Short and Long-Term Clinical Outcomes in Octogenarian Patients With Non-ST-Elevation Myocardial Infarction: A Comparative Analysis of Revascularization Strategies Versus Medical Management.

INTRODUCTION: As the primary cause of morbidity and mortality among older individuals, cardiovascular disease remains a major concern. Choosing between revascularization and medical management of elderly patients remains controversial. This study aims to evaluate the clinical implications of these treatment approaches in the context of non-ST-elevation myocardial infarction (NSTEMI) in octogenarian patients. METHODS: This observational cohort study involved 41 octogenarian patients who were diagnosed with NSTEMI from 2019 to 2021 and were managed by revascularization (with either percutaneous coronary intervention, coronary artery bypass graft surgery, or both) or conservative medical therapy. All NSTEMI patients were diagnosed based on symptoms, electrocardiographic changes, and cardiac biomarkers. The study compared the short- and long-term outcomes of 13 patients in the revascularization group and 28 in the medical therapy group. RESULTS: Overall, the mean patient age was 84.63 years. Eighteen patients were men (43.9%), and 23 were women (56.1%). The most prevalent disease among the sample was hypertension (34 patients, 82.9%), followed by diabetes mellitus (27 patients, 65.9%) and prior ischemic heart disease (21 patients, 51.2%). Almost all patients in the revascularization-treated group developed complications after the procedure (84.6%), while 46.4% of the patients in the medication-only group developed a complication later on. The revascularization-treated group showed higher mortality rates in both the short- and long-term (23.1% and 38.5%, respectively) compared to the medication-only group, which showed better survival rates numerically in both the short- and long-term (14.3% and 32.1%, respectively). This was not statistically significant. CONCLUSION: Revascularization treatment in elderly patients with NSTEMI was associated with a higher risk of complications and a higher mortality rate compared with conservative medical management. Patients managed with only medications had a better survival rate in both the short- and long-term.

Marked Efficacy of a Therapeutic Strategy in a Patient With Necrotizing Myopathy Associated With Anti-signal Recognition Particle (SRP) Autoantibodies.

Necrotizing autoimmune myopathy (NAM) is a rare muscular disorder characterized by severe proximal muscle weakness. Risk factors include statin use, malignancy, and connective tissue diseases. The current study presents the first case of NAM in Saudi Arabia in a 26-year-old female who presented with proximal upper and lower limb weakness, dysphagia, dysarthria, and dyspnea with no previous medical or surgical history and was not on medication. Targeted myopathic antibody analysis revealed antibodies to signal recognition particles (SRP), and the serum creatinine kinase level reached 9308 U/L. A diagnosis of NAM was made, and the patient was started on the management plan. We discussed an interesting case progression and adverse effect challenges, as well as the management of these difficult-to-treat conditions.

Perampanel-Induced, New-Onset Thrombocytopenia in a Patient With Refractory Seizures: A Case Report.

Perampanel (Fycompa) is a glutamate receptor antagonist known to be a safe, effective, and well-tolerated medication; nevertheless, adverse effects are possible. This case report aims to raise the suspicion of perampanel-induced thrombocytopenia and discuss its possible pathways implicated. Here, we present the case of a 66-year-old female patient with a generalized tonic-clonic seizure initially managed with levetiracetam, valproic acid, and lacosamide; however, the patient continued to have seizures clinically as well as on the electroencephalogram. The patient was initiated on 2 mg of perampanel and reached up to 12 mg within a week, after which the seizure was controlled. Nevertheless, after perampanel initiation, a gradual platelet count reduction was observed. Upon withdrawal of perampanel, the platelet count dramatically improved reaching up to her baseline. Although perampanel is known to be a safe medication, a hematological complication such as thrombocytopenia is possible. The exact mechanism remains unclear. Further studies are required to understand the association between thrombocytopenia and perampanel to identify high-risk populations and prevent this condition sequentially.

Evaluation of the Awareness, Beliefs, and Psychological Impact of Patients with Alopecia Areata in Makkah City, Saudi Arabia.

Methods: A descriptive cross-sectional study was conducted among patients diagnosed with AA at different hospitals. A total of 211 patients were included in the investigation between November 2021 and June 2022. The participants were subjected to a well-structured, Arabic-based, validated questionnaire. Results: More than half of the patients were men (54.0%) and single (50.7%). The most common age groups were 30 to 44 years (46.9%) and 18 to 29 years (36.0%). More than two-thirds of the participants (67.8%) had heard of AA before their diagnosis. Of these, the level of knowledge was low among 36.4%, medium among 42.0%, and high among 21.7%. Most of the patients believed that AA may be caused by genetic, nutritional, or health factors (77.3%) and that it is a serious health problem that necessitates treatment (64.0%). The most common psychological attributes caused by AA are feeling ashamed in front of other individuals (63.0%), anxiety (47.9%), and depression (36.0%). Conclusion: Our results show more than two-thirds of the participants were knowledgeable about AA. Most believed that the cause of AA is genetic, nutritional, or health factors and suffered negative psychological effects. According to our study, high levels of anxiety and depression are closely associated with AA patients, which affect their quality of life.

