Scope and extent of healthcare-associated Middle East respiratory syndrome coronavirus transmission during two contemporaneous outbreaks in Riyadh, Saudi Arabia, 2017.

OBJECTIVE: To investigate a Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak event involving multiple healthcare facilities in Riyadh, Saudi Arabia; to characterize transmission; and to explore infection control implications. DESIGN: Outbreak investigation. SETTING: Cases presented in 4 healthcare facilities in Riyadh, Saudi Arabia: a tertiary-care hospital, a specialty pulmonary hospital, an outpatient clinic, and an outpatient dialysis unit. METHODS: Contact tracing and testing were performed following reports of cases at 2 hospitals. Laboratory results were confirmed by real-time reverse transcription polymerase chain reaction (rRT-PCR) and/or genome sequencing. We assessed exposures and determined seropositivity among available healthcare personnel (HCP) cases and HCP contacts of cases. RESULTS: In total, 48 cases were identified, involving patients, HCP, and family members across 2 hospitals, an outpatient clinic, and a dialysis clinic. At each hospital, transmission was linked to a unique index case. Moreover, 4 cases were associated with superspreading events (any interaction where a case patient transmitted to ≥5 subsequent case patients). All 4 of these patients were severely ill, were initially not recognized as MERS-CoV cases, and subsequently died. Genomic sequences clustered separately, suggesting 2 distinct outbreaks. Overall, 4 (24%) of 17 HCP cases and 3 (3%) of 114 HCP contacts of cases were seropositive. CONCLUSIONS: We describe 2 distinct healthcare-associated outbreaks, each initiated by a unique index case and characterized by multiple superspreading events. Delays in recognition and in subsequent implementation of control measures contributed to secondary transmission. Prompt contact tracing, repeated testing, HCP furloughing, and implementation of recommended transmission-based precautions for suspected cases ultimately halted transmission.

Intragastric balloon for preoperative weight reduction in candidates for laparoscopic gastric bypass with massive obesity.

BACKGROUND: Laparoscopic bariatric operations can be technically challenging in massively obese patients. The potential of the intragastric balloon for preoperative weight reduction was evaluated in candidates for laparoscopic Roux-en-Y gastric bypass (LRYGBP) with super obesity. METHODS: From January 2004 to March 2005, 10 patients with super obesity who were potential candidates for LRYGBP were included in a prospective observational study. An intragastric balloon was placed endoscopically under general anesthesia. Patients were then followed by a multidisciplinary team until removal of the balloon after 6 months. Weight, BMI, and percent excess weight lost (%EWL) were monitored after 1, 3 and 6 months. RESULTS: The 10 patients were all female with mean +/- SD age of 33+/-11 years (range 17-51). Initial weight was 175+/-25 kg (range 135-223) and initial BMI was 64+/-7 kg/m2 (range 59-78). After completion of 1, 3 and 6 months, weight, BMI, and %EWL reached respectively: 166+/-27 kg*, 165+/-27 kg*, and 169+/-26 kg*; 61.1+/-7.6 kg/m2*, 60.8+/-8.4 kg/m2*, and 61+/-8.2 kg/m2*; 9+/-5%, 10+/-7%, 7+/-6%. (*=P<0.01 vs preop). CONCLUSION: In potential candidates for LRYGBP with super obesity, preoperative placement of an intragastric balloon can reduce the excess weight by 10% within 3 months. Extending this period failed to improve these results further.

Place of upper endoscopy before and after bariatric surgery: A multicenter experience with 3219 patients.

