Antifungals in a case of basidiobolomycosis: role and limitations.

A 10-year-old Saudi boy was diagnosed to have basidiobolomycosis after a stormy course of his ailment. Therapy was initiated with intravenous antifungal, voriconazole, which was well tolerated for 6 weeks except for local excoriation at the site of ileostomy. He developed drug-induced hepatitis on oral voriconazole, therefore, switched to oral itraconazole following which he experienced severe chest pain. Alternatively, co-trimoxazole (bactrim) an antibacterial with antifungal activity was prescribed but he had the intolerance to it as well. Unfortunately, posaconazole as an alternative antifungal was not available in our centre. We report here a Saudi boy who developed an intolerance to most common antifungals used clinically 6 weeks after the therapy was initiated.

Efficacy and safety of endoscopic dilatation in the management of esophageal strictures in children.

OBJECTIVES: To determine the outcomes  of endoscopic dilatation of esophageal strictures in children. METHODS: Children younger than 18 years of age diagnosed with esophageal strictures over a period of 7 years (June 2010 to June 2017) were reviewed and analyzed retrospectively. The study took place at King Khalid University Hospital, Riyadh, Saudi Arabia. The patients' clinical characteristics, endoscopic findings, and details of the strictures, treatment, and outcomes were documented. RESULTS: Forty-three children with esophageal strictures were identified (median age, 8.1 years; range, 2-17 years; 23 [53.5%] boys). The median age at presentation was 2 years (range, 1-16 years), and the median follow-up period was 3 years (range, one month-17 years). Tracheoesophageal fistula (n=14, 32.6%), gastroesophageal reflux disease (n=10, 23.3%) and eosinophilic esophagitis (n=8, 18.6%) were the leading causes of esophageal strictures. Forty-three patients underwent 180 dilatation sessions; the median number of dilatation sessions per patient was 3 (range, 1-48), and the median interval between sessions was 8 weeks (range, 1-24 weeks). Among 180 dilatation sessions, 3 events (1.7%) of esophageal perforation were observed. The outcomes varied depending on the primary cause of the stricture; complete response was achieved the best in eosinophilic esophagitis-related strictures (87.5%), followed by anastomotic strictures post tracheoesophageal fistula repair (71.4%) and gastroesophageal reflux disease-related strictures (70%). CONCLUSION: Endoscopic dilatation is a safe and effective intervention in the management of esophageal strictures in children, with minimal complications when conducted by experts.

Trend, clinical presentations and diagnosis of eosinophilic esophagitis in Saudi children.

OBJECTIVES: To observe the frequency of eosinophilic esophagitis (EoE), pattern of clinical presentation and diagnosis among Saudi children at 2 tertiary carehospitals in Riyadh, Saudi Arabia. METHODS: The database of children admitted or seen, and aged less than 18 years over 5 years period and diagnosed with EoE was collected and reviewed. Patients with esophagitis other than EoE were excluded. Patients who had eosinophils count more than 15/high power field (HPF) on esophageal biopsies were given the diagnosis of EoE. Demographic database, clinical parameters, and diagnostic modalities were analyzed by using the Statistical Package for Social Sciences version 22. RESULTS: A total of 37 children with the diagnosis of EoE were gathered from 398 upper gastrointestinal endoscopic procedures with the frequency of 9.3%. There were 22 (59.4%) males with a mean±SD age of 9.6±2.3 years and all were Saudi nationals. Dysphagia was the leading presentation in 21 (56.7%) children followed by vomiting in 18 (48.6%), impaction of food bolus in 8 (21.6%) and foreign body in 3 (8.1%). Allergic symptoms were present in 13 (35.1%) children in the form of asthma, 11 (29.7%) multiple food allergies and 5 (13.5%) eczema. Peripheral eosinophil count and immunoglobulin E were raised more than normal in 6 and 5 children respectively. The pH measurements were carried out in 16 (43.2%) and ruled out the reflux. Contrast studies with barium (n=6; 16.2%) and endoscopic findings were significant (n=27; 72.9%). CONCLUSION: Eosinophilic esophagitis is an emerging disease and have a rising trend in Saudi children. Dysphagia, vomiting, and food impaction are the more common presenting features in older children and recurrent vomiting in younger children in addition to associated allergic conditions.

Pre-illness diet as risk factor in pediatric inflammatory bowel disease in Saudi Arabia.

