Management of Tarlov cysts: an uncommon but potentially serious spinal column disease-review of the literature and experience with over 1000 referrals.

Tarlov cysts were thought to be anatomic variants of uncertain etiology and clinical significance when initially described over 80 years ago. They are often detected in routine lumbosacral imaging and generally not reported in a differential diagnosis. There is increasing evidence that at least some Tarlov cysts are symptomatic and can have a significant adverse impact on patients' health and well-being. Women are disproportionately affected with this condition, often presenting with long-standing pain and neurological dysfunctions. Significant gender bias has been a concern in the management of these patients. Unfortunately, there is no consensus on patient selection or management approaches for symptomatic Tarlov cysts. This review article updates information on the prevalence, diagnosis, clinical significance, and treatments of these cysts. Based on these findings and experience with over 1000 patient referrals, a treatment decision algorithm for symptomatic Tarlov cysts was constructed to provide guidance for appropriate management of patients with these complex cysts.

Evaluating the Transvaginal Ultrasound Diagnostic Criteria for Abnormal First-Trimester Pregnancy With Follow-Up Into the Third Trimester and Validation of Results.

OBJECTIVE: To evaluate the current ultrasound diagnostic criteria for non-viable pregnancy in the first trimester. METHODS: We conducted a retrospective chart review involving 3 tertiary care institutions. Consecutive first-trimester ultrasound reports between January 2013 and June 2016 were reviewed. All first-trimester ultrasound examinations performed to assess pregnancy viability with adequate imaging or clinical follow-up were included. Inclusion criteria based on follow-up were adequate imaging to document ongoing intrauterine pregnancy or clinical follow-up demonstrating viability or non-viability. Data on mean sac diameter (MSD), yolk sac presence/diameter, embryo presence/length, presence of a heartbeat, and heart rate were collected. This was followed by a retrospective validation review of another consecutive cohort. RESULTS: Two hundred and forty-five examinations with a viable-pregnancy outcome and 301 examinations with a non-viable pregnancy outcome were reviewed. The main predictor of non-viable pregnancy was an MSD of ≥20 mm in the absence of a yolk sac (positive predictive value [PPV] 100%; 95% CI 93%-100%), embryo (PPV 100%; 95% CI 90%-100%), or heartbeat (PPV 100%; 95% CI 96%-100%]). Other predictors of non-viability were a measurable embryo without a yolk sac (PPV 100%; 95% CI 91%-100%), yolk sac diameter ≥8 mm (PPV 100%; 95% CI 91%-100%), and absence of heartbeat with an embryo ≥3 mm (PPV 100%; 95% CI 97%-100%). These findings were confirmed in a validation cohort of 45 viable and 53 non-viable pregnancies, with the exception of 1 case of viable pregnancy with no heartbeat and an embryo length 3.3 mm. Based on the median daily growth of 1.2 mm in the viable cohort, 21% of follow-up ultrasound examinations were performed too early for an MSD threshold of 20 mm and 55%, for an MSD threshold of 25 mm. CONCLUSION: In our cohort, MSD ≥20 mm in the absence of yolk sac or an embryo with heartbeat always predicted a non-viable pregnancy.

Arachnoid granulations may be protective against the development of shunt dependent chronic hydrocephalus after aneurysm subarachnoid hemorrhage*.

BACKGROUND AND PURPOSE: Chronic hydrocephalus may develop as a sequela of aneurysmal subarachnoid hemorrhage, requiring long-term cerebrospinal fluid shunting. Several clinical predictors of chronic hydrocephalus and shunt dependence have been proposed. However, no anatomical predictors have been identified. MATERIALS AND METHODS: A retrospective cohort study was performed including 61 patients with aneurysmal subarachnoid hemorrhage. Clinical characteristics were noted for each patient including presentation World Federation of Neurosurgical Societies grade, modified Fischer grade, aneurysm characteristics, requirement for acute and chronic cerebrospinal fluid diversion, and 3-month modified Rankin scale. CT images were evaluated to determine the Evans' index and to enumerate the number of arachnoid granulations. Association between the clinical characteristics with ventriculoperitoneal shunt insertion and the 3-month modified Rankin scale were assessed. RESULTS: The initial Evans' index was positively associated with mFisher grade and age, but not the number of arachnoid granulations. 16.4% patients required insertion of a ventriculoperitoneal shunt. The number of arachnoid granulations were a significant negative predictor of ventriculoperitoneal shunt insertion [OR: 0.251 (95% CI:0.073-0.862; p = 0.028)]. There was significant difference in the number of arachnoid granulations between those with and without ventriculoperitoneal shunt (p = 0.002). No patient with greater than 4 arachnoid granulations required a ventriculoperitoneal shunt, irrespective of severity of initial grade. CONCLUSION: Arachnoid granulations may be protective against the development of shunt dependent chronic hydrocephalus after aneurysmal subarachnoid hemorrhage. This is irrespective of presenting hemorrhage severity. This is a potentially novel radiologic biomarker and anatomic predictor of shunt dependence.

