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Objectives: The Do-Not-Resuscitate (DNR) order is part of most hospitals' policies on the process of making and communicating decisions about a patient's resuscitation status. Yet it has not become a part of our society's ritual of dying in the Middle East especially among children. Given the diversity of pediatric patients, the DNR order continues to represent a challenge to all parties involved in the care of children including the medical team and the family. Methods: This was a retrospective review of the medical charts of patients who had died in the pediatric intensive care unit (PICU) of a tertiary academic institution in Beirut, Lebanon within the period of January 2012 and December 2017. Results: Eighty-two charts were extracted, 79 were included in the analysis. Three were excluded as one patient had died in the Emergency Department (ED) and 2 charts were incomplete. Most patients were male, Lebanese, and from Muslim families. These patients clinically presented with primary cardiac and oncological diseases or were admitted from the ED with respiratory distress or from the operating room for post-operative management. The primary cause of death was multiorgan failure and cardiac arrest. Only 34% of families had agreed to a DNR order prior to death and 10% suggested "soft" resuscitation. Most discussions were held in the presence of the parents, the PICU team and the patient's primary physician. Conclusions: The DNR order presents one of the most difficult challenges for all care providers involved, especially within a culturally conservative setting such as Lebanon. As the numbers suggest, it is difficult for parents to reach the decision to completely withhold resuscitative measures for pediatric patients, instead opting for "soft" resuscitations like administering epinephrine without chest compressions.

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Thyroid dysfunction (TD) is a very common entity in clinical practice nowadays. Prevalence may be underestimated because of the limitations of epidemiological studies. There are mainly genetic and environmental factors that interact on thyroid function. Genetic factors are extensively described in literature but molecular advance on the field may change older classifications based on B-cell or T-cell mediated disorders. The dominant pattern of inheritance makes family predisposition a relevant question in patient medical history but clinical research show that immune system is not enough to cause overt dysfunction. The role of environmental factors generates debate on medical literature. Some classic factors as iodine intake are well characterized but others as fetal microhimerism or new antineoplastic agents are less known. A review of medical literature on thyroid dysfunction has been performed and genetic and environmental factors are described in this article.

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Ever since the introduction of suction-assisted lipectomy in the United States in 1981, the technique has been applied to an increasing number of disorders of the subcutaneous tissues. Indeed, suction-assisted lipectomy has evolved into the method of choice in the treatment of certain pathological entities. While the extraction of lipomas is the most common functional application, suction-assisted lipectomy has also been used successfully to treat such conditions as gynecomastia, axillary hyperhidrosis, benign symmetric lipomatosis (Madelung's disease), congenital body asymmetry, congenital or acquired lymphedema, flap defatting, traumatic or postoperative hematomas, and fat necrosis. We have successfully treated patients presenting with the above disorders. No morbidities or mortalities were encountered in our series of 18 patients. The final results were considered favorable by the majority of patients. Acceptance by the patients of this treatment modality was extremely high because of the smaller incisions required, the exactness in contouring, the simple and minimal postoperative care needed, and the ease with which the procedure can be repeated to refine the results. A comprehensive review of the literature is presented along with our own patient management and long-term results.

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The treatment of patients with differentiated carcinoma of the thyroid is a controversial subject. This article discusses the authors' approach in the clinical practice. A description of the various types of papillary and follicular carcinoma is presented. Diagnostic tests, biologic behavior, and management are reviewed.

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Congenital preauricular sinuses must not be considered trivial lesions. They can and should be differentiated from branchial cleft cysts. Cure is achieved only through complete excision of the sinus tract and its associated cysts. Total extirpation of the sinus tract is difficult in the presence of infection. The embryoanatomy and treatment of congenital preauricular sinus tracts as well as our experience with 6 patients are reported. We recommend excision of asymptomatic congenital preauricular sinus tracts.

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Congenital epulis is a benign tumor with no potential for growth following birth. Because of the tumor's rarity, few clinical and laboratory studies have been done. A search of the medical literature published in English revealed that congenital epulis occurs most often in female infants; only seven cases have been reported in male infants. We report a case of congenital epulis in a male infant.

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