The Use of Pain Severity and Its Impact as a Predictor for MRI Findings: A Cross-Sectional Study in Ta'if, Saudi Arabia.

Background Low back pain (LBP) is common and considerably impacts daily lives across all age groups. MRI is not frequently used as a first-line investigation for patients presenting with LBP, except in the presence of red-flag symptoms. This study aimed to use pain severity and its impact as a predictor for MRI findings to help physicians decide whether a patient needs an MRI. Methods This cross-sectional study was conducted at the outpatient clinic of the neurosurgery department. The questionnaire included demographic data of the patients, red-flag symptoms, and the Dallas Pain Questionnaire (DPQ). The primary physician then determines whether the patient should have an MRI appointment. Results The study included 100 patients with LBP, of which 71 had chronic LBP (CLBP). Out of these 71, an MRI was requested for 62, but only 26 had findings related to LBP. Regarding the impact of CLBP on daily activities as measured by the DPQ, there was a significant association between those whose CLBP affected their daily activities and the decision to request an MRI. However, no significant statistical association was found between the three other parameters of the DPQ and the primary physician's decision to request an MRI. Conclusion Concerning the use of the DPQ questionnaire to predict MRI findings in patients with CLBP, the study indicates that significant pain impact on the DPQ does not necessarily correlate with MRI findings related to LBP. This suggests that the DPQ evaluation tool has no advantage over a physician's clinical judgment.

Pneumomediastinum and Pneumopericardium as Uncommon Complications of COVID-19 Infection: A Review Article.

There is an emerging body of literature describing an increasing incidence of pneumomediastinum and, to a lesser extent, pneumopericardium as a complication of COVID-19. However, the literature lacks information regarding patients' characteristics and a general view of this unusual condition. The purpose of this paper is to summarize the current literature on this phenomenon. In this study, we summarize the risk factors/etiology, imaging modalities, management, and prognosis of known cases in the literature. In total, 48 articles were included in the study, ranging from case reports to case series. Most patients were male (83.3%). The overall mortality rate was 27.1% and the recovery rate was 62.5%.

Drugs utilization profile in England and Wales in the past 15 years: a secular trend analysis.

BACKGROUND: Medication use assessment has a critical role in promoting the effective and rational use of pharmaceutical medications. There are no studies that have explored the utilization of all medications in England and Wales in the past 15 years without restrictions in the age group being studied or class of medications. AIM: To explore the medication utilization pattern of dispensed medications in England and Wales in the past 15 years. METHOD: A secular trend analysis study using publically available dispensing data on the population level in England and Wales for the duration between 2004 and 2019. Medication dispensing data was extracted from the Prescription Cost Analysis database. RESULTS: Medication prescriptions rate increased by 42.6% [from 1,345,095.75 (95% CI 1,345,004.25 - 1,345,187.26) in 2004 to 1,918,138.48 (95% CI 1,918,038.38 - 1,918,238.57) in 2019 per 100,000 persons, trend test, p < 0.001]. During the study period, the most common medication prescriptions were for the cardiovascular system, central nervous system, and endocrine system, which accounted for 30.2%, 18.8%, and 9.4%, respectively. The rate of medication prescriptions for skin, immunological products and vaccines, infections, and musculoskeletal and joint diseases decreased by 18.4%, 15.8%, 9.8%, and 5.7%, respectively. CONCLUSION: The last two decades have witnessed a remarkable rise in the quantity of medications dispensed in community settings. Utilization of chronic disease medications has increased in the past 15 years, specifically, dispensed medications for the cardiovascular system, central nervous system, and endocrine system. It is necessary to conduct additional cohort studies to investigate the clinical outcomes and prescribing safety of these medications.

Spinal Cord Ischemia Secondary to Aortic Dissection: Case Report with Literature Review for Different Clinical Presentations, Risk Factors, Radiological Findings, Therapeutic Modalities, and Outcome.