To What Extent the Emergency Physicians in Riyadh City Are Aware of Patient Radiation Exposure From Diagnostic Imaging Requested in the Emergency Department.

Introduction Radiological imaging that uses ionizing radiation in emergency departments (EDs) has increased with advances in radiological diagnostic methods. Emergency (ER) physicians' awareness of the radiation doses and the associated cancer risks that the patients are exposed to was surveyed using a questionnaire. Aims To assess the ER physicians' awareness of radiation doses associated with the diagnostic imaging and to describe their practice about discussing radiation risk with patients at different hospitals in Riyadh city, Saudi Arabia. Methods A prospective, questionnaire-based observational study was conducted in 2016 among 176 ER physicians at different hospitals in Riyadh city. The percentage knowledge score and the frequency of discussing radiation risk with patients based on responses to three scenarios were rated on a visual analog scale (VAS), where a score of 100 indicated that physicians would always discuss it. Results The overall mean knowledge score was 28% (95% CI: 22-34). None of the studied parameters (gender, experience, country of medical qualification, type of degree, and employment level) showed a significant correlation with the overall awareness of ED physicians about radiation exposure. Over three-quarters of physicians (77%) underestimated the lifetime risk of fatal cancer attributed to a single computed tomography (CT) scan of the abdomen. Majority of physicians (60%) reported never discussing radiation risk with patients. The frequency at which physicians were discussing radiation risk with patients varied greatly depending on the clinical scenario (mean VAS scores between 46 and 82). Conclusions ER physicians of different hospitals in Riyadh city had a varied knowledge about the radiation exposure risks, although overall the perception was inadequate. The physicians should receive education, and the diagnostic imaging request may need to include information on radiation doses and risks.

To what extent are Arab pilgrims to Makkah aware of the middle east respiratory syndrome coronavirus and the precautions against it?

BACKGROUND: Approximately, 80% of the many cases of the Middle East respiratory syndrome coronavirus (MERS-CoV) confirmed worldwide were diagnosed in the Kingdom of Saudi Arabia (KSA). The risk of the disease spreading internationally is especially worrying given the role of KSA as the home of the most important Islamic pilgrimage sites. This means the need to assess Arab pilgrims' awareness of MERS-CoV is of paramount importance. MATERIALS AND METHODS: A cross-sectional study was carried out during Ramadan 2015 in the Holy Mosque in Makkah, Saudi Arabia. Self-administered questionnaires were distributed to 417 Arab participants at King Fahad Extension, King Abdullah Prayer Extension and, King Abdullah Piazza Extension after Taraweeh and Fajr prayers. RESULTS: The mean MERS-CoV knowledge score was 52.56. Majority of the respondents (91.3%) were familiar with MERS-CoV. Saudis had significantly higher knowledge of MERS-CoV than non-Saudis (56.92 ± 18.55 vs. 44.91 ± 25.46, p = 0.001). Females had significantly more knowledge about consanguineous MERS-CoV than males (55.82 ± 19.35 vs. 49.93 ± 23.66, p = 0.006). The average knowledge was significantly higher in respondents who had received health advice on MERS-CoV (56.08 ± 20.86 vs. 50.65 ± 22.51, p = 0.024). With respect to stepwise linear regression, knowledge of MERS-CoV tended to increase by 14.23 (B = 14.23%, p = 0.001) in participants who were familiar with MERS-CoV, and by 8.50 (B = 8.50, p = 0.001) in those who perceived MERS-CoV as a very serious disease. CONCLUSION: There is a great need for educational programs to increase awareness about MERS-CoV.

Socioeconomic factors affecting patients' utilization of primary care services at a Tertiary Teaching Hospital in Riyadh, Saudi Arabia.

BACKGROUND: Primary care services utilization is dependent on socioeconomic factors. It is proven that variation in socioeconomic factors result in discrepancies in the use of such services. Admittedly, research is limited on the socioeconomic factors affecting the utilization of primary care services in Saudi Arabia. OBJECTIVES: The aim of this research was to study the effect of the main socioeconomic factors affecting patients' utilization of primary care services at a tertiary teaching hospital, Riyadh, Saudi Arabia. MATERIALS AND METHODS: A cross-sectional study was conducted from January to February 2014 in a primary care clinic of a tertiary teaching hospital in Riyadh city; subjects selected using a random consecutive sampling technique. A self-administered questionnaire in Arabic was given to the participants to collect the data which comprised sociodemographic data, utilization measures, and health needs. The data were analyzed using SPSS version 21. RESULTS: A total of 358 subjects participated in the study. The main factors that best determine the utilization of primary health care clinic in a tertiary teaching hospital were the possession of a health insurance (P = 0.046, odds ratio [OR] = 8.333), and bad self-health-perception (P < 0.014, OR: 2.088). Chronic illness was also associated with higher utilization (OR = 2.003). CONCLUSION: Our results reveal that chronic health problems, self-health-perception, and health insurance are the most significant socioeconomic factors affecting the utilization of primary care services.