruction," and "LARS." Inclusion criteria covered studies on the LARS technique. Data extraction included study design, patient demographics, surgical details, follow-up, and outcomes. The study quality was assessed using the Risk of Bias in Non-Randomized Studies of Interventions. Data were synthesized via meta-analyses. Also, publication bias was evaluated using funnel plots and Egger's test. From 200 records, three studies with 114 patients met the inclusion criteria. Meta-analysis showed significant improvements in functional recovery and pain reduction post-LARS surgery. Constant-Murley scores improved from a mean of 62.3 to 94.5. Visual analog scale pain levels decreased from 5.1 to 0.7. Despite high heterogeneity (I²=96%), the overall effect size strongly favored the LARS technique (standardized mean difference=-4.12 (95% CI: -4.63 to -3.60)). Complications were generally low, with calcification occurring in four patients, degenerative changes in two, and minor graft failures in another two. Patient satisfaction was high because they reported significant improvements in function and pain. Egger's test indicated no strong evidence of publication bias (p=0.083). The LARS technique enhances functional recovery and reduces pain. However, further research with larger, standardized studies and longer follow-ups is needed., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Elsenosy et al.)

Background Rheumatoid arthritis (RA) is a chronic autoimmune disorder characterized by joint inflammation, pain, and progressive disability. Identifying biomarkers that accurately reflect disease severity is crucial for effective management. Interleukin-6 (IL-6) is a pro-inflammatory cytokine involved in the pathogenesis of RA, and the systemic immune-inflammation index (SII) is emerging as a useful marker of systemic inflammation. This study aims to explore the relationship between serum IL-6 levels, SII, and various biomarkers to better predict disease severity in RA patients. Objective To determine the relationship between serum IL-6 levels and the SII, along with various biomarkers, across different severity levels for predicting the severity of RA in patients. Methods This cross-sectional, observational study was conducted at the Mardan Medical Complex from January 2024 to August 2024, involving 67 RA patients. Clinical assessments included demographic data, disease activity (DAS28), pain (VAS), joint damage (Larsen score), and functional status (HAQ-DI). Serum IL-6 levels, along with other biomarkers such as C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and the SII, were measured through fasting blood samples. Statistical analyses, including density plots, scatter plots, boxplots with ANOVA, and random forest models, were performed to explore associations between IL-6 and all other variables. Significance was set at p < 0.05. Results The study included 67 RA patients (mean age: 41.79 ± 10.51 years, 53.73% male). Elevated IL-6 levels (mean: 80.28 ± 35.27 pg/mL) were strongly associated with disease severity. Patients with DAS28 > 5.5 had IL-6 levels over 100 pg/mL, while those in remission had around 40 pg/mL. IL-6 levels correlated with joint damage (100 pg/mL in severe cases) and pain (over 120 pg/mL for severe pain). Patients with metabolic and cardiovascular comorbidities had the highest IL-6 levels, particularly with diabetes and hypertension (98.6 pg/mL) or cardiovascular disease (119.3 pg/mL). IL-6 correlated strongly with CRP (r = 0.65), ESR (r = 0.51), and SII (r = 0.62). Regression confirmed IL-6 as an independent predictor of severity (p < 0.001), with comorbidities being key predictors. Conclusion Elevated IL-6 and SII levels serve as critical markers for predicting the severity of RA. Addressing these markers may lead to more targeted and effective therapeutic strategies for managing disease progression., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Medical Teaching Institution Bacha Khan Medical College issued approval 634/BKMC. This is to certify that Ethical Approval has been granted to Dr. Zahir Khan, Assistant Professor, Department of Orthopedics, at Bacha Khan Medical College/Mardan Medical Complex Mardan, KP, Pakistan. Title for his article: "Relationship Between Serum Interleukin-6 Levels, Systemic Immune-Inflammation Index, and Other Biomarkers Across Different Rheumatoid Arthritis Severity Levels". Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: This study was supported by Pro-Gene Diagnostics and Research Laboratory, which provided funding for the biomarker analysis. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Zeb et al.)

Introduction Plantar fasciitis, a common cause of heel pain, is often treated conservatively. Platelet-rich plasma (PRP) injections have emerged as a promising treatment option. This study aimed to evaluate the efficacy of autologous PRP injections for plantar fasciitis. The objective of this study was to assess the effectiveness of autologous PRP injections delivered at the plantar fascia origin in reducing pain (measured by the Visual Analog Scale (VAS) pain intensity score) in patients with plantar fasciitis. Materials and methods A prospective cohort study was conducted at the Department of Orthopedics, Hayatabad Medical Complex, Peshawar. Patients with plantar fasciitis, a VAS pain score ≥ 7, and failure of conservative treatment were included. A single injection of autologous PRP was administered to the plantar fascia. Pain reduction was assessed using the VAS score at a 12-week follow-up. Result The study included 163 patients. Success was achieved in 80.3% of cases, showing that autologous PRP injection resulted in significant pain improvement in patients with plantar fasciitis (p≤0.05). An increased likelihood of successful treatment was observed in individuals with symptoms lasting less than 12 months. No other variables (gender, age group, residence, literacy) significantly impacted treatment efficacy. Conclusion Autologous PRP injections may be a promising treatment option for plantar fasciitis, particularly when administered early. Further research is needed to validate these findings and explore optimal patient selection criteria., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Hayatabad Medical Complex Research Hospital and Ethical Committee issued approval 1412. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Ahmad et al.)

