A Pilot Study of Percutaneous Cholecystoenteric Anastomosis: A New Option for High-Risk Patients with Symptomatic Gallstones.

PURPOSE: To evaluate the safety and effectiveness of percutaneous cholecystoenteric anastomosis (PCEA) creation in patients with indwelling cholecystostomy tubes who are high-risk surgical candidates. MATERIALS AND METHODS: Fourteen (male, 10; female, 4) patients with a mean age of 79 years (range, 53-92 years) with previously inserted cholecystostomy tubes underwent PCEA with the adjacent duodenum using a lumen-apposing metal stent (LAMS) between January 2015 and October 2022. Intraprocedural adverse events and postprocedural safety and effectiveness outcomes were evaluated. Nine procedures were performed under sedation and 5 under general anesthesia. RESULTS: Technical success was achieved in 100% of the patients. In 12 patients (86%), the existing cholecystostomy tube was removed after the insertion of the LAMS. Three patients (21%) had a pre-existing cholecystoduodenal fistula, in which the stent was placed, and 11 (79%) underwent creation of a de novo anastomosis. The mean procedure time was 1.5 hours (range, 1-2 hours). The mean length of stay after the procedure was 2.4 days (range, 1-10 days). There were no intraprocedural adverse events. One patient with severe pre-existing cardiac comorbidities died during his postprocedural stay despite a technically successful procedure. One patient had delayed closure of the long-standing cholecystocutaneous tract. CONCLUSIONS: Early clinical experience with PCEA using an LAMS suggests that it is a safe and effective option for the creation of internal gallbladder drainage in patients who are not candidates for surgical cholecystectomy.

Paediatric hospitalisation related to medications administration errors of non-opioid analgesics, antipyretics and antirheumatics in England and Wales: a longitudinal ecological study.

OBJECTIVE: This study aimed to explore paediatric hospitalisation related to medication administration errors (MAEs) of non-opioid analgesics, antipyretics and antirheumatics in England and Wales. DESIGN: An ecological study. SETTING: A population-based study on hospitalised patients in England and Wales. Hospital admission data were extracted from the Hospital Episode Statistics database in England and the Patient Episode Database for Wales for the period between April 1999 and April 2020. Admissions cause was confirmed using the diagnostic codes T39.0-T39.9. PARTICIPANTS: Paediatric patients aged 15 years and below who were hospitalised at all National Health Service (NHS) trusts and any independent sector funded by NHS trusts. PRIMARY OUTCOME MEASURE: Hospitalisation rates related to MAEs of non-opioid analgesics, antipyretics and antirheumatics. RESULTS: The yearly number of admissions for MAEs associated with non-opioid analgesics, antipyretics and antirheumatics experienced a notable growth of 21.7% over the span of two decades, rising from 4574 cases in 1999 to 5568 cases in 2020. The observed increase demonstrates a significant upward trend in hospital admissions rate, with a 12.3% growth from 46.16 per 100 000 individuals in 1999 to 51.83 per 100 000 individuals in 2020 (95% CIs 44.83 to 47.50 and 50.47 to53.19, respectively, trend test, p<0.05). The therapeutic categories that exhibited the highest frequency of MAEs were '4-aminophenol derivatives' and 'other non-steroidal anti-inflammatory drugs', accounting for 79.3% and 16.0% of cases, respectively. It is worth noting that there was a significant increase of 28.9% in hospitalisations linked to MAEs specifically associated with '4-aminophenol derivatives.' CONCLUSION: The research revealed a notable rise in the overall yearly number of hospital admissions associated with MAEs within the paediatric population. This study emphasises the necessity for additional research aimed at mitigating the potential hazards associated with the ingestion of these medications, particularly within susceptible demographics, such as young children.

Myeloablative Dose of Busulfan and Fludarabine Combined with In Vivo T Cell Depletion Is Safe and Effective Conditioning for Acute Myeloid Leukemia and Myelodysplastic Syndrome Patients.

