A great wealth of information is hidden amid medical research data that in some cases cannot be easily analyzed, if at all, using classical statistical methods. Inspired by nature, metaheuristic algorithms have been developed to offer optimal or near-optimal solutions to complex data analysis and decision-making tasks in a reasonable time. Due to their powerful features, metaheuristic algorithms have frequently been used in other fields of sciences. In medicine, however, the use of these algorithms are not known by physicians who may well benefit by applying them to solve complex medical problems. Therefore, in this paper, we introduce the genetic algorithm and its applications in medicine. The use of the genetic algorithm has promising implications in various medical specialties including radiology, radiotherapy, oncology, pediatrics, cardiology, endocrinology, surgery, obstetrics and gynecology, pulmonology, infectious diseases, orthopedics, rehabilitation medicine, neurology, pharmacotherapy, and health care management. This review introduces the applications of the genetic algorithm in disease screening, diagnosis, treatment planning, pharmacovigilance, prognosis, and health care management, and enables physicians to envision possible applications of this metaheuristic method in their medical career.

Objectives: Empty follicle syndrome (EFS), although rare, is a disappointing condition in which no oocytes are retrieved from mature follicle after ovulation induction in in vitro fertilization (IVF) cycles. The aim of this study was to estimate the incidence and factors associated with EFS. Methods: All cycles resulting in EFS from May 2012 to September 2013 were retrospectively identified at a tertiary referral infertility center. Among the 3,356 cycles performed, 58 (1.7%) women who underwent their first IVF cycle and had no oocyte retrieval were enrolled in the study. Three different stimulation protocols (long, antagonist, and miniflare) were mainly used for induction of follicular growth. Data relating to the age, follicle stimulating hormone (FSH) level, anti-Müllerain hormone (AMH) level, and the number of ampules and follicles for each patient was obtained. Results: Out of 58 individuals, 10 (17.2%) showed false type and 48 (82.8%) showed genuine EFS. The most frequent findings in our study were diminished ovarian reserve, low anti-Müllerian hormone (AMH; ≤0.5 ng/mL), and less than four mature follicles, indicating EFS in 1.7% of the patients. Conclusion:  Low serum AMH levels and a small number of follicles after ovarian stimulation is the manifestation of diminished ovarian reserve. Thus, we suggest that EFS could be a manifestation of low ovarian reserve.

Objectives: Parathyroid carcinoma (PC) is a rare parathyroid tumor compared to parathyroid adenoma (PA) and atypical parathyroid adenoma (APA). Recent studies have suggested parafibromin has a role in the differential diagnosis of parathyroid tumors. We sought to determine the role of parafibromin as well as galectin-3, Ki-67, and HBME-1 as diagnostic markers in the differential diagnosis of parathyroid tumors. Methods: A total of 92 cases diagnosed with PA, APA, or PC at Sifa University and Private Ege Pathology Laboratory between 2006–2012 were included in the study. Parafibromin (microarray), galectin-3, Ki-67, and HBME-1 were evaluated using immunohistochemistry in all parathyroid tumors. Results: Eighty-four cases were diagnosed with PA, six with APA, and two with PC. The study group consisted of 82 females and 10 males. Their mean age was 50.9 years, and the mean tumor diameter was 1.97 cm. Parafibromin was negative in the two PC cases but positive in all APA and PA cases. Positivity was observed with galectin-3 in 17 adenoma cases, three atypical adenomas, and two carcinoma cases. Positivity with HBME-1 was found in 26 PA cases and one PC case. Parafibromin and galectin-3 expression was significant between the three tumor groups but not for HBME-1 expression. Parafibromin expression increased in PA whereas galectin-3 expression decreased. A statistical significance was found between the three tumor groups according to the Ki-67 score (p=0.010). Additionally, the Ki-67 proliferation index was under 1% in PAs. Conclusion: The number of PCs in our series was small so our data mostly reflects the immunohistochemical characteristics of PAs. Parafibromin expression, galectin-3 negativity, and a Ki-67 proliferation index under 1% were estimated as beneficial in the differential diagnosis of difficult parathyroid tumors.

Objective: We sought to determine the validity of cancer antigen 125 (CA-125) and the risk of malignancy index (RMI) in the diagnosis of ovarian cancer in women presenting with adnexal lesions of various histopathology types. Methods: This retrospective cross- sectional study included all women with adnexal lesions who were evaluated at the Royal Hospital, Oman, between January 2012 and December 2014. The inclusion criteria included women who underwent surgical intervention and who had preoperative CA-125 testing and pelvic ultrasound in the work-up plan of their management. The surgical intervention was usually followed by a histopathological diagnosis of the nature of the lesion, which was used as the gold standard for the evaluation of both CA-125 and RMI. Results: The cohort included 361 women who had serum CA-125 and pelvic ultrasound prior to the surgical intervention of the adnexal lesion. Of these women, 61 (17%) had malignant ovarian lesions. Using the proposed cut-off 35 U/ml for CA-125 and 200 for RMI, the CA-125 test was more sensitive for detecting the majority of malignant ovarian tumors compared to the RMI (69% vs. 57%). Both tests were more sensitive in detecting epithelial ovarian cancer compared to other ovarian cancers. However, RMI was more specific in excluding benign ovarian lesions compared to CA-125 (81% vs. 68%). Additionally, RMI had a better area under the curve compared to CA-125 (0.771 vs. 0.745; p<0.005). Lowering the RMI cut-off to 150 resulted in a better sensitivity (62% vs. 57%) and had an acceptable specificity (78% vs. 81%) compared to a cut-off of 200. Conclusion: Both CA-125 and RMI have good validity in the diagnosis of ovarian tumors. CA-125 has higher sensitivity; however, RMI has higher specificity. In combination, CA-125 might be more valid for the diagnosis of malignant ovarian cancer while RMI is more valid for excluding the diagnosis of these tumors. Differential use of these two tools will improve the triage of women with suspected ovarian tumors since both are measured in their work-up. We recommended the use of both tools in primary care to reduce referral to gynecology or oncology units.

Objective: Sinonasal tumors are a highly heterogeneous group of tumors that account for less than 1% of all cancers. Precise diagnosis is essential because the natural history, treatment, and prognosis vary for different neoplasms. We reviewed 610 cases of sinonasal lesions to understand this entity better. Methods: A total of 610 sinonasal biopsies/specimens were received over a period of 10 years (2004–14). All the samples were processed and stained with hematoxylin and eosin. Special staining for microorganisms and immunohistochemistry were performed where indicated. Results: Benign lesions were 72% with nasal polyp being the most common. Malignant lesions made up 21.2% of lesions with nasopharyngeal carcinoma being the most common while 7.7% cases were inflammatory/non-neoplastic. The most common cause for this was fungal sinusitis. The maxillary sinus was the most frequently involved site in all the lesions (62%). The average age of presentation was 40 years old, and the male to female ratio was 3:1 in those with benign tumors. The average age of presentation in the malignant and inflammatory group were 45 and 43 years, respectively, with an almost equal sex ratio in both categories. Computed tomography and magnetic resonance imaging scans were done in virtually all cases to assess the extent of the tumor as well as bony destruction. Local recurrence was the most frequent cause of treatment failure. Conclusion: Tumors of the nasal cavity are often grouped with those in the paranasal sinuses. Benign tumors constituted approximately 75% of tumors in our hospital. Squamous cell carcinoma was the most common malignancy of this region. These tumors need to be studied closely and accurately because their proximity to vital structures pose significant challenges for their treatment and may be the source of significant patient morbidity.

Objectives: Pressure ulcers are a multifactorial, prevalent, and preventable morbidity. They cause a burden both financially and emotionally, to the individual, their family and doctor, and to society as a whole. Pressure ulcers are extremely difficult to treat; therefore, prevention is key. Methods: We started a Wound Care Surveillance Program in 2012 involving nurses, physiotherapists, and doctors. We intended to prevent the occurrence of pressure ulcers, ensure early detection, and facilitate the healing process. The Braden scale was used to stratify patients’ risk. The number of patients observed in our study was 2,974 over a one-year period. Results: The pressure sore prevalence was 3.1%. Younger and middle-aged patients were most commonly affected; 27% of these patients did not survive. Mortality was not attributed to the pressure ulcer directly. The most common mode of injury was road traffic accidents. Most of our patients had just a single pressure area affected, most commonly the sacrum. Most patients were managed with debridement and dressings while 12% received surgical treatment. Of those with stage one ulcers, 29% healed completely at two months. In stage two and three patients, 17% and 6% healed in two months, respectively, and this number was zero in stage four patients. Conclusion: The Wound Care Surveillance Program has been a very effective strategy for the prevention and management of pressure ulcers. Stage two ulcers were the most common in our setup. Braden scoring, traditionally used to screen these ulcers, can be used as a predictive and prognostic tool to predict healing of pressure ulcers. Poor healing is expected in higher staged ulcers and patients with spinal injury and major solid organ injury and those who need a tracheostomy. Home-based care is not up to mark in our society and accounts for most of the cases in the follow-up.