Obesity is an exacerbated public health challenge, increasing the risk of several diseases and mortality while deteriorating the quality of life. There is significant dedication to exploring obesity therapies using glucagon-like peptide-1 (GLP-1) agonists, which have shown efficacy in reducing the number of deaths and complications associated with type 2 diabetes. This research aimed to examine the recent search popularity of GLP-1 agonists using Google Trends at both national (in Iraq) and global levels. To quantify relative search volume (RSV), the total search query activity has been transformed to a percentage scale ranging from 0% to 100%. The word "Ozempic" was chosen because of its extensive coverage in social media and web/print publications pertaining to this subject matter. A comparative search was performed targeting the phrases "Wegovy," "Saxenda," and "Mounjaro" to identify a novel combination GLP-1 agonist from August 2023 to August 2024. The present study demonstrated a statistically significant difference in the RSV among the four drugs (P < 0.0001) nationally and globally. In Iraq, the highest RSV for Ozempic was documented in Duhok, followed by Sulaymaniyah and Erbil. A comparable RSV profile has been noted for Saxenda, while substantial interest in Wegovy is seen in Ninawa. Meanwhile, globally, the highest RSV for Ozempic was recorded in Canada, the United States of America, and Australia. A distinct RSV profile has been observed for Saxenda, with heightened search interest recorded in Latin America, Poland, Sweden, and Australia. By contrast, Mounjaro received search interest primarily in Greenland and the United States, while Mounjaro search interest was noted in Canada, the United States, and Australia. This study demonstrates a significant and growing public interest in GLP-1 agonists, namely, Ozempic, Saxenda, Wegovy, and Mounjaro. As the use of GLP-1 agonists for weight loss becomes more common, more knowledge, understanding, and continuous scientific research will make it more convenient to obtain the best patient outcomes., Competing Interests: Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Shareef et al.)

Thalamic abscesses are rare, life-threatening conditions and represent only a few percent of the total cases of brain abscesses. Due to their deep location and critical involvement of sensory and motor pathways, they remain one of the most challenging entities to diagnose and manage. Despite advances in neuro-imaging and neurosurgical techniques, thalamic abscess continues to be a challenge or question in clinical practice regarding optimum treatment modality. Given the nature of the description, a systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Case reports were retrieved after extensive searches in PubMed and Scopus with specified inclusion criteria: isolated thalamic abscesses that needed surgical interventions. The reporting quality was assessed according to CARE (CAse REports) guidelines, while data on clinical presentation and diagnostic approach were extracted. Thirty-three cases with the diagnosis of thalamic abscess were reviewed. The most common presentations included headache, hemiparesis, and altered sensorium. CT and MRI were the common diagnostic tools for these patients; stereotactic aspiration was the most common surgical intervention performed. Streptococcus species were the most common causative organisms. At follow-up, the majority of patients had a good outcome with complete or near-complete recovery. There were rare complications, such as hydrocephalus and recurrence, and mortality was low. Thalamic abscesses are infrequent but have a good prognosis in case of appropriate diagnosis and treatment with stereotactic aspiration and appropriate antibiotic therapy. The present systematic review points out the need for adopting an individual approach to treatment and for further studies that could provide better information on diagnostic and therapeutic strategies regarding this severe disease., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Sulaiman et al.)

The orbital vascular malformations are very rare congenital lesions characterized by a connection directly between arteries and veins, thus bypassing the capillary network. These lesions may be associated with clinical features ranging from mild proptosis to vision-threatening conditions like visual loss and elevated intraocular pressure. Despite advances in imaging and treatment strategies, the management of orbital arteriovenous malformations (AVMs) still remains daunting because of the high risk of complications, including hemorrhage and incomplete resection. This systematic review was done according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A detailed search of the major databases such as PubMed and Scopus was performed using the keywords "Ocular OR orbit AND arteriovenous malformations OR AVM" without specifying the date. All case reports, case series, and observational studies reporting the diagnosis, treatment, and outcome of patients with orbital AVM were included. Data extraction was focused on clinical presentations, diagnostic modalities, treatment interventions, and outcomes; narrative synthesis was done due to heterogeneity in the studies. This review contains 27 case reports, where the number of patients ranged between three years and 75 years with a mean age of 34 years. The majority of the patients were males constituting 66%. The common clinical features include proptosis in 16 cases, visual loss in 12 cases, and chemosis in seven cases. Most of the patients underwent surgical resection and embolization of the malformations. In most of the cases, surgical resection was uneventful; however, a few cases with high risks showed hemorrhage and loss of vision as complications. Conservative management was also effective in certain stable or asymptomatic cases. Orbital vascular malformations include complex diagnostic and therapeutic challenges due to the complex anatomy of the orbit and the high risk of serious complications. This systematic review aimed at presenting the clinical features, diagnostic challenges, and treatment outcomes of orbital arteriovenous malformations for a better management strategy. Further research is required in the refinement of treatment protocols, especially regarding high-flow lesions, and a critical look at improving long-term efficacy., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Sulaiman et al.)

Aim: This study investigated the prognostic value of the pan-immune-inflammation value (PIV) in patients with advanced-stage pancreatic cancer (PC)., Materials and Methods: The cohort comprised 71 patients, with a median age of 65 years (range: 37-83). The majority (69%) of patients received the FOLFIRINOX regimen as first-line therapy. Using ROC curve analysis, PIV demonstrated high diagnostic accuracy in predicting mortality, with an area under the curve (AUC) of 0.84 (95% CI: 0.72-0.97) and an optimal cut-off point of 276.5., Results: Elevated PIV was significantly associated with mortality (p = 0.014), and patients with high PIV exhibited significantly poorer overall survival (OS) and progression-free survival (PFS) than those with low PIV (OS: 9.0 months vs. 26.0 months, p < 0.001; PFS: 7.0 months vs. 15.0 months, p < 0.001). Univariate and multivariate analyses identified PIV and the selected chemotherapy regimens as independent prognostic factors for OS and PFS., Conclusion: High PIV values are associated with worse clinical outcomes, reinforcing its role as a reliable prognostic biomarker in advanced-stage PC. These findings underscore the importance of PIV in guiding therapeutic strategies and warrant further investigation in larger cohorts., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Institutional Review Board of the Health Science University Antalya Education and Research Hospital issued approval 2024-249. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Aydin et al.)

