Mortality Due to Complications Associated With Acute Ogilvie's Syndrome in an Older Adult Treated for Psychosis: A Case Report.

Acute colonic pseudo-obstruction or Ogilvie's syndrome is a disorder causing massive colonic dilation with no evidence of mechanical obstruction. The actual incidence of acute colonic pseudo-obstruction is unclear; However, electrolyte imbalance, psychiatric disorders, the use of medications such as anticholinergics or antipsychotics, and recent abdominal surgery are the most common predisposing factors associated with this syndrome. Ogilvie's syndrome is most likely caused due to impairment of the gut's motor system and an imbalance of the autonomic nervous system including a reduction in the activity of stimulatory neurotransmitters. The predisposition to psychotic disorders could be, in some instances, due to neurodevelopmental abnormalities of the brain and the gut's autonomic nervous system. The symptoms of Ogilvie's syndrome are similar to mechanical obstruction of the colon but no physical cause of obstruction is usually present. Ogilvie's syndrome can be managed conservatively; however, if left untreated, Ogilvie's syndrome can lead to bowel perforation, which is associated with a high mortality risk. Antipsychotics have been considered the cornerstone treatment for psychiatric disorders including schizophrenia. Even though they are highly effective in treating psychiatric illnesses, their usage carries multiple risks. Overall, constipation is a common side effect of antipsychotic medications with some classes posing more risk than others. Constipation can be severe and may lead to serious complications such as paralytic ileus, bowel ischemia, and death. We present here a case of delusional disorder managed with risperidone and complicated by intestinal pseudo-obstruction. This case reiterates the need to consider all complications of antipsychotic medications, even rare ones, and include them in the discussion with patients and their caregivers before commencement.

Time for a do-not-resuscitate policy? Outcomes of inpatient cardiopulmonary resuscitation in very old patients in Bahrain.

Background: Globally, do-not-resuscitate orders have been used for many years. Due to the lack of a do-not-resuscitate policy, full resuscitative measures including cardiopulmonary resuscitation (CPR) are applied for all patients admitted to our institution regardless of prognosis. Aims: To observe the outcomes of very old patients who underwent CPR, including mortality rate and length of stay. This will allow discussion of the need to implement a do-not-resuscitate policy in Bahrain, and its associated challenges. Methods: This was a retrospective observational study conducted in a 1200-bed tertiary hospital in Bahrain. We included patients aged ≥ 80 years admitted under general medicine who underwent CPR between January and July 2018. Medical records were reviewed for patients' characteristics and outcomes. Results: Ninety patients were included in the study with an average age of 87.91 (6.27) years. The inhospital mortality rate was 96.67%, and 57.78% of patients died immediately after the first CPR attempt and 38.89% died during subsequent attempts. The survival rate at 1-year follow-up was only 1.11%. Conclusion: Survival of very old patients after cardiopulmonary arrest is low, and survival at discharge is even lower. The increase in the very old population will lead to a higher demand for critical care resources given the absence of a do-not-resuscitate policy. Our results demonstrate that implementing such a policy at our institution is crucial to reduce the number of futile CPR attempts, minimizing patients' suffering, and optimizing resource allocation.

Early discontinuation of biological therapy among inflammatory bowel disease patients in Bahrain: Real world experience.

Background: Despite the effectiveness of several biological agents in the treatment of inflammatory bowel disease (IBD), some patients respond better than others. Such discrepancies are often evident early in the treatment course. The aim of this study is to identify the risks and assess the rate of early biological discontinuation (BD) among IBD patients. Methods: In this retrospective cohort study conducted in Bahrain all IBD patients who were administered biological agents between June 2009 and June 2019 were included. Medical records were reviewed to collect study data and confirm IBD diagnoses. Early discontinuation of biological agents was defined by discontinuation of a biological agent (within 6 months from administration). Montreal classification was used to classify Crohn's disease and ulcerative colitis (UC) according to location and extension, respectively. Results: Ineffectiveness was the most common reason for early BD. Early BD was not related to the type of IBD, biological agent used, or to most patient-related factors (such as gender and family history). Patient age at index biological initiation was the only independent significant predictor of early BD (P = 0.045, adjusted odds ratios (95% CI): 1.06 (1.001-1.116)] even after correction of two significant factors: comorbid diabetes and marked weight loss at diagnosis. Conclusion: The older the IBD patient at the time of biological therapy initiation, the higher the incidence of early BD. Therefore, caution and close follow-up are required for biological therapy among elderly patients to assess effectiveness and adverse drug reactions.