BACKGROUND/AIM: Inflammatory bowel disease (IBD) is increasing in Saudi Arabia but there's little knowledge about its risk factors. Our aim is to investigate the dietary risk factors of this disease in Saudi children. PATIENTS AND METHODS: The children investigated for IBD were prospectively enrolled. Those with confirmed IBD were designated cases and the others were controls. The average food frequency intake at least 3 months before onset of illness was obtained by direct interview and recorded on a modified food frequency questionnaire. Fast food, sweet gaseous soft drinks, fruits, and vegetables were selected. Statistical analysis included descriptive statistics, multivariate logistic regression was used, and the odds ratio was calculated to report the statistical significance of the results. RESULTS: A total of 91 children, 52 IBD (38 CD, 14 UC) and 39 controls were enrolled. Consumption of fast food and sweet gaseous drinks was more frequent in children with IBD than controls, whereas consumption of fruits and vegetables was less frequent in children with IBD. Only less fruits consumption was significantly associated with IBD as the odds of children getting IBD was 2.89 (1.06, 7.87). CONCLUSIONS: We report statistically significant positive association between less fruits consumption and IBD. Awaiting the results of larger sample size and more quantitative studies, the benefits of frequent fruit consumptions should be part of public health education.

Substantial reduction in hospital stay of children and adolescents with diabetic ketoacidosis after implementation of Clinical Practice Guidelines in a university hospital in Saudi Arabia.

RATIONALE, AIMS AND OBJECTIVES: We aimed to determine the effect of Clinical Practice Guideline (CPG) implementation on length of hospital stay of children and adolescents with diabetic ketoacidosis (DKA). METHODS: This was a 6-year (2008-2014) case-control retrospective study conducted at King Khalid University Hospital, Riyadh, that compared patients with DKA managed using CPG with those treated before CPG implementation. RESULTS: There were 63 episodes of DKA in 41 patients managed using CPG compared with 40 episodes in 33 patients treated before implementation of CPG. Baseline characteristics of the 2 groups were similar (age, sex, newly diagnosed patients, recurrent DKA, DKA severity, and mean glycosylated hemoglobin). The mean length of hospital stay (±SD) was 68.6 ± 53.1 hours after implementation of CPG compared with 107.4 ± 65.6 hours before implementation (P < .001). The reduction in length of hospital stay equals to 1700 bed days saved per year per 1000 patients. CONCLUSIONS: Implementation of CPG for DKA decreased the length of hospital stay.

Nasogastric Tube Placement in Newborns Before Discharge.

The aim of this study was to assess the knowledge of medical staff (physicians) at different levels about insertion or placement of nasogastric tube (NGT) in a normal newborn before discharge. It was a survey-based, observational study conducted at King Khalid University Hospital. Atotal of 103 doctors were sent text message; among those 81 (78.6%) responded. Among the respondents, 27, 16, 11 and 27 were neonatologists, general physicians, obstetricians/ ENT/pediatric surgeons, and senior registrars neonatology (SRN), respectively. Majority of physicians, 57 (70.3%) rejected the idea of insertion of NGTin a normal newborn but in 24 (29.6%), answer was to insert NGTin all the newborns before discharge to check the patency of nasal cavities. Regarding the position, region of doctors and their response, majority from Center said &lsquo;No&rsquo;(not in favour of insertion) but from South, 17/18 (94.4%) said &lsquo;Yes&rsquo;(in favour of insertion). Regarding other specialties, majority of them showed rejection of this idea. In conclusion, most of the healthcare professionals, directly involved with neonatal care, rejected the idea of routine insertion of NGTin normal newborn examination before discharge; rather, some non-invasive technique could be opted.

Assessment of knowledge of celiac disease among health care professionals.

OBJECTIVES: To assess knowledge of celiac disease among medical professionals (physicians).   METHODS: We conducted a cross-sectional survey of hospital-based medical staff in primary, secondary, and tertiary care public, and private hospitals in Riyadh, Saudi Arabia (KSA). We carried out the study between January 2013 and January 2104 at King Khalid University Hospital, King Saud University, Riyadh, KSA. A pretested questionnaire was distributed to the potential participants. A scoring system was used to classify the level of knowledge of participants into 3 categories: poor, fair, and good.  RESULTS: A total of 109 physicians completed the survey and of these participants, 86.3% were from public hospitals, and 13.7% from private hospitals; 58.7% were males. Of the physicians, 19.2% had poor knowledge. Interns and residents had fair to good knowledge, but registrars, specialists, and even the consultants were less knowledgeable of celiac disease.   CONCLUSION: Knowledge of celiac disease is poor among a significant number of physicians including consultants, which can potentially lead to delays in diagnosis. Educational programs need to be developed to improve awareness of celiac disease in the health care profession.