This article explores the challenges in diagnosing dysphagia aortica through the case of an 89-year-old man with a medical history of hypertension, ischemic heart disease, and chronic kidney disease. Over a three-month period, the patient experienced progressively worsening dysphagia and indigestion. On the day of presentation, his condition further deteriorated, marked by hypotension. Point-of-care ultrasound (POCUS) identified a large infrarenal abdominal aortic aneurysm (AAA) measuring 13 cm, which was later confirmed by CT to involve dissection and a contained rupture. This case highlights the rare presentation of dysphagia secondary to an infrarenal AAA, known as dysphagia aortica, emphasizing the importance of considering AAAs in elderly patients with vague gastrointestinal symptoms. Despite prompt diagnosis and referral for vascular surgery, the patient's prognosis was poor due to advanced age, frailty, and multiple comorbidities. Unfortunately, he passed away a few hours after presenting to the emergency department. This article underscores the critical role of imaging modalities such as POCUS and CT in identifying life-threatening conditions like AAAs, and it advocates for a comprehensive differential diagnosis in older adults while also serving as a reminder of the atypical presentations of AAAs., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Abughazal et al.)

Aim The aim of the present study was to evaluate the in vitro comparative assessment of root canal centering ratio and canal transportation associated with ProTaper Universal (PTU) (Dentsply Maillefer, Ballaigues, Switzerland), ProTaper Next (PTN) (Dentsply Maillefer, Ballaigues, Switzerland), and ProTaper Gold (PTG) (Dentsply Tulsa Dental Specialties, Tulsa, OK, USA) rotary file systems, with or without glide-path preparation, using cone beam computed tomography (CBCT) analysis. Materials and methods A total of 120 mesial roots of extracted human mandibular first molar teeth were collected and randomly divided into three groups (n = 40) depending on the type of rotary file system used for mesiobuccal root canal instrumentation: Group 1: PTU, Group 2: PTN, and Group 3: PTG rotary file systems. Each group was further divided into two Sub-groups (a and b) with 20 specimens, depending on whether glide-path preparation was performed using the ProGlider (PG) file (Dentsply Maillefer, Ballaigues, Switzerland). Before the root canal instrumentation, mesiobuccal root canals of all specimens were first scanned using the NewTom Go CBCT machine (Cefla S.C., Imola, Italy), and all root canals were then instrumented according to their groups and sub-groups. All rotary files were used according to their manufacturer's guidelines. Post-instrumentation, CBCT images of all specimens were taken with the same exposure parameters as those used in pre-instrumentation CBCT imaging. The distance between the external root surface and the internal canal wall was measured in both bucco-lingual and mesio-distal planes at 3 mm, 5 mm, and 7 mm levels of the mesiobuccal root canal of all specimens, comparing the pre-instrumentation and post-instrumentation CBCT scans for the evaluation of canal centering ratio and canal transportation using NewTom NNT software (Cefla S.C., Imola, Italy). Data were analyzed using one-way analysis of variance (ANOVA), multiple pairwise Tukey post-hoc tests, and Student's t-tests; a p-value ≤ 0.05 was considered statistically significant. Results Canal centering ratio was significant bucco-lingually and mesio-distally at 3 mm and 5 mm levels between Groups 1a, 1b, and 3a, 3b (p < 0.05). However, at 7 mm bucco-lingually, a significant difference was observed between groups 3a and 3b, and mesio-distally between Groups 2a and 2b (p < 0.05). Canal transportation was significantly bucco-lingually at 3 mm, 5 mm, and 7 mm levels between Groups 3a and 3b (p < 0.05). However, mesio-distally, no statistically significant difference (p > 0.05) was seen between the groups at all three levels of the root canal. Conclusion The use of the PG/PTN rotary file system showed the maximum canal centering ratio at all three levels of the root canal compared to the PTU and PTG rotary file systems, whether used with or without a glide-path. The PG/PTN rotary file system showed the least canal transportation at the 3 mm level, while at the 5 mm and 7 mm levels, the PG/PTU rotary file system showed the least canal transportation., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Triveni Institute of Dental Sciences, Hospital and Research Centre issued approval TIDSHRC/IEC/2021/D007. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, G. P. V. et al.)

Orbital Langerhans cell histiocytosis (LCH) is an extremely rare disorder, and widely different manifestations often make it diagnostically challenging. The variability of symptoms - from common presentations, such as eyelid swelling and exophthalmos, to very atypical symptoms, like headaches and diplopia - frequently results in delayed diagnosis and mismanagement. This systematic review aims to describe in detail the clinical presentation, diagnostic approaches, treatment modalities, and outcomes of orbital LCH. This systematic review was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Literature searches were conducted in PubMed and Scopus up to August 2024. Synthesis of data involved 228 patients from 18 studies. Extracted data included study design, sample size, patient demographics (age, gender, ethnicity), clinical presentation, diagnostic criteria, treatment modalities, follow-up duration, recurrence rates, and complications. The review found that orbital LCH mostly affects subjects with a mean age of 8.5 years (SD ± 7.1 years), indicating that a greater number of subjects are from younger populations, with 152 males (66.7%) and 76 females (33.3%). The most common presenting symptom was eyelid swelling, reported in 108 patients (47.4%), often serving as the initial sign prompting further investigation, exophthalmos was observed in 95 patients (41.7%), indicating more significant orbital involvement, and palpable mass was detected in 80 patients (35.1%). Imaging played a critical role in the diagnosis, with CT or MRI revealing lytic lesions in nearly all cases (99%). Histopathology confirmed LCH with CD1a and S-100 proteins serving as hallmark markers of LCH. Treatment strategies for orbital LCH varied depending on the extent of disease, patient characteristics, and institutional practices. Surgical intervention was the most common treatment modality, used in 136 patients (59.6%), and it was very effective in localized disease. Radiation therapy was employed in 68 patients (29.8%), often as an adjunct to surgery or as a primary treatment for residual or inoperable disease. Chemotherapy was administered to 85 patients (37.3%), especially those with multisystem involvement. Observation and follow-up were employed in selected cases, particularly those with solitary or asymptomatic lesions, allowing for the possibility of spontaneous regression. Although the remission rate was high, at 79.8%, there was a recurrence in 14.9% of the patients, thus requiring close follow-up. Diabetes insipidus was a complication, and it was also a pointer to multisystem involvement. Orbital LCH is a diagnosis that requires a multidisciplinary approach for accurate diagnosis and effective management, with individualized treatment guided by advanced imaging and molecular markers. Further studies are needed to refine treatment protocols in an attempt to reduce recurrence rates., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Al-Wassiti et al.)