Primary hyperparathyroidism caused by an ectopic parathyroid adenoma in an uncommon location: a case report.

Primary hyperparathyroidism caused by an ectopic parathyroid adenoma in the mediastinum is a rare clinical condition. We present a 75-year-old male with primary hyperparathyroidism caused by an ectopic parathyroid adenoma in the mediastinum. This patient was initially referred to the clinic for suspected incidental hypercalcemia. Initial imaging showed two suspicious lesions: one adjacent to the thyroid gland and another in the mediastinum. Further investigations identified a sole mediastinal adenoma. The diagnosis was confirmed by normalization of parathyroid hormone levels after its surgical resection. Thoroughly diagnosing such cases can prove challenging and using a single modality such as ultrasonography, computed tomography, or nuclear imaging alone may not yield conclusive findings or can give false positive results. Our case demonstrates that a combination of several imaging modalities can lead to accurate localization of the cause of primary hyperparathyroidism. This will obviate the performance of unnecessary surgical procedures. In addition, the possibility of missing additional sources of ectopic secretions of the parathyroid hormone will be reduced.

New-Onset Diabetes Mellitus Presenting As Diabetic Ketoacidosis in Patients With COVID-19: A Case Series.

Coronavirus disease 2019 (COVID-19), a 2020 pandemic, has been linked to another global health problem, the diabetes pandemic. Both are existing in a bi-directional association. COVID-19 has been shown to be associated with worse outcomes in those with pre-existing diabetes mellitus. Nevertheless, recent data have emerged highlighting the inter-relationship between new-onset diabetes mellitus and COVID-19. Here, we present four cases admitted to the hospital with newly diagnosed diabetes mellitus associated with COVID-19. We aim to review the available literature regarding the complex association between COVID-19 and new-onset diabetes, causative factors and triggers, treatment strategies, outcomes, and its burden on the health system in general.

A Uniquely Challenging Case of Poorly Controlled Hyperthyroidism With a Coexisting Thyroglossal Cyst.

Hyperthyroidism is a common disease. Thyroglossal duct cysts are also a very common type of congenital anomalies. Their co-existence is, however, rare with only a few cases described in the literature of the same. We describe the case of a 44-year-old female who presented initially 16 years ago with hyperthyroid symptoms related to Graves' disease diagnosed serologically and by thyroid scan and ultrasound. Incidentally, she was also noted to have a non-complicated thyroglossal duct cyst. She was initially started on anti-thyroid medications but remained in a hyperthyroid state throughout most of her illness. Radioiodine ablative therapy and surgical resection were delayed due to the patient's dispreference. After a long period of missed follow up, she presented with a thyroid storm and underwent a total thyroidectomy and cyst resection. The key endocrine issues learned from this case include: 1) dealing with non-compliant patients in terms of poorly controlled hyperthyroidism and refusal to follow the recommended treatment, 2) observing the natural disease progression of untreated Graves' disease coexisting with a thyroglossal duct cyst, and 3) describing a rare incidental finding of a thyroglossal duct cyst coexisting with Graves' disease in the absence of ectopic hormone production. A few cases have described hyperthyroidism related to remnants of thyroid tissue in the thyroglossal duct or related to the thyroid gland. To the best of our knowledge, there are no cases reported of Graves' disease coexisting with a non-complicated thyroglossal duct cyst making our case unique and first of its kind.

Interlobar Pulmonary Hamartoma With an Unusual Neighboring Lesion: A Case Report.

Pulmonary hamartomas are benign lung tumors. They are uncommon and represent a small percentage of all solitary lung lesions. Hamartomas are composed of an abnormal mixture of epithelial and mesenchymal elements. They are usually discovered incidentally as patients are asymptomatic in most cases. On the other hand, sclerosing pneumocytomas are rarely discovered and are one of the most uncommon benign lung tumors. Herein, we present the case of a 37-year-old female who presented with hemoptysis. A computed tomography scan of her thorax revealed a right-sided round lesion in the interlobar fissure with no additional findings. Surgical excision was performed, which demonstrated an uncommon and unique finding of a pulmonary hamartoma coexisting with a sclerosing pneumocytoma found on exploration. This highlights the importance of exploration during surgical procedures in order identify missed lesions on imaging.

Health Care Providers' Attitudes and Beliefs on Providing Palliative Care to Patients in Bahrain: Findings From a Qualitative Study.

CONTEXT: Present studies suggested that cultural and religious factors, as well as law and policy, may have impeded the advancement of palliative care in the Middle East. Little is known about health care providers' perceptions of palliative care and the barriers to its development in the Gulf Cooperation Council. OBJECTIVES: To understand health care professionals' attitudes and beliefs regarding palliative care and highlight current practice barriers in Bahrain. METHODS: Semistructured interviews with 16 health care providers (physicians and nurses) were conducted. Thematic analysis was then performed after interviews were transcribed verbatim. RESULTS: Health care professionals perceived palliative care as a service only delivered to patients at the end of life. Palliative care was only offered to patients who have been diagnosed with cancer and had exhausted all curative treatments. Do-not-resuscitate orders and code status discussions are not currently practiced. Palliative care decisions are usually decided by patients' families. Middle Eastern culture, health care law and policy, conservative interpretations of Islam, and a lack of professional expertise were identified as barriers. CONCLUSION: This study unveiled the perceptions of palliative care among health care professionals in a Gulf Cooperation Council country. Six major barriers that hindered palliative care practice were identified. Future health care policy in the region needs to address these barriers within the current health care system while taking culture, religion, and social factors into consideration.

Adenocarcinoma arising from a gastric duplication cyst: a case report and literature review.

INTRODUCTION: Alimentary tract cystic duplication is a rare congenital anomaly predominantly affecting females, and diagnosed mostly in the early years of life. CASE REPORT: We present here a case of a 51-year-old man presenting with a 2-day history of melena. Gastroscopy showed fresh blood, as well as a mass lesion and cavity at the fundus. Biopsies of the mass edge reported the occurrence of moderately differentiated adenocarcinoma and mild chronic gastritis. Computed tomography imaging showed a 5.1×6.5 cm cystic mass in the gastric greater curvature. The patient received six cycles of epirubicin, capecitabine, and oxaliplatin, followed by uncomplicated total gastrectomy. LITERATURE REVIEW: Data from all 11 reports of similar cases were reviewed and pooled. The result shows male predominance and variable symptoms, as well as a wide age range (25-76 years) at presentation. The cysts are commonly located along the greater curvature and are unilocular. Surgery was the treatment in most cases. CONCLUSION: Alimentary tract cystic duplication is rare and may predispose to malignancy. Early diagnosis and prompt surgical intervention is important for the best outcome.

Inflammatory bowel disease in Bahrain: single-center experience.

PURPOSE: The number of newly diagnosed inflammatory bowel disease (IBD) cases such as ulcerative colitis (UC), Crohn's disease (CD), and indeterminate colitis (IC) is rapidly increasing in Gulf countries and Saudi Arabia. The aim of this study was to investigate the incidence and prevalence of IBD in patients who have attended the Salmaniya Medical Complex, Bahrain, between the years 1984 and 2014. PATIENTS AND METHODS: All patients who had attended the Salmaniya Medical Complex, Bahrain, and had been diagnosed with UC, CD, or IC, between the years 1984 and 2014, were included in the analysis. Data collected were: patient demographics, symptoms, clinical signs, complications, surgical interventions, extent of disease, endoscopic findings, histopathology, and lab measurements. RESULTS: A total of 187 cases were included; 61 had CD, 123 had UC, and a further 3 cases presented with IC. A clear increase in the incidence and prevalence of IBD can be seen in this cohort. The prevalence of IBD was calculated to be 26.25/105 cases. The average number of IBD cases increased from 3 cases (average for the years 1984-2001) to 12 cases (average for the years 2002-2014). A number of factors correlate positively or negatively with CD and UC. In the current study, a link between gastrointestinal complications in CD cases and the use of steroids as a treatment was noted (p-value -0.02). Age also had a significant influence on the need for surgery in CD cases (p-value -0.04), and a family history of UC was statistically linked to surgical intervention (p-value -0.05). CONCLUSIONS: IBD can no longer be considered a rare disease in Bahrain. The incidence of both UC and CD is steadily increasing. There is a need for increasing awareness of the Bahraini public to IBD in order for proper medical care to be given.