Aortic dissection (AD) is a serious condition that causes transient or permanent neurological problems that include spinal cord ischemia (SCI), which occurs when AD extends into the descending aorta resulting in insufficient perfusion of segmental arteries that supplies the spinal cord. We report a 64-year-old male, presented with severe back pain, asymmetrical paresthesia, and weakness of both limbs, more in the left lower limb with loss of pinprick, temperature, and fine touch sensation on the lower left lower limb below the level of T5 with preserved proprioception and vibration and urine hesitancy. Computed tomography showed AD, Stanford type A, and spinal magnetic resonance imaging (MRI) showed hyperintense owl's eye sign at T5. The patient was diagnosed as anterior spinal artery syndrome secondary to an AD and referred for aortic surgical repair with good functional outcome. In our review to cases of SCI due to AD, it was more common in males above 55 years, pain only found in 47.8% of patients, with anterior cord syndrome on top of the clinical presentations, and hypertension is the most common risk factor. MRI spine showed thoracic location predominance. Surgical or endovascular repair especially for type A and complicated type B should be considered to avoid complications, and cerebrospinal fluid drainage is a very useful tool in reversing SCI specially if done early with favorable outcome. Only the old age is associated with increased risk of mortality. Early diagnosis and appropriate management are crucial for better outcome.

Elevation of CA 19-9 in Mirizzi Syndrome in the Absence of Malignancy: A Case Report.

BACKGROUND Mirizzi syndrome (MS) is relatively a rare condition; incidence rates may increment with age. It is characterized as an obstruction of the common hepatic duct (CHD) auxiliary to outward compression of an infected stone in the cystic duct. Carbohydrate antigen (CA) 19-9 is a tumor marker that is usually related to upper-gastrointestinal malignancies. However, a few case reports have shown high levels of CA19-9 in the absence of malignancy. In this case, we report a case of a patient with MS, elevated CA19-9, and radiological findings suggesting gallbladder cancer, which shows the challenges of diagnosis and therapeutic procedures. CASE REPORT We report the case of a 71-year-old Saudi man who presented to the emergency department with signs of obstructive jaundice. Magnetic resonance cholangiopancreatography (MRCP) revealed cholelithiasis, with a huge cystic duct stone compressing the CHD, resulting in mild intra-/extrahepatic biliary dilatation and positive MRCP pearl necklace sign for adenomyomatosis of the gallbladder. Serum tumor markers revealed raised levels of CA19-9 to 21 068 u/ml. The patient underwent laparoscopic cholecystectomy. Biopsy results confirmed the diagnosis of acute calcular cholecystitis and adenomyosis with no malignancy. CONCLUSIONS We report what can be considered a rare case of Mirizzi syndrome with a very high CA19-9 marker, in an elderly patient, in the absence of malignancy. This illustrates that Mirizzi syndrome and cholangiocarcinoma are difficult to distinguish, and the diagnosis is considered challenging. Thus, a high index of suspension must be kept in mind, especially in elderly patients, to rule out the cause of malignancy and thus to create an appropriate management plan.

Neurological Symptoms and Complications of COVID-19 Among Patients in a Tertiary Hospital in Saudi Arabia.

Objectives In this study, we aimed to determine the frequency of neurological signs, symptoms, and complications in coronavirus disease 2019 (COVID-19) patients. We also sought to explore the general characteristics of stroke patients in particular. Methods A retrospective cohort study was conducted among COVID-19 patients who were hospitalized between April-September 2020 at the Al-Noor Specialist Hospital in Makkah city, Saudi Arabia. The study included patients who were aged ≥18 years and presented with or were reported to have any neurological manifestations and/or complications secondary to COVID-19 infection. Results A total of 79 patients were included. The mean age of the cohort was 63.6 years, with a significant male predominance (67.1%). The most commonly reported neurological signs and symptoms were altered level of consciousness (45.9%), dizziness (11.5%), and focal neurological deficit (10.4%). Acute ischemic stroke was seen in 18 patients. Most of them were males (66.7%). Most strokes were in the right middle cerebral artery territory (MCA) (50.0%). Diabetic patients were four times more at risk to develop stroke [odds ratio (OR)=3.76; 95% confidence interval (CI): 1.1-29.9]. Patients with respiratory failure were 21 times more likely to have a stroke (OR=21.3; 95% CI: 2.2-54.6). Patients with acute respiratory distress syndrome recorded a three-fold increased risk for developing stroke (OR=2.96; 95% CI: 1.25-37.3). Critically ill patients had double the risk of stroke (OR=1.8; 95% CI: 1.1-6.9). Other neurological complications were hemorrhagic stroke (3.3%), subacute/chronic infarction (23.3%), meningitis (10%), and brain mass lesion (3.3%). Conclusions Neurological symptoms and complications are not uncommon among COVID-19 patients. Most of these patients had poor outcomes. Acute ischemic stroke was the most common finding on neuroimaging.

Persistent Parosmia Caused By COVID-19 Infection: An Emerging Symptom.

Objectives Coronavirus disease 2019 (COVID-19) is associated with several known signs and symptoms, including olfactory disturbances leading to anosmia and parosmia. This study aimed to evaluate the clinical features of the emerging symptoms of post-COVID-19 parosmia and to report the outcome of commonly used intervention methods. Methods The study's sample included post-COVID-19 patients who complained of parosmia, presented to otorhinolaryngology clinics at private tertiary care hospitals from December 2020 to April 2021. Patients' data were collected from the hospital system and through direct phone interviews. The Modified Arabic 20-Items Sino-Nasal Outcome Test (MA-SNOT-20) was used to measure the severity of rhinosinusitis symptoms. Results Twenty-one patients were included in the study, and their ages mainly ranged between 20 and 39 years (76.2%), predominantly females 19 (90.5%). Post the COVID-19 illness course, nearly half of the patients (9; 42.9%) reported full recovery of olfaction and taste senses. Nine cases (42.9%) received treatment with intranasal and oral steroids, of which only three cases (14.3%) noticed improvement. The remaining 12 cases (57.1%) did not receive any treatment, two of which improved (9.5%). The maximum MA-SNOT score was 37 while the minimum was 3, and eight patients (38.1%) scores were between one and 10 points. Conclusion Olfactory and taste dysfunctions are common symptoms of COVID-19. The emerging symptom of parosmia is worth reporting in the literature to increase the awareness of this particular symptom in this pandemic era. Many management strategies have been introduced that might be effective. However, further studies are needed to establish evidence-based management protocols.

Learning Environment Quality for Medical Students at Umm Al-Qura University: A Comprehensive Study on Stressors, Sources, and Solutions After Introduction of a New Bachelor of Medicine and Bachelor of Surgery (MBBS) Curriculum.

OBJECTIVE: Due to introduction of a new curriculum and the related stressors that medical students might encounter, we aimed to assess the quality of the students' learning environment across academic years at Umm Al-Qura University (UQU), by evaluating stress levels, their sources, and impacts on students, to help improve the quality of learning environment and protect students from personal and academic burnout. METHODS: We conducted a descriptive cross-sectional study in August and September of 2020 on 572 students enrolled in the new Bachelor of Medicine and Bachelor of Surgery (MBBS) curriculum at UQU. All statistical analyses were performed using SPSS software and two-tailed tests. RESULTS: In total, 46.5% of participants encountered severe stress levels during their studies at UQU. In term of stressor sources, the highest prevalence of severe stress was found among students who lacked learning resources (68.8%), followed by those who complained of ambiguity in teaching, learning, and assessment strategies (64.1%). Self-study strategy issues (58.4%) and difficulty in reading textbooks (58.2%) also ranked high. Anxiety was often reported by the students as an impact of stress (62.9%), followed by mood swings (60%). Severe stress levels showed a statistically significant relationship to gender, being highest among females (P = 0.001). For a solution to manage the stress, 79% of the students suggested a supportive learning environment and identification of students' struggles at early stages. CONCLUSION: Almost half the medical students were severely stressed after the new curriculum was introduced. Therefore, professors and universities should look out for potential stressors and help students overcome them. Universities can also help by offering counseling services to students, improving the student tutoring system, providing appropriate learning environment and resources, and including stress management courses as a part of the overall curriculum.

Giant Ileocecal Inflammatory Fibroid Polyp: Unique Clinical Presentation.

Inflammatory fibroid polyps (IFPs) are infrequent gastrointestinal tract benign neoplasms. They mostly occur in the stomach especially the antrum. Signs and symptoms depend on their anatomic location and lesion size. Lesion biopsies are very challenging for accurate diagnosis in these lesions. Histopathological examination of resected tissue along with immunohistochemical studies is the perfect way to confirm the final diagnosis. In this paper, the authors present an unusual case of IFP in a 23-year-old female patient presented to the emergency room (ER) with a picture of intestinal obstruction and severe abdominal pain. Her investigations revealed a huge mass located at the ileocecal valve, with overall features mimic gastrointestinal stromal tumor (GIST) clinical presentation. Surgical resection is considered the most commonly used treatment method. The overall prognosis is good with a low risk of recurrence.

Granular Cell Tumor of Thyroid: Challenging Pitfalls and Mimickers in Diagnosis.

Mesenchymal tumors of the thyroid are extremely rare. Only few isolated cases of primary thyroid granular cell tumor (GrCT) have been reported. The anatomic location of this lesion plays an important role in the differential diagnosis. It is well-known that GrCT commonly involves the head-and-neck region, lower extremity, nuchal region, chest wall, and internal viscera such as the gastrointestinal tract. However, primary GrCT of the thyroid are unexpected and might lead to misdiagnosis, especially with pathological diagnosis limitations such as frozen section and fine-needle aspiration. We believe that it is important to establish a good differential diagnosis because of its ability to simulate the appearance of invasive carcinoma, especially in cases lacking tissue block examination. In this paper, we try to focus on clinical, radiological potential characteristics, and the differential diagnosis of the tumor.