Background: Surgical repair is recommended for symptomatic full-thickness rotator cuff tears to restore muscle function and alleviate pain. Advances in arthroscopic techniques and new implant designs have led to more reliable repair methods. The choice of technique is crucial for achieving favorable clinical outcomes., Objectives: This study evaluates the short-term clinical and radiological outcomes of patients treated with the arthroscopic transosseous technique (ATO)., Methods: Data from 43 patients who underwent full-thickness rotator cuff (RC) repair using the arthroscopic transosseous technique between February 2014 and April 2016 were prospectively collected and retrospectively reviewed. Included patients had medium-sized (1-3 cm) full-thickness supraspinatus tears extending to the infraspinatus and underwent tenotomy or biceps tenodesis. Functional outcomes were assessed using the Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, and constant score at their final follow-up appointment., Result: Radiological evaluation included postoperative MRI to assess re-tear development. The mean follow-up period was 26.52±8.14 months. Postoperative VAS, ASES, and constant scores significantly improved compared to preoperative values (3.14±1.20, 88.4±8.12, and 88.9±10.6, respectively)., Conclusion: The ATO technique provides strong mechanical and biological repair, yielding good functional outcomes for full-thickness rotator cuff tears (RCTs). It is an effective method for early recovery of shoulder joint range of motion (ROM) and pain reduction., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Yıldırım Beyazit University Clinical Research Ethics Committee issued approval 02/04/2018-63. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Aydın et al.)

Sickle cell anemia (SCA) is a genetic disorder characterized by the production of abnormal hemoglobin S, leading to red blood cell sickling and subsequent vaso-occlusive events. Neurological complications, particularly strokes, significantly contribute to the morbidity and mortality associated with SCA. While ischemic strokes are more common, hemorrhagic strokes, though less frequent, present significant challenges, especially in the pediatric population. Understanding the complex interplay of genetic, environmental, and hematological factors is crucial for managing these cases. We report two cases of pediatric patients with SCA who experienced rare hemorrhagic strokes. The first case involves a nine-year-old male presenting with a subarachnoid hemorrhage, revealing cortical ischemia and multiple cerebral artery strictures. Early supportive measures resulted in a good clinical improvement, after which the patient underwent bone marrow transplantation. The second case describes a seven-year-old male who developed an epidural hematoma during a vaso-occlusive crisis, necessitating emergency surgical intervention. After initial persistent neurological deficits, the patient began to show gradual improvement with ongoing management, reflecting the complexity and severity of such events. Hemorrhagic strokes in pediatric SCA patients, though rare, represent significant clinical challenges due to their multifactorial etiology and complex management needs. These cases underscore the importance of a multidisciplinary approach and advanced diagnostic tools in managing hemorrhagic complications in SCA. Further research is essential to unravel the pathophysiological mechanisms and develop targeted prevention strategies to improve outcomes for this vulnerable population., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Research and Ethical Committee, King Salman Armed Forces Hospital issued approval KSAFH-REC-2024-593. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Mustafa et al.)

This systematic review synthesizes findings from 12 studies to evaluate the effectiveness of dietary interventions in managing irritable bowel syndrome (IBS), with a focus on low-FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diets, probiotics, and prebiotics. The review rigorously follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and includes studies selected through comprehensive database searches. In adults diagnosed with IBS, this review assesses how effective dietary interventions, specifically low-FODMAP diets, probiotics, and prebiotics, are compared to standard management or placebo in improving clinical outcomes, modifying gut microbiota composition, and reducing inflammatory markers. Our analysis reveals that low-FODMAP diets consistently alleviate IBS symptoms and improve quality of life. However, the effectiveness of probiotics and prebiotics varies, with outcomes dependent on specific strains and individual patient microbiota profiles. The studies demonstrate significant improvements in gastrointestinal symptoms and microbiota composition, highlighting the potential of dietary strategies to beneficially modify gut health. However, the research points to the necessity of personalizing dietary approaches based on individual responses and microbiota profiles to optimize treatment efficacy. The risk of bias was assessed using the Cochrane risk-of-bias 2 tool for randomized controlled trials (RCTs) and the AMSTAR 2 tool for systematic reviews, with varying degrees of bias across the studies. This review identifies gaps in the long-term efficacy of these interventions and calls for more extensive trials to explore their sustained impacts. Our findings suggest that dietary management should be integrated into routine IBS treatment protocols and emphasize the need for further research to establish standardized dietary recommendations tailored to patient-specific characteristics., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Shams et al.)

Dry eye disease (DED) is a common condition characterized by a loss of the tear film function, leading to symptoms of ocular discomfort and damage to the ocular surface. The prevalence and associated risk factors of DED may vary by region due to environmental, cultural, and genetic differences. The aim of the present study is to systematically review and analyze the prevalence and risk factors of DED in the Middle East (ME) region. This study adhered to the PRISMA 2020 guidelines. A comprehensive literature search was conducted using databases such as Web of Science, Scopus, Google Scholar, and PubMed to identify relevant studies published from January 2004 to July 2024. Studies included in the review were those that provided data on the prevalence and risk factors of DED in Middle Eastern populations. Data were extracted and analyzed to determine overall pooled prevalence and associated risk factors using a random-effects model. The study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) with the registration number CRD42024583897. The meta-analysis included 17 studies from 10 countries with a total of 22,087 subjects. The estimated pooled prevalence of DED in the ME region was 28.33% (95% CI: 27.74-28.93). The primary risk factors include age, female gender, and smoking. Other risks are contact lens use, prolonged screen time (over six hours daily), diabetes, glaucoma medications, allergies, autoimmune diseases, refractive surgery, arthritis, high cholesterol, acne treatments, antihistamines, antidepressants, thyroid disease, and a history of conjunctival infections or corneal abrasions. The prevalence of DED in Middle Eastern countries was higher than the global estimate, highlighting significant regional variation. Common risk factors for DED include older age, female gender, and smoking. These findings underscore the need for targeted prevention and management strategies that address the specific risk factors prevalent in the Middle Eastern population., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Mohamed et al.)