Allogeneic hematopoietic stem cell transplantation (HSCT) is a curative strategy for acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS). The prediction of transplantation-related mortality (TRM) using the Hematopoietic Cell Transplantation Comorbidity Index (HCT-CI) score and an arbitrary upper age limit of 55 years for administering myeloablative conditioning (MAC) are common strategies to ensure a safe procedure. The use of reduced-toxicity conditioning regimens is an additional approach to providing safe and effective myeloablation. Herein we report the outcome of AML and MDS patients conditioned with fludarabine and a myeloablative dose of busulfan (FB4) stratified by age and HCT-CI score. The primary objective was overall survival (OS) for patients age ≥55 years. Secondary objectives were total OS, TRM, graft-versus-host disease (GVHD), and GVHD, relapse-free survival (GRFS). The 2 year OS was 72% in patients age <55 and 51% in patients age ≥55. In patients age ≥55 with an HCT-CI <2, the estimated 2 year OS was 64%, with median OS not reached. In those with HCT-CI ≥2, the 2-year OS was 43%, with a median OS of 14 months. The total cumulative incidence of relapse was 30% regardless of age or HCT-CI score. FB4 conditioning regimen offers a high rate of prolonged remission with a relapse rate similar to that reported in previous studies. These positive outcomes suggest that this conditioning platform can be offered to patients age ≥55 years in the absence of comorbidities, and that age should not be the sole determinant of conditioning intensity.

De novo lymphoid blastic phase chronic myeloid leukemia: report and contemporary discussion.

OBJECTIVE: We herein describe two cases of de novo lymphoid blastic transformation in patients with no history of chronic-phase chronic myeloid leukemia (CP-CML), both of whom were labeled initially as Philadelphia positive B-Acute Lymphoblastic Leukemia (B-ALL). METHODS: The first patient was an 18-year-old male who presented with subjective fever, intentional weight loss, generalized fatigue, and headache. Investigations showed leukocytosis (312 × 10^3/ul), thrombocytopenia and anemia. Flowcytometry was consistent with B-ALL, with aberrant expression of CD13 and CD33. He was found to be positive for BCR::ABL by FISH, and karyotype confirmed the presence of the Philadelphia chromosome. He received a pediatric-inspired regimen and achieved remission with negative measurable residual disease (MRD) by flowcytometry, however with persistent cytogenetic abnormality using FISH for BCR::ABL. FISH abnormality was confirmed to be in the myeloid compartment using myeloid segregated FISH, reclassifying the disease to de novo lymphoid blastic phase CML. The second patient was a 52-year-old male who presented with fever and shortness of breath. Bilateral cervical lymphadenopathy and hepatosplenomegaly were identified on examination, and investigations showed leukocytosis (371 × 10^3/ul), anemia, and thrombocytopenia. BCR::ABL rearrangement was identified by FISH, molecular testing, and confirmed with karyotype. He was treated with Mini-CVD and Ponatinib, achieved complete remission with negative MRD by flow cytometry, however molecular studies showed BCR-ABL1 level at 58% IS indicating a persistent cytogenetic abnormality. RESULTS: De novo lymphoid blastic-phase CML can therefore be difficult to differentiate from Philadelphia positive B-ALL due to their overlapping clinical and laboratory picture, implying the need to do myeloid compartment evaluation at the time of diagnosis. CONCLUSION: With recent progress in the treatment of Philadelphia positive B-ALL, including the role of transplant with the use of novel agents, a better characterization of this disease entity in retrospective and prospective trials is warranted.

Haematological Traits in Symptomatic and Asymptomatic COVID-19 Positive Patients for Predicting Severity and Hospitalization.

Objective: The present investigation aims on the clinical attributes and haematological parameters between symptomatic (COVID-19 ICU) and asymptomatic (COVID-19 homes isolation) patients as predisposing sign for COVID-19 related mortality. Materials and Methods: A retrospective cohort research was conducted of admitted patients to ICU, who were suffering from severe COVID-19 in Aseer Central Hospital, Abha, Kingdom of Saudi Arabia (KSA) from July 2020 until September 2020. The study included individuals with COVID -19 and ICU admission as symptomatic group and others who are COVID-19 positives with quarantine as asymptomatic group. Epidemiological, clinical and haematological laboratory data were retrospectively collected, analysed with control subjects. Results: Of the 38 ICU patients studied, the most common symptoms were fever and respiratory distress (100%), cough (86.8%). Majority were of Saudi origin (78.9%). Eighteen (47.4%) COVID-19 ICU patients showed leukocytosis, 6 (15.8%) had severe thrombocytopenia (with most having thrombocytopenia), 18 (47.4%) were anaemic. A significant correlation was observed between the WBC, RBC, Hb, platelets, neutrophil and lymphocyte count between ICU inmates compared with quarantine (p < 0.001) and RBC, Hb, neutrophil and lymphocyte count with control groups (p < 0.001). Conclusion: From the observations it is evident that, the blood tests have potential clinical value in predicting COVID-19 progression. Further, patient characteristics including age, leukocyte count, RBC, platelets and differential leukocyte counts may be significant predictors for monitoring the progression of the critical illness observed in SARS-COV-2 patients. Also, treatment procedures can be re-defined further to reduce COVID-19 mortalities in more critically ill COVID-19 individuals.

Patients' Impression of Health Care Providers' Attire in the Emergency Department.

Background The level of patient satisfaction and, ultimately, the assessment of the quality of care are greatly influenced by physicians' capacity to leave a positive impression on patients during provider-patient interactions. The way doctors dress affects how people view their care. There have been few studies on the impact of doctors' attire on patient confidence and trust. The objective of this study is to assess patients' preferences concerning specific cultural attire and its influence on patients' trust, compliance, and perceptions of the quality of care in the emergency department. Methods A cross-sectional study was performed using the survey methodology for patients in emergency departments. Participants completed a written survey after reviewing doctors' portraits in different dress styles. Respondents were asked questions about the importance of the health service providers' attire in the emergency department on the patient's perception. The Statistical Package for Social Sciences version 21 (SPSS; IBM Inc., Armonk, New York) was used to perform the analysis after the data were entered into Microsoft Excel 2016 (Microsoft, Redmond, Washington). The categorical analysis was performed using the Chi-squared test to explore for relationships between the results and various variables. Result A self-administered questionnaire was completed by 395 patients; two responses were excluded for lack of completeness of the answers in it: 33.8%) were males (66.2%) were females (56.7%) were married (73.8%) completed university education (44.8%) were employed and (74.5%) with excellent health conditions. The questionnaire was devoted to the local setting, with pictures of the health care provider (male and female), in different types of doctor's attire included. Respondents overwhelmingly prefer male emergency physicians to dress in medical scrub (50%, p=.0001) and prefer female emergency physicians to dress in a medical scrub with a white coat (68.7%, p=.0001).  Conclusion First impressions based on a physician's appearance serve as the foundation for assumptions about trust, confidence, and competency, particularly in circumstances when patients or family members do not already have a relationship with the provider.

Role of 18F-Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography Imaging in the Prediction of Prognosis in Patients With Indolent Lymphoma: Prospective Study.

BACKGROUND: The role of fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) in indolent lymphoma has been minimally studied. OBJECTIVE: This study aims to assess the value of FDG-PET/CT in predicting the prognosis of indolent lymphoma. METHODS: We prospectively recruited 42 patients with indolent lymphoma. A total of 2 patients were excluded, and 40 underwent baseline PET/CT and follow-up at various time points. A total of 9 patients were observed only, 7 received 4 doses of rituximab alone, and 24 received chemoimmunotherapy. Metabolic response on follow-up PET/CT was assessed using the maximum standardized uptake value (SUVmax) and Deauville criteria (DC). We aimed to obtain the best SUVmax and DC to predict optimal survival rates, risk stratification, and optimize therapeutic strategies. The mean follow-up from the initial diagnosis was 33.83 months. RESULTS: SUVmax <4.35 at interim PET/CT provided the best discrimination, with a progression-free survival (PFS) of 100% and a median survival time of 106.67 months compared with SUVmax ≥4.35 (P=.04), which had a PFS of 43.8% and a median survival time of 50.17 months. This cutoff was also valuable in predicting overall survival at baseline, that is, 100% overall survival with baseline SUVmax <4.35, versus 58.4% for SUVmax ≥4.35 (P=.13). The overall survival of patients with a baseline DC score <3.0 was 100%, with a median overall survival of 106.67 months. CONCLUSIONS: We demonstrated the utility of PET/CT in indolent lymphomas. SUVmax (<4.35 vs ≥4.35) on interim PET/CT performed best in predicting PFS.

Occurrence of Diarrhea and Feