Thoracic Outlet Syndrome (TOS) is a condition characterized by the compression of the neurovascular structures passing through the thoracic outlet, resulting in a variety of symptoms including pain in the upper limb, neck, and head with varying degrees of neurological deficits ranging from numbness to muscle wasting and deformities. This disorder has been the subject of extensive medical debate among surgeons and physicians [1]. This editorial aims to explore the controversies regarding TOS and shed light on the complexities to be studied by specialized researchers.
One of the primary controversies surrounding TOS lies in the diagnostic process. TOS presents with a wide range of symptoms, making it difficult to differentiate from other conditions. The absence of standardized diagnostic criteria and the lack of definitive tests contribute to diagnostic uncertainty. Some argue that TOS is over-diagnosed, leading to unnecessary interventions, while others believe it is underdiagnosed, resulting in delayed treatment for those affected [2].
The optimal treatment strategy for TOS is another contentious issue. Conservative therapies, such as physical therapy, exercise, and posture correction, are often recommended as the first line of treatment. However, their effectiveness in relieving symptoms and improving functional outcomes remains uncertain. Surgical intervention, including decompression operation and resection of the first rib, is considered in refractory cases, but the timing, indications, and long-term outcomes of surgical interventions are debated. Additionally, the variability in surgical techniques and lack of large-scale randomized controlled trials further contribute to the controversies surrounding treatment approaches [3].
TOS shares similarities with various other conditions, such as cervical radiculopathy, brachial plexopathy, and peripheral nerve entrapment syndromes. The overlap in symptoms and diagnostic challenges often leads to misdiagnosis and inappropriate management further complicating the condition and intensifying the debate. Distinguishing TOS from these conditions and establishing clear diagnostic criteria are crucial for accurate diagnosis and effective treatment [2,3].
There are other less crucial controversies regarding TOS like its classification, and etiologies [1,2].
Thoracic Outlet Syndrome remains a subject of significant controversy within the medical community. The diagnostic challenges, treatment approaches, and overlap with other conditions contribute to ongoing debates. To address these controversies and improve patient care, it is essential for researchers and healthcare professionals to collaborate, establish standardized guidelines, conduct further studies, and refine diagnostic criteria and treatment approaches.
Ameer M. Salih, Nashaddin A. Mohammed, Yousif M. Mahmood, Sabah J. Hassan, Hiwa S. Namiq, Abdullah K. Ghafour, Saywan K. Asaad, Suhaib H. Kakamad, Fakher Abdullah, Karokh F.H. Hussein, Hussein M. HamaSalih, Muhammed Karim, Fahmi H. Kakamad, Berun A. Abdalla, Shvan H. Mohammed
ChatGPT Insight and Opinion Regarding the Controversies in Neurogenic Thoracic Outlet Syndrome: A Case-Based Study
Ameer M. Salih, Nashaddin A. Mohammed, Yousif M. Mahmood, Sabah J. Hassan, Hiwa S. Namiq,...
Introduction
There are several controversies regarding thoracic outlet syndrome. This manuscript evaluates the utility of ChatGPT in providing insights into the controversies surrounding neurogenic thoracic outlet syndrome (nTOS).
Methods
The following questions were chatted with ChatGPT based on OpenAI's GPT-4 architecture, which was last updated in September 2021. What is your opinion regarding the psychological abnormalities in patients with nTOS? What is your opinion about the role of duplex ultrasound in the diagnosis of nTOS? In your opinion, which one is preferred? First rib resection or only scalenectomy for the surgical management of nTOS?
Results
ChatGPT was accurate in addressing the psychiatric disorders associated with nTOS and the outcome of different types of surgical intervention while it failed to highlight the role of duplex scanning in this disease apart from ruling out another differential diagnosis.
Conclusion
While ChatGPT offers valuable insights, it should be noted that its last update was in September 2021. Hence, some newer developments in the field may not be addressed. Nonetheless, a comprehensive approach to understanding and managing nTOS, combining both clinical expertise and technological advancements, is vital for the well-being of patients.
Rebaz M. Ali, Fahmi H. Kakamad, Hiwa O. Abdullah, Shalaw H. Abdulla, Shaho F. Ahmed, Bnar J. Hama Amin, Marwan N. Hassan, Sabah J. Hasan, Hussein M. Hamasalih, Berun A. Abdalla, Rawezh Q. Salih, Gasha S. Ahmed
Pembrolizumab (Anti-PD-1) Immunotherapy in Malignant Pleural Mesothelioma: A Systematic Review of the Current Literature
Rebaz M. Ali, Fahmi H. Kakamad, Hiwa O. Abdullah, Shalaw H. Abdulla, Shaho F. Ahmed, Bnar J. Hama...
Abstract
Introduction
Malignant pleural mesothelioma is an infrequent and aggressive type of cancer that is difficult to treat, and standard therapies have shown limited effectiveness. There have been recent advances in the development of targeted therapies for malignant pleural mesothelioma, including immunotherapy with pembrolizumab.
Methods
This is a systematic review of the current role of pembrolizumab in the treatment of this disease. A systematic search was conducted through the databases and search engines. The eligible studies to be included were those that primarily focused on the outcomes of treating this disease with pembrolizumab, regardless of study design, line of therapy, mode of therapy, and ECOG performance status.
Results
After the initial and full-text screenings, 15 studies were reviewed. The number of cases was 454 with a mean age of 68.13 years, of which males (79.7%) were the predominant gender. Most of the cases were affected by epithelioid mesothelioma (76.7%). Pembrolizumab had been used as the first line of treatment in 62 (13.7%) cases. In 92.73% of cases, the therapy mode was pembrolizumab monotherapy. A total of 68 different adverse events were recorded. The most commonly associated adverse events were fatigue (14.8%), pruritis/rash (13.7%), and diarrhea (9.7%). Two patients died due to adverse events. The overall objective response was 17.8%, stable disease was 35.7%, progression-free survival was about 47.6% with a mean of 4.73 months, and 117 cases (25.8%) could reach treatment-related survival.
Conclusion
Pembrolizumab can serve as a viable alternative in the management of malignant pleural mesothelioma, offering satisfactory outcomes and acceptable safety profiles.
Huda M. Muhammad, Nahida HA. Ahmed, Gasha S. Ahmed, Fahmi H. Kakamad, Sabah J. Hasan, Berun A. Abdalla, Shvan H. Mohammed, Snur Othman, Sanaa O. Karim, Hussein M. Hamasalih, Yousif M. Mahmood, Hawbash M. Rahim
Adverse Pregnancy Outcomes (Maternal, Fetal, and Neonatal) in COVID-19: A Review
Huda M. Muhammad, Nahida HA. Ahmed, Gasha S. Ahmed, Fahmi H. Kakamad, Sabah J. Hasan, Berun A....
Abstract
Pregnant women represent a vulnerable population due to their altered immune response, potentially leading to increased susceptibility and severity of infections. The COVID-19 infection might increase the risk of adverse pregnancy outcomes in this population, however, to date, it has not been established whether SARS-CoV-2 infection leads to these outcomes as differing conclusions have been made by the published studies and reviews. This comprehensive review explores the impact of COVID-19 on pregnancy outcomes, encompassing maternal, fetal, and neonatal health. The current literature reports higher rates of adverse maternal outcomes among pregnant women with COVID-19, this includes increased rates of cesarean section, preeclampsia, and elevated risk of intensive care unit (ICU) admission and maternal death. Fetal and neonatal outcomes are also influenced by COVID-19 infection during pregnancy. Findings suggest an elevated risk of preterm birth, low birth weight, stillbirth, and Neonatal ICU admissions among newborns of mothers with COVID-19. The emergence of SARS-CoV-2 variants, such as the Delta variant, raises concerns about their potential impact on more adverse outcomes compared to the wild type. Vaccination has demonstrated safety and efficacy in pregnant women, providing a potential preventive measure against COVID-19. However, the potential impact of vaccination on adverse pregnancy outcomes requires further investigation. To address current knowledge gaps, future research should also focus on long-term effects, fertility considerations, child development, and the impact of emerging variants.
Hydatid Cysts of the Bladder: A Systematic Review of the Literature
Ranj A. Hasan, Fakher Abdullah, Bokan Talib Saeed
Abstract
Introduction
Hydatid cysts mainly involve the liver and lungs, other areas may rarely be affected by the disease. Urinary bladder hydatid cysts are extremely rare. The aim of this study is to review hydatid cysts of the bladder.
Methods
We conducted a systematic literature search using various PubMed, Scopus, Web of Science, and Google Scholar were explored to identify papers that discussed hydatid cysts in the urinary bladder. Studies with incomplete reports or insufficient data were excluded, as were those published in predatory journals. The studies were identified through both electronic and manual searches. Sociodemographic and clinical data were extracted and discussed.
Results
The study included 122 articles, 6 studies were for full assessment and review. Seven cases were found in the papers, 4 patients (57%) were female, and 3 patients (43%) were male. Surgical intervention was the mainstay of the management without significant complications.
Conclusion
Bladder hydatid cyst is a rare condition with few reported cases. It presents a diagnostic challenge to the physician. Surgical intervention is the best management option.
Nsren Sharef Sabr, Fakher Abdullah, Hiwa Shafiq Namiq, Nashaddin A. Mohammed, Zardasht Mahmud Ahamed, Abdullah K. Ghafour, Saywan Kakarash Asaad, Fahmi H. Kakamad, Ayoob Asaad Mohammed Abid, Diyar A. Omer, Suhaib H. Kakamad, Soran H. Tahir, Berun A. Abdalla, Choman Sabah Omer, Rezheen J. Rashid
Neurogenic thoracic outlet syndrome (nTOS), characterized by brachial plexus compression within the thoracic outlet, poses diagnostic challenges due to its variable symptoms and lack of standardized criteria. Ultrasound has emerged as a valuable diagnostic tool, offering dynamic imaging, high-resolution visualization of soft tissues, and differentiation between neurogenic and vascular forms. We reviewed the literature regarding ultrasound's role in nTOS diagnosis. Ultrasound's dynamic assessment aids in understanding nerve and vessel compression during arm movements, providing insights beyond static imaging. High-resolution imaging detects structural anomalies contributing to nTOS and reveals direct and indirect signs, such as brachial plexus or vessel compression. Varied findings exist regarding ultrasound sensitivity and specificity. Despite potential benefits, controversy remains, highlighting the need for further research to establish standardized protocols, refine techniques, and explore integrated diagnostic approaches for nTOS.
Abdulwahid M. Salih, Shko H. Hassan, Rezheen J. Rashid, Zanyar A. Mohammed, Ahmed L. Ali, Ahmad H. Awakhti, Marwan N. Hassan, Berun A. Abdalla, Fahmi H. Kakamad
Self-Induced Pneumoparotid as a Result of Covering Mouth While Coughing: A Case Report
Abdulwahid M. Salih, Shko H. Hassan, Rezheen J. Rashid, Zanyar A. Mohammed, Ahmed L. Ali, Ahmad...
Abstract
Introduction
Pneumoparotid is a rare condition characterized by the presence of air in the parotid gland, usually caused by the retrograde flow of air through the parotid duct. This report presents a rare occurrence of self-induced pneumoparotid.
Case presentation
A-41-year-old female presented with a recurrent painless right-sided parotid gland swelling for one month. She reported covering her mouth with her hands while coughing. Clinical examination revealed a right parotid swelling inferior to her right ear. The mass was non-tender and compressible. The neck and skull base computed tomography with contrast revealed a large thin wall cystic space with small air bubbles in the course of Stenson's duct. The patient underwent conservative management with good outcome.
Conclusion
Pneumoparotid is an extremely uncommon condition characterized by the presence of air in the parotid gland. Diagnostic imaging techniques such as ultrasound, sialography, or CT scans are valuable in confirming the diagnosis.
Soran Mohammed Gharib, Swara Ali Mawlud, Shaho F. Ahmed, Zana B. Najmadden, Aland Salih Abdullah, Dana T. Gharib, Hoshmad R. Asaad, Berun A. Abdalla, Fahmi H. Kakamad
Soran Mohammed Gharib, Swara Ali Mawlud, Shaho F. Ahmed, Zana B. Najmadden, Aland Salih Abdullah,...
Abstract
Introduction
Bartter syndrome is a rare genetically inherited salt-wasting disorder that is typically seen in children and neonates with association to many morbidities. We present a case of Bartter syndrome in an adult who showed excellent response to treatment.
Case presentation
The patient was a 23-year-old male presenting with polyuria, polydipsia, nocturia, and fatigue, especially within the lower limbs for the last two years but no history of vomiting. He was clinically diagnosed with Bartter syndrome and received conservative management with a good response.