Castleman disease (CD) is a rare lymphoproliferative disorder with unicentric (UCD) and multicentric (MCD) forms, first detailed by Benjamin Castleman in 1956. It has three subtypes: hyaline vascular, plasma cell, and mixed. CD incidence is higher in HIV patients and is often associated with human herpes virus-8 (HHV-8). We report a 68-year-old woman with diabetes and mixed connective tissue disease (MCTD), which was diagnosed six months prior to presentation, who presented with lymphadenopathy, splenomegaly, and B symptoms. Imaging showed diffuse adenopathy. Biopsy confirmed the plasma cell subtype of MCD, with polyclonal plasmacytosis. The patient tested negative for HIV and HHV-8. Initial treatment with rituximab and corticosteroids resolved her symptoms. Six years later, she relapsed and was treated with an anti-IL-6 agent, which she could not complete due to adverse effects but still showed symptom improvement. This case is notable for the patient's age and the plasma cell subtype of MCD, as well as the concurrent diagnosis of MCTD. The patient's clinical presentation and histopathological findings underscore the importance of considering CD in the differential diagnosis of lymphadenopathy with systemic symptoms. Chronic inflammation and B lymphocyte proliferation, potentially linking MCTD and CD, were evident in this case. Despite extensive comorbidities, the patient remained clinically stable due to intensive multidisciplinary management. CD is a rare, heterogeneous disorder requiring a high index of suspicion. The potential link between CD and MCTD warrants further research. Effective management involves targeted therapies and close monitoring due to relapse risk. This case underscores the importance of individualized treatment plans considering comorbidities and treatment tolerability. Further research is needed to better understand CD's pathogenesis and develop effective treatments., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Saparov et al.)

Garcin syndrome is a rare neurological condition characterized by progressive unilateral involvement of multiple cranial nerves, without typical intracranial hypertension. It is often linked with aggressive malignancies and invasive infections; hence, it presents significant diagnostic and therapeutic challenges. Despite the advances in medical technology, the prognosis still remains poor, and there is limited literature on comprehensive reviews regarding its etiology, diagnosis, and management. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-based systematic review was performed in order to compile updated evidence related to Garcin syndrome. The PubMed and Scopus databases were comprehensively searched using the search terms "Garcin syndrome" AND ("etiology" OR "diagnosis" OR "treatment" OR "management"). Information was obtained from case reports and focused on common etiologies, clinical presentations, diagnostic methodologies, treatment protocols, and outcomes. The review discussed very diverse etiologies of Garcin syndrome. The most common among these were skull base tumors, metastatic lesions, and invasive infections like mucormycosis. Most of these were multiple cranial nerve (CN) involvements in which CN V (trigeminal nerve), CN VII (facial nerve), or CN XII (hypoglossal nerve) involvement was common. Advanced imaging, especially MRI, played a very crucial role in diagnosis, showing the presence of extensive bony destruction with the involvement of cranial nerves. Treatment was varied according to the etiology, ranging from chemotherapy and radiotherapy in neoplastic cases to active surgical intervention supported by antifungal therapy in infected cases. Garcin syndrome is a clinical challenge due to its diverse etiologies and complex management profile. While early diagnosis and intervention are emphasized, the prognosis remains grave, especially in cases presenting with metastatic disease or immunocompromised states. Future research should focus on better, more sensitive diagnostic modalities and the investigation of newer therapeutic approaches for Garcin syndrome patients., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Alshalchy et al.)

Individuals diagnosed with COVID-19 are at a higher risk of arterial and venous thrombosis, mostly pulmonary microvascular thrombosis, which may significantly impair treatment and result in morbidity. This is a systematic review and meta-analysis of research papers that aim to evaluate the risk of bleeding and thrombosis among patients treated with low molecular weight heparin or fondaparinux (LMWH/F). Additionally, we measured the overall death events. This study was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. A search was conducted in the Clinicaltrials.gov, PubMed, Scopus, and Web of Science databases to identify observational cohort studies and randomized-controlled clinical trials (RCTs) that compared LMWH/F in proven COVID-19 patients. A total of 220 people from two studies were included. Patients who were treated with fondaparinux had a lower risk of developing venous thromboembolism (VTE) (odds ratio (OR) 0.39; 95% confidence interval (CI) (0.14, 1.096); p = 0.168); pulmonary embolism (OR 0.169, 95% CI (0.021, 1.356), p = 0.094); and deep vein thrombosis compared to patients who received LMWH therapy. The data show a lower mortality rate in the LMWH groups (OR 1.135, 95% CI (0.463, 2.785), p = 0.781) and a lower frequency of bleeding (OR 1.657, 95% CI (0.456, 5.908), p = 0.436). Both drugs have shown anti-thrombotic properties in COVID-19 patients. Fondaparinux was somewhat more effective in reducing thrombosis episodes. This research demonstrates the safe use of LMWH for VTE prophylaxis in hospitalized COVID-19 patients based on bleeding and mortality outcomes., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Shareef et al.)

The event in which the entire thickness of the rectum protrudes through the anal canal is called rectal prolapse. This ailment is common in the elderly population and especially in females. It causes some disastrous symptoms, including incontinence to feces and flatus, constipation, and discomfort, because of the weakness in the anorectal junction, making it mandatory for surgical correction. Over time, several surgical techniques have been developed; these are broadly classified into two categories: abdominal and perineal techniques. However, the best approach for surgery that minimizes recurrence while maximizing patient quality of life is still up for debate. A comprehensive review was conducted adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines; a systematic search of the PubMed Database was performed to identify studies published between 2000 and 2024 with the keywords ((Rectal Prolapse) AND ("Perineal" OR "Laparotomy")). The inclusion criteria were focused on studies comparing the outcomes between surgical approaches at the abdominal and perineal locations, particularly on the recurrence rate, postoperative complications, and functional outcomes. In total, 21 studies were included in the review: these ranged from retrospective analysis and prospective studies to a multicentric randomized trial. In this review, abdominal approaches, particularly in the form of laparoscopic rectopexy, consistently demonstrated improved results compared to perineal techniques, with a much lower recurrence rate. The rates of mortality and morbidity were also remarkably lower in laparoscopic operations, which were advocated for suitable patients. However, perineal approaches, while still producing higher rates of recurrence, are a valuable alternative for elderly and high-risk patients due to their being relatively less invasive. Laparoscopic rectopexy can be considered a better surgical method for rectal prolapse, as it has a lower recurrence rate and better functional outcomes. In contrast, perineal approaches will have their place in the management of rectal prolapse, given patient selection for patients at high risk with regard to surgery. Future research should be directed toward multicenter trials with long-term outcomes in order further to fine-tune surgery strategy and criteria for patient selection., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Al Zangana et al.)

Postoperative management often demands the introduction of several strategies in an attempt to minimize complication rates. One of the routine strategies includes the use of spinal drains, which have been questioned for their efficacy in improving postoperative outcomes. However, its role in postoperative outcomes is still debated. In general, this elucidation of an extensive literature review supports the synthesis of current evidence regarding the role of spinal drains in infection rates, hematoma formation, and overall patient recovery. A comprehensive search of PubMed from 2000 to 2024 was performed, focusing on studies investigating the use of spinal drains in spinal surgeries and their associated postoperative outcomes. It followed the guidelines outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The inclusion criteria were studies related to spinal surgeries, excluding case reports, reviews, and editorials, and limited to articles published in English. Quality assessment was performed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. A total of 19 studies were included, with different designs and varied sample sizes. The sample size was from 25 to 2,446 patients. Findings on infection rates were mixed; while one group of studies showed no significant differences in patients with and without drains, another group showed a reduced rate of reoperation for surgical site infections in patients with drains. In general, hematoma formation rates were reported to be the same across groups, while a few studies indicated that drains were more effective in managing wound exudates compared to no drains. Recovery outcomes indicated that patients who had a wound drain were more likely to stay in the hospital longer, although an improvement was noticed with time-driven wound drain removal, which resulted in shorter hospital stays and earlier ambulation. The use of spinal drains in postoperative spinal surgery presents both benefits and drawbacks. Spinal drains can assist in the management of wound exudates, and earlier detection of infection complications increases hospital stays and complications. Indeed, whether to use spinal drains or not should be an individual decision, weighing the potential benefits and risks. Future studies need to be done in order to establish clear guidelines for the use of drainage systems in various spinal surgical cases., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Matti et al.)

The neural tube abnormality known as split cord malformation (SCM) is characterized by longitudinally separated functional hemicords. SCM is the result of a single basic ontogenetic error and may be associated with other anomalies. One such anomaly is Klippel-Feil syndrome (KFS), which is characterized by abnormal fusion of two or more cervical vertebrae. We present the case of a 15-year-old boy with a history of mandibular deformity, neck pain, and stiffness. Diagnostic imaging revealed type II cervical SCM, KFS, C1 vertebral arch anomaly, thoracic syringomyelia, and S1 paraspinous cleft. He was treated symptomatically with ultrasound-guided intramuscular injection of botulinum toxin (BT). Follow-ups showed that the treatment had a good effect on pain and stiffness, and an improvement in head posture was also achieved. Seven months after the first injection, a second injection was performed because the effect of BT diminished. In this report, we present the first case of cervical SCM type II associated with KFS treated symptomatically with BT injection. This is also the first reported case in a male patient; only 10 cases with both anomalies have been published in PubMed, and all of these cases are in females., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Ali et al.)

Induction of labor (IOL) has become a common practice in obstetrics, leading to an increase in antenatal admissions and workload. This review aims to explore the available options for outpatient IOL and their effectiveness. We conducted an electronic search for trials on Cochrane, PubMed, Google Scholar, and Web of Science databases for randomized control trials (RCTs) comparing inpatient and outpatient labor induction and covering the period until 2024. We selected randomized trials that compared IOL in outpatient vs. inpatient settings and involved mechanical or hormonal agents. The participants were pregnant women with singleton fetuses who were more than 37 weeks and low risk for IOL with a Bishop score <6. When comparing outpatient and inpatient induction methods, we found no significant differences in cesarean section rates and vaginal delivery. Outpatient induction generally resulted in shorter hospital stays. Using a Foley catheter for outpatient induction reduced the cesarean section rate and total hospital stay. There were no safety concerns with this approach. IOL in this analysis was shown to be similar to inpatient IOL in most of the measured outcomes. Implementation of IOL in an outpatient setting proved to be safe with similar outcomes to inpatient IOL., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Mustafa et al.)

Introduction As part of the Milestones Initiative of the Accreditation Council for Graduate Medical Education (ACGME), residents in neurosurgery are expected to participate in either clinical research or basic science research. Therefore, each neurosurgical training program must offer the support and opportunity to achieve this goal. In 2012, a structured effort to promote a resident culture of research was introduced into the authors' neurosurgery residency training curriculum. This study reviews this experience over the last decade. Methods Data were collected from the authors' departmental neurosurgery website and Scopus to create a database of neurosurgical residents who graduated 10 years before and after 2012 and their publication output. Bibliometric measures were collected for all articles published by residents. Results were compared between residents who graduated before and after the introduction of the research initiative. Results A total of 127 publications were analyzed from 37 residents, constituting 174 authorships. There was a statistically significant increase in the number of publications per resident (P < 0.001), citation number per author (P = 0.002), and author h-index (P < 0.001) after implementing the initiative. There were no significant differences in the pre-residency and baseline demographic variables between the two groups. Conclusion This study relates the experience of initiating a research culture at the authors' neurosurgery training program, which did not emphasize scholarly productivity historically. The effort focused on creating a culture of curiosity as opposed to formal requirements. The results provided evidence that this strategy yielded a significant increase in academic output and impact. These findings have important implications for neurosurgical training programs., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Motiwala et al.)

Orbital tuberculosis (O-TB) is an extremely rare manifestation of extra-pulmonary tuberculosis (TB), which affects orbital structures and causes very complex clinical scenarios that may simulate other pathologies affecting the orbit. Its diagnostic and therapeutic challenges are due to its rarity and lack of specificity on symptoms. This systematic review aims to give an in-depth analysis regarding the presentation of clinical features, diagnosis methods, treatment outcomes, and complications, enhancing the current understanding and management of O-TB. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Literature searches were conducted in PubMed and Scopus up to August 2024. The literature review included case series, case reports, and retrospective studies focusing on O-TB and involved a total of 113 cases from 12 studies. The extracted data were qualitatively synthesized regarding patient demographics, clinical presentations, diagnostic methods, treatment regimens, and the ensuing outcomes. The review found that O-TB mostly affects subjects with a mean age of 37.75 years, although there is a very wide age range of reported cases: 2-82 years with an almost equal gender distribution. The most common symptoms were vision impairment at 71.68%, eyelid swelling at 9.73%, and exophthalmos at 5.31%. Imaging, especially with computed tomography (CT) scans in 60.18% of patients, along with histopathological confirmation and molecular biological confirmation positive in 46.02%, was the principal tool for diagnosis. In most cases, antitubercular therapy (ATT) was the mainstay of treatment, leading to complete resolution. However, 30.09% of these cases had some complications like glaucoma and cataracts that point to careful management and follow-up. O-TB still remains a diagnostic challenge due to its rarity and changing clinical presentations. Early diagnosis and identification, presently mainly through imaging and histopathological examination, is important for the management. This review shows the effectiveness of ATT in the treatment of O-TB but also brings out the need for better diagnostic facilities and uniformity in treatment protocols so that complications can be prevented and outcomes improved. Future studies must be directed toward the development of more sensitive diagnostic tools and the elucidation of immune responses in O-TB guiding better clinical practice., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Sulaiman et al.)

Myxopapillary ependymoma (MPE) is a rare, slow-growing tumor that commonly arises in the lumbosacral region of the spinal cord, within the filum terminale and cauda equina. The frequent presentation of MPE is back, sacral, or leg pain. The tumor's size, site, and extension usually influence these symptoms. MPE is usually evaluated using magnetic resonance imaging (MRI) because of its superior soft tissue contrast. The best treatment modality is total surgical resection, which improves the long-term survival rate, with follow-up imaging recommended to ensure total resolution. Here, we present the case of a 29-year-old male who presented with symptoms suggestive of severe neurological impairment. An MRI scan revealed an intradural lesion arising from the cauda equina with peripheral and intrathecal haemorrhage, consistent with MPE. He was managed with laminectomy and microsurgical resection of the tumor, which achieved total resection. Postoperative follow-up found gradual improvement in his symptoms, and routine surveillance imaging confirmed the complete resolution of the tumor., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Al-Banna et al.)

Iatrogenic coronary artery fistula (CAF) can occur following acute myocardial infarction, percutaneous coronary intervention (PCI) procedures, and heart surgery. Iatrogenic CAF linked to PCI has a low incidence rate. Early diagnosis and treatment are crucial when an iatrogenic fistula develops, as it may lead to cardiac tamponade, myocardial infarction, or death. In this report, we present a case of iatrogenic CAF secondary to coronary perforation caused by guidewire-induced trauma, followed by stent implantation and balloon inflation in the context of acute coronary syndrome (ACS). It was successfully managed through prolonged balloon inflation within the previously implanted stent just prior to the rupture zone., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Yurtdaş et al.)

The ultimate preferred treatment for hepatocellular carcinoma (HCC) complicated with cirrhosis and portal hypertension is an orthotopic liver transplant (OLT). Loco regional therapy (LRT) has emerged to prevent tumor growth and progression of disease beyond the Milan criteria to achieve transplant. There is a paucity of data regarding safety, posttransplant survival benefits, and tumor recurrence rate achieved by these LRT modalities. We aim to assess and compare the five-year survival rate and tumor recurrence rate with or without LRT in patients after OLT with diagnosed HCC utilizing the nation's largest dataset. This is a retrospective observational study approved by Saint Louis University institutional review board. We utilized the largest dataset from the years 2003-2013 where pertaining data were gathered from Organ Procurement Transplant Network (OPTN) standard analysis and research files (STAR) through novel linkages with Medicare bills. Descriptive and comparative statistics were performed. 2412 (51.6%) patients received any form of locoregional therapy (single or combination) out of 4669 total study sample size. The overall five-year survival in the study sample was 76.1%. There was statistically no significant improvement seen in five-year posttransplant survival in the group that received one mode of LRT (adjusted hazard ratio (aHR) 0.97, P<0.64) or a combination of LRT (aHR 0.94, P<0.58) in comparison to those that received none after adjusting donor and recipient clinical characteristics. However, five-year survival trended higher among those treated with combination therapy over those treated with single LRT or none. Overall HCC recurrence was 4.8%, while no significant difference was noted when comparing above-mentioned groups. Five-year posttransplant survival and HCC recurrence rate were also found to have no difference when compared between above-mentioned groups after adjusting explant pathology. This is the largest retrospective study comparing liver transplant patients with HCC who received LRT to none. Although it did not show any statistically significant benefit of single or combination of LRT on survival or tumor recurrence after liver transplant for HCC patients, the outcomes encourage the safe and feasible use of LRT as a bridging therapy. Our study also suggests an observed pattern of improved posttransplant survival and tumor recurrence rate with combination loco-regional therapy. Larger multicenter prospective studies will be required to achieve the effect size to determine the best therapies for maximizing patient survival cost-effectively., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Desai et al.)

Background: Rectal malignancy ranks among the most prevalent malignancies in humans. Neoadjuvant chemoradiotherapy (nCRT) is advocated as the standard treatment for locally advanced rectal cancer. In patients who achieve complete clinical response (cCR), successive surgical intervention may result in favorable immediate and long-lasting results; however, it may be associated with decreased quality of life. This study aims to evaluate the incidence of local recurrence in rectal adenocarcinoma between patients who underwent a watch-and-wait approach and those who underwent abdominoperineal resection following the achievement of a cCR after nCRT., Methods: This is an analytic cohort study that included 68 patients and was conducted in Baghdad Teaching Hospital/Medical City, Baghdad. The data were collected from the 1st of April 2021 to the 1st of October 2023. All patients with stage II and III rectal adenocarcinoma who achieved cCR after receiving nCRT were included in the study., Results: There was no statistically significant difference between the two study groups regarding non-regrowth disease-free survival (p-value = 0.708). Cox-regression multivariate analysis revealed that baseline T stage and serum carcinoembryonic antigen (CEA) were significantly associated with locoregional failure., Conclusion: The present study reveals that implementing the watch-and-wait strategy had the benefit of avoiding major surgery, stoma, and their complications without coming at the cost of reduced locoregional recurrence., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Iraqi Board for Medical Specializations issued approval 1053. Verbal and written consent has been obtained from all participants before data collection. An official letter of approval has been obtained from the Scientific Committee of the Scientific Council of General Surgery – Iraqi Board for Medical Specializations. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Mahmood et al.)

An avulsion fracture of the second metacarpal is a rare injury often resulting from resisted wrist hyperflexion, and there is no consensus on the optimal treatment. A review of the literature reveals 20 articles documenting 25 cases of similar injuries. Of these, nine cases were initially managed conservatively, while 16 were treated surgically. Among the nine conservative cases, five (55.6%) required late surgical intervention due to unsuccessful initial treatment. In contrast, none of the 16 surgically treated cases reported poor clinical outcomes. This case involves a 23-year-old male with an extensor carpi radialis longus avulsion fracture at the base of the second metacarpal, treated with open reduction and tension band wiring. The patient achieved favorable postoperative results. In other reported cases, fixation methods included Kirschner wires, screws, or miniplates. To our knowledge, this is the first case using tension band wiring for this type of injury., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Institutional Review Board (IRB) issued approval i11-795-23. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Özyildiran et al.)

Objective: To evaluate the effect of pan-retinal photocoagulation (PRP) on central macular thickness (CMT) in a sample of Iraqi patients with proliferative diabetic retinopathy (PDR)., Methods: This prospective study was conducted at Ghazi Al-Hariri for Surgical Specialties Hospital, Baghdad, from March 2024 to May 2024. A total of 24 eyes from 18 treatment-naive PDR patients with no previous diabetic macular edema (DME) were enrolled. Each eye received PRP in two sessions, one week apart, using the Nidek GYC 500 laser system. CMT was measured at baseline and four weeks after the second PRP session using the Topcon DRI Triton Plus optical coherence tomography (OCT). Statistical analyses, including paired t-tests and Shapiro-Wilk tests for normality, were performed to evaluate changes in CMT., Results: The mean CMT increased from 258.4 ± 30.7 microns at baseline to 269.9 ± 36.8 microns post PRP, with a mean increase of 11.5 ± 26.3 microns. This increase was statistically significant (p = 0.042). The Shapiro-Wilk test confirmed that the data were approximately normally distributed both before (W = 0.960, p = 0.445) and after (W = 0.931, p = 0.103) PRP treatment., Conclusion: PRP significantly increases CMT in PDR patients, although no additional treatment for macular edema was necessary. These findings align with previous studies, suggesting that PRP-induced macular thickening is a common outcome. Further research is recommended to explore long-term effects and potential mitigation strategies., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. The Institutional Review Board of the College of Medicine, University of Baghdad issued approval 36. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Abbas et al.)

Medullary thyroid cancer (MTC) is a relatively rare thyroid malignancy, constituting a small percentage of all thyroid cancer cases. Even more rare is the occurrence of mixed MTC and papillary thyroid cancer (PTC), found in a very small fraction of MTC cases. These cancers originate from different cell types with distinct developmental origins. The coexistence of MTC and PTC in the same patient raises questions about whether this occurrence is merely coincidental or if there is an underlying genetic link. We present the case of a woman with metastatic mixed MTC and PTC. A 61-year-old woman with a history of Hashimoto's disease was found to have bilateral thyroid nodules; the largest (1.7 cm) was in the right lobe. This nodule met fine needle aspiration (FNA) biopsy criteria and was found to have a follicular neoplasm of undetermined significance. The patient elected to pursue total thyroidectomy instead of lobectomy given the presence of bilateral nodules. Postoperative pathology showed mixed medullary carcinoma (pT3b) and follicular variant papillary thyroid microcarcinoma (pT1a) involving the right lobe with positive anterior and posterior margins and lymphovascular invasion. Preoperative calcitonin was not checked. However, post-thyroidectomy calcitonin was 1599 pg/mL. She underwent central and right lateral neck dissection which showed 27 out of 35 lymph nodes were positive for malignancy. Postoperative calcitonin dropped to 38.7 pg/mL. She then established care in our endocrine clinic. Screening for pheochromocytoma and primary hyperparathyroidism was normal. She underwent external beam radiation of the neck. A year after her initial surgery, her neck ultrasound and computed tomography (CT) studies show no signs of local or distant anatomic recurrence. Her thyroglobulin level remains undetectable, carcinoembryonic antigen (CEA) within normal range, and calcitonin stable at about 20 pg/mL. She is on levothyroxine 100 mcg daily with thyroid-stimulating hormone (TSH) at a suppression goal of <0.1 mIU/L. Mixed PTC and MTC is poorly studied due to its rarity. The origin of these mixed tumors is unclear, but some suggest that they arise from neoplastic changes of remnant multipotent cells in the thyroid. While patients with PTC often have a favorable prognosis following surgical therapy, MTC has a more aggressive course. We suggest monitoring patients like ours for both MTC and PTC, as if present in isolation. Our case highlights the clinical aspects of this condition and our current knowledge of its pathophysiology., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Alshaakh Mohd Mari et al.)