Objectives: There is evidence to support the correlation between a stronger sense of coherence (SOC) and better perceived quality of life (QOL). However, this association has not been described among Iranian students.  Methods: Students were selected by stratified randomization and demographic data including age, gender, and employment status were collected. SOC was measured using the short-form of the Sense of Coherence Scale (SOC-13). The World Health Organization Quality of Life (WHOQOL)-BREF questionnaire was used to assess the QOL. Data was collected over one year between 2014 and 2015.  Results: A total of 459 students participated in the study. The Cronbach’s alpha score in domains of physical health, psychological health, environmental health, social relationships, and WHOQOL-BREF total score were 0.84, 0.83, 0.84, 0.78, and 0.94, respectively. Measured Cronbach’s alpha for domains of meaningfulness, manageability, comprehensibility, and SOC-13 total score were 0.68, 0.67, 0.76, and 0.87, respectively. Marital status was not related to SOC whereas married students had significantly higher scores of QOL in the domains of psychological health, social relationships, and environment health (p=0.006, p<0.0001 and p=0.043, respectively). There were significant strong positive relationships between all components of SOC (meaningfulness, manageability, and comprehensibility) and all domains of WHOQOF-BREF (p<0.0001 for all).  Conclusion: This study shows that SOC and marital status are significant predictors of QOL among Iranian students.

Objectives: Squamous cell carcinoma (SCC) is the most common oral malignancy, and verrucous carcinoma (VC) is a less invasive type of SCC. Leukoplakia (LP) is the most frequent premalignant lesion in the oral cavity. The human papillomavirus (HPV) has been recognized as one of the etiologic factors of these conditions. The association of anogenital and cervical cancers with HPV particularly its high-risk subtypes (HPV HR) has been demonstrated. The purpose of our study was to investigate the hypothetical association between HPV and the mentioned oral cavity lesions. Methods: One hundred and seventy-three samples (114 SCCs, 21 VCs, 20 LPs) and 18 normal mucosa samples (as a control group) were retrieved from the Department of Oral and Maxillofacial Pathology of Mashhad Dental School, Iran. The association of HPV genotypes in LP, VC, and SCC was compared to normal oral mucosa using the polymerase chain reaction. Results: The results showed the absence of HPV in normal mucosa and LP lesions. In three samples of VC (14.3%), we observed the presence of HPV HR (types 16 and 18). All VCs were present in the mandibular ridge of females aged over 65 years old. No statistically significant correlation between HPV and VC was observed (p=0.230). Additionally, 15 (13.1%) SCCs showed HPV positivity, but this was not significant (p=0.830). The prevalence of SCC was higher on the tongue with the dominant presence of less carcinogenic species of HPV (types 6 and 11). A statistically significant association was not observed between HPV and SCC or VC in the oral cavity. Conclusions: More studies are necessary to better understand the relationship between HPV and malignant/premalignant oral cavity lesions.

Objectives: Tumors and tumor-like lesions (TLL) of the paratesticular region are rare. Very few studies depicting the spectrum of lesions of this location are available in the literature. Malignant neoplasms arising in the paratesticular region represent only 7.0% of malignant tumors presenting as a scrotal mass. TLL and benign tumors are of great interest, because of their topography they can simulate a neoplasm in the paratesticular structures. We sought to study the incidence, nature, pattern, clinical, immune, and histopathological characteristics of tumors and TLL of the paratestis. Methods: In this six-year study, records of the cases were reviewed and the histopathology slides were reassessed. Blocks were retrieved and stained immunohistochemically for relevant markers. Results: A total of 47 cases of tumor and TLL of the paratestis were diagnosed over a six-year period. The patients ranged from one to 76 years old and most presented with a scrotal mass. Of these, seven (14.9%) were benign. Lipoma was the most common benign tumor. One case each of adenomatoid tumor, scrotal hemangioma, solitary fibrous tumor, and papillary cyst adenoma were reported. The TLL (70.2%) comprised of 17 cases of epididymal cyst, seven cases of tuberculous epididymitis, four cases of filarial epididymitis, two cases each of non-specific granulomatous epididymitis and fibromatous periorchitis, and one case of mesothelial cyst. Seven malignant tumors (14.9%) were diagnosed all of which were sarcomas. All seven were primary to the paratesticular region. The most common malignant tumor was embryonal rhabdomyosarcoma. One case each of malignant mesothelioma, malignant fibrous histiocytoma, atypical lipomatous tumor/well-differentiated liposarcoma, and myxoid liposarcoma were identified. Conclusion: Neoplasms of the paratesticular region affect patients of all ages, with potentially life-threatening sequelae. Awareness of the entire spectrum and meticulous histopathological examination and immunohistochemical studies are of prime importance in the diagnosis of the various lesions as these influence the mode of therapy and subsequent prognosis of the patient.