Conclusion
Bartter syndrome is a rare disease. It has a wide range of clinical presentations. It can be diagnosed clinically and confirmed by genetic testing. Conservative management has a good clinical outcome.
Wirya N. Sabr, Rawa M. Ali, Ali H. Hasan, Hadeel A. Yasseen, Dlsoz M. Hussein, Zana B. Najmadden, Fahmi H. Kakamad, Berun A. Abdalla, Sasan M. Ahmed, Shvan H. Mohammed
Pulmonary Sequestration and Congenital Pulmonary Airway Malformation (CPAM) 1 Presented as A Left Suprarenal Mass:ACase Report
Wirya N. Sabr, Rawa M. Ali, Ali H. Hasan, Hadeel A. Yasseen, Dlsoz M. Hussein, Zana B. Najmadden,...
Abstract
Introduction
Pulmonary sequestration is a rare condition accounting for 0.1% to 6% of all congenital lung malformations. The correlation with Congenital Pulmonary Airway Malformation (CPAM) type 1 has not been adequately elucidated.
Case presentation
From routine fetal sonographic screening, a 20-day-old female baby's ultrasound revealed hydronephrosis with enlargement above the left kidney. Magnetic resonance imaging during a follow-up appointment uncovered a left suprarenal lesion of approximately 30 mm, which was not suspected to be adrenal neuroblastoma. After resection, histological analysis was consistent with pulmonary sequestration and confirmed the connection with CPAM type 1.
Conclusion
Surgery remains the only effective therapeutic choice for intra-abdominal pulmonary sequestration. The definitive diagnosis is confirmed through histological examination.
Wirya N. Sabr, Marwan N. Hassan, Yadgar A. Saeed, Hardi M. Dhahir, Aso S. Muhialdeen, Zanyar A. Mohammed, Fahmi H. Kakamad, Abdulwahid M. Salih, Zana B. Najmadden, Shko H. Hassan
Infraorbital Myofibroma of Infra-orbital Region: A Rare Case Report
Wirya N. Sabr, Marwan N. Hassan, Yadgar A. Saeed, Hardi M. Dhahir, Aso S. Muhialdeen, Zanyar A....
Abstract
Introduction
Infantile myofibroma is a rare tumor of myofibroblastic origin that can affect soft tissue, bones, or internal organs. The aim of the current study is to report a rare case of a solitary infra-orbital infantile myofibroma.
Case presentation
An 11-month-girl presented with progressive swelling of the left infra-ocular region for two weeks. On examination, there was a well-defined swelling with a localized border that was firm, non-mobile, tender, fixed to the underlying bone, and non-adherent to the superficial skin. Under general anesthesia, the right infraorbital mass was excised. The wound was closed by layers, and the histopathological examination revealed a 3 cm myofibroblastic mass that invaded the margins at multiple spots.
Conclusion
Infraorbital myofibroma is an extremely rare type of myofibroma. Excision with primary closure is the definitive management therapy.
Pituitary Stalk Interruption Syndrome in a Child: A Rare Case Report with Literature Review
Honar O. Kareem, Bilal A. Mohammed, Karzan M. Hasan, Shaho F. Ahmed, Fahmi H. Kakamad, Hawbash M....
Abstract
Introduction
Pituitary stalk interruption syndrome is an exceedingly rare congenital abnormality affecting the pituitary gland that is still not fully understood. This study presents a 7-year-old child with the disease.
Case presentation
A 7-year-old male child was presented with short stature, school performance postponement, and an intellectual disability at a mild level. At 6.5 years of age, he had no facial features, was wearing eyeglasses, and had a weight and height of 20 kg (25th percentile) and 101 cm (3rd percentile), respectively. At the age of 7 years, his height was 117 cm (10th percentile) and his weight was 25 kg (50th percentile). Most laboratory tests were normal. However, insulin-like growth factor-1 and glucagon levels were low. A dynamic magnetic resonance imaging of the pituitary gland revealed an ectopic posterior pituitary lobe and the absence of a pituitary stalk. The patient was put on hormone replacement therapy (Norditropin pen) to control the growth hormone deficiency, and he was put under a close follow-up to monitor growth and panhypopituitarism.
Conclusion
Although hormone replacement therapy is associated with satisfactory outcomes in treating the syndrome, lifelong follow-up is indicated as new hormone deficiencies may arise later in life.