Incidence and diagnostic features of eosinophilic esophagitis in a group of children with dysphagia and gastroesophageal reflux disease.

OBJECTIVE: To investigate the incidence and diagnostic features of eosinophilic esophagitis (EoE) in a group of children with dysphagia and gastroesophageal reflux disease. METHODS: This study was designed as a retrospective case analysis of 229 patients who underwent upper gastrointestinal endoscopy between January 2009 and January 2012 at a private tertiary care hospital in Riyadh, Saudi Arabia to ascertain the proportion of patients with eosinophilic esophagitis. RESULTS: Out of 229 children, 14 children were diagnosed as EoE (esophageal eosinophil count more than 15/high power field on esophageal biopsies), but 3 children were excluded because of other associated conditions. There were 8 males and 3 females with a mean age of 8.4 years (<18 years). The major presentation was dysphagia followed by vomiting and epigastric pain. History of allergy and bronchial asthma was present in 40-50% of children. Peripheral eosinophilia was present in 36.3% (range 7-28%). Barium contrast was abnormal in 3 children. Typical ringed (circular) appearance of esophagus was found in 3, linear furrowing in 2, and moderate to severe esophagitis in 8 children. All the patients were managed with swallowed inhaled steroids, except 2 patients who were initially given systemic steroids. CONCLUSION: Eosinophilic esophagitis is not an uncommon manifestation in children with dysphagia, and should be considered as one of the top differential diagnoses in patients with reflux esophagitis.

Presenting features of childhood-onset inflammatory bowel disease in the central region of Saudi Arabia.

OBJECTIVE: To investigate the presenting features of childhood-onset inflammatory bowel disease (IBD) in the central region of Riyadh, Saudi Arabia and to compare with those reported in the literature. METHODS: This is a retrospective review of medical records of children below 18 years of age at onset of symptoms with confirmed diagnosis of IBD for age, gender, family history, presenting clinical and laboratory findings in the Divisions of Pediatric and Adult Gastroenterology, King Khalid University Hospital (which provides free health care) and the Department of Gastroenterology Al Mofarreh Poly Clinic, Riyadh, Saudi Arabia, between January 1993 and December 2010. RESULTS: Two hundred and eighteen children diagnosed with IBD with predominance of males in Crohn's disease (CD) (56%) and females in ulcerative colitis (UC) (59%). There was no significant difference between UC and CD regarding age of onset of symptoms (p=0.347); however, the difference in the age at presentation and age at final diagnosis were significant (p=0.027 and p=0.008). There was a significant increase of IBD diagnosis from the period 1993-2001 to 2002-2010 (p<0.0001). The family history was positive in 15.3%. CONCLUSION: The presenting clinical features and laboratory abnormalities are similar to those reported in other populations. Further studies are needed to establish the incidence and prevalence.

Pattern of celiac disease in infants and children.

This study involved all children with celiac disease admitted and seen in the Paediatric Gastroenterology Clinic at King Khalid University Hospital (KKUH) over a 10-year period. In the first year, we identified 62 cases with celiac disease. Their mean age at presentation, introduction to cereals in the diet, and onset of symptoms were 6.5, 6 and 6 months, respectively, and most of the children belonged to the indigenous population. There were three Arabia families with more than one affected child and most families were of good social status. The main symptoms noted were diarrhoea in 34 (57%), growth failure in 47 (74.6%), abdominal distension in 21 (33%), and vomiting in 14 patients (14%). The significant physical signs at the time of presentation were short stature, seen in 44 patients (69.8%), pallor in 25 (40.3%) and abdominal distention in 21 (33%). The mean haemoglobin, serum feritin, serum folate, calcium, and serum albumin were 10.25 g/dL, 2.49 g/mL, 0.25 ng/mL, 8.86 mg/dL, and 3.7 g/dL. The mean anti-reticulin IgG, anti-endomyseal IgG, IgA and anti-gliadin IgG, IgA were one in 246, 332, 720, 121 and 300 units. There was total villous atrophy in each patient at the time of initial presentation; repeat small bowel biopsies were done in 12 patients of whom 6, 4 and 2 had normal villi, partial villous atrophy and subtotal villous atrophy, respectively. A third biopsy was performed in 2 patients while on gluten containing diet, which revealed villous atrophy. Most of the children improved on gluten-free diet.