Esophageal duplication is the second most common site of gastrointestinal duplication and most cases present with complications. These complications include bleeding, infection, dysphagia, and dyspnea. We report an incidental case of a true intramural esophageal duplication cyst in a new military recruit. The patient was diagnosed in Armed Forces Hospital, Oman. The patient came for a pre-recruitment routine check-up, he was found to have a suspicious soft tissue lesion on chest X-ray. He was referred to the thoracic surgeon for further investigations. The investigations included computed tomography and magnetic resonance imaging chest scans, barium swallow, endoscopy and, finally, an endoscopic ultrasound. All workup pointed to a diagnosis of esophageal duplication cyst; therefore, the decision was made to excise the lesion after discussion with the patient about the possible diagnosis and nature of the treatment. The cyst was completely excised thoracoscopically with uneventful recovery. The patient was discharged a few days later and was doing well in subsequent visits to the outpatient department. The histopathological exam confirmed the diagnosis of a true congenital duplication cyst, which was lined by pseudostratified ciliated columnar epithelium overlying double layers of thick bundles of smooth muscle fibers.

Ischemic stroke following cardiac surgery is one of the devastating complications that surgeons may encounter, and may lead to serious disabilities for the patient. The clinical course of such a complication may be prolonged if it is not treated properly. Making a quick decision when choosing a revascularization method is very helpful in this matter. Effective treatment options are usually limited. Neurointerventional maneuvers have recently emerged as a possible therapeutic modality in this field. We present the case of a 52-year-old woman who had open heart surgery in Queen Alia Heart Institute, Jordan, to replace a severely stenotic rheumatic mitral valve and repair a leaking tricuspid valve. Her surgery went smoothly with no major event. However, she developed a massive ischemic stroke during her recovery period despite being on adequate anticoagulation therapy. Urgent radiological work-up confirmed the diagnosis of ischemic stroke in the territory of the right middle cerebral artery. We chose a neuro-interventional method for her treatment, and mechanical thrombectomy was performed with a successful outcome and no apparent complications.

A young female patient presenting with recurrent hemoptysis, neck swelling, and mediastinal mass mimicking lymphadenopathy was admitted to the Institute of Post Graduate Medical Education and Research and SSKM hospital, Kolkata, India. Clinical features, radiological studies, fibre optic bronchoscopy, and fine needle aspiration cytology from the neck swelling created a diagnostic dilemma until surgical resection and immunohistochemistry reports confirmed the diagnosis of multifocal epithelioid hemangioendothelioma, a rare vascular tumor with intermediate malignancy potential. Because it is a slow-progressing disease and due to the non-availability of standard chemotherapy, the patient, and her legal guardian, opted for palliative care only. She was asymptomatic for four years but again presented with hemoptysis, reappearance of the neck swelling on the same side, and a mediastinal mass compressing the superior vena cava and right pulmonary artery. This report describes the diagnostic problems and therapeutic challenges in the management of this rare tumor over a four-year follow-up period. The clinical course emphasizes the highly unpredictable nature of this tumor.

A solid pseudopapillary neoplasm is a rare pancreatic tumor accounting for 1–2% of exocrine pancreatic neoplasms. It is usually asymptomatic and discovered incidentally. It is mainly seen in young women between the second and third decades of life. Although it usually has a large size at the time of diagnosis, it is considered to have low malignant potential. Solid pseudopapillary tumors (SPTs) have characteristic magnetic resonance imaging (MRI) features that enable it to be differentiated from other more common pancreatic tumors.  Here, we report the case of a 34-year-old pregnant woman who was admitted to The Royal Hospital, Oman, with a large mass in her pancreas, which was incidentally discovered during abdominal ultrasonography. The mass was investigated further with MRI. The MRI revealed a well-defined mass related to the tail and body of the pancreas with solid and cystic components. It had a heterogeneous texture with fluid levels of different signal intensities due to the presence of blood of different ages.  The cystic-solid appearance of an encapsulated lesion with characteristic signal intensity on MRI suggested the possibility of a SPT. Postoperative histopathology results confirmed the diagnosis of a SPT. In this case report, we highlight the MRI features of a SPT and discuss how to differentiate it from other cystic pancreatic tumors to increase the awareness of clinicians to this rare pancreatic tumor.