AIM: To study the preoperative and postoperative role of upper esophagogastroduodenoscopy (EGD) in morbidly obese patients. METHODS: This is a multicenter retrospective study by reviewing the database of patients who underwent bariatric surgery (laparoscopic sleeve gastrectomy, laparoscopic Roux en Y gastric bypass, or laparoscopic minigastric bypass) in the period between 2001 June and 2015 August (Jahra Hospital-Kuwait, Hafr Elbatin Hospital and King Saud Medical City-KSA, and Mansoura University Hospital - Egypt). Patients with age 18-65 years, body mass index (BMI) > 40, or > 35 with comorbidities after failure of many dietetic regimen and acceptable levels of surgical risk were included in the study after having an informed signed consent. We retrospectively reviewed the medical charts of all morbidly obese patients. The patients' preoperative data included clinical history including upper digestive symptoms and preoperative full workup including EGD. Only patients whose charts revealed weather they were symptomatic or not were studied. We categorized patients accordingly into two groups; with (group A) or without (group B) upper digestive symptoms. The endoscopic findings were categorized into 4 groups based on predetermined criteria. The medical record of patients who developed stricture, leak or bleeding after bariatric surgery was reviewed. Logestic regression analysis was used to identify preoperative predictors that might be associated with abnormal endoscopic findings. RESULTS: Three thousand, two hundred and nineteen patients in the study period underwent bariatric surgery (75% LSG, 10% LRYDB, and 15% MGB). Mean BMI was 43 ± 13, mean age 37 ± 9 years, 79% were female. Twenty eight percent had presented with upper digestive symptoms (group A). EGD was considered normal in 2414 (75%) patients (9% group A vs 66% group B, P = 0.001). The abnormal endoscopic findings were found high in those patients with upper digestive symptoms. Abnormal findings (one or more) were found in 805 (25%) patients (19% group A vs 6% group B, P = 0.001). Seven patients had critical events during conscious sedation due to severe hypoxemia (< 60%). Rate of stricture in our study was 2.6%. Success rate of endoscopic dilation was 100%. One point nine percent patients with gastric leak were identified with 75% success rate of endoscopic therapy. Three point seven percent patients developed acute upper bleeding. Seventy-eight point two percent patients were treated by conservative therapy and EGD was performed in 21.8% with 100% success and 0% complications. CONCLUSION: Our results support the performance of EGD only in patients with upper gastrointestinal symptoms. Endoscopy also offers safe effective tool for anastomotic complications after bariatric surgery.

Sigmoid colon endometriotic mass. A rare cause of complete large bowel obstruction.

Large bowel obstruction is a rare complication of gastrointestinal endometriosis. A 32-year-old female patient presented to the emergency department with complaints of diffuse abdominal pain and constipation for 10 days with progressive abdominal distention and vomiting. Plain abdominal x-ray showed grossly dilated large bowel up to the sigmoid colon with no gas in the rectum. Abdominal computed tomography revealed hugely dilated large bowel up to the sigmoid colon, with sigmoid soft tissue mass. Flexible sigmoidoscopy showed a non-ulcerating sigmoid mass, with complete obstruction of the sigmoid colon, which impeded the further advancement of the scope. She underwent exploratory laparotomy with provisional diagnosis of complete large bowel obstruction due to sigmoid tumor. Sigmiodectomy with end colostomy was performed. Histopathology revealed endometrial glands with stroma in muscularis properia of the sigmoid colon mass. Endometriosis should be considered in women of reproductive age presenting with symptoms of large bowel obstruction.

Risk factors for lateral cervical lymph node involvement in follicular thyroid carcinoma.

BACKGROUND: Metastases from follicular thyroid carcinoma (FTC) are usually blood borne and far less to lymph nodes (LN). The present study was designed to evaluate the factors that are associated with LN metastases in patients operated on for FTC. METHODS: A retrospective review of 70 patients (25 men; mean age, 47 (range, 14-92) years) operated on between January 1995 and December 2005 for FTC was undertaken. All patients had histopathology study of the regional LN and postoperative radioiodine scintigraphy. According to LN invasion, they were divided into two groups in which various parameters were compared. RESULTS: The length of follow-up was 52 (range 17-108) months. A total of 375 LN were examined from ipsilateral neck side and 87 LN from the contralateral side. LN metastases were found in five (7%) cases: all ipsilateral. Comparing data from the patients with and without LN metastases, respectively, age was 60 and 47 years (p = 0.12), male/female ratio was 1/4 and 24/41 (p = 0.44), tumor size was 68 and 37 mm (p < 0.01), tumor differentiation (well/moderate) was 3/2 and 25/19 (p = 0.89), distant metastases were detected in 1 and 8 cases (p = 0.72) .The tumor size was >40 mm in 35 (50%) patients. All patients with LN metastases were found in this group (5/35; 14%). CONCLUSIONS: Follicular thyroid carcinoma results in metastases to regional lymph nodes in 7% of cases but only to the ipsilateral neck side. Tumor size is the only factor that impacts it. We do not recommend lymph node dissection in follicular thyroid carcinomas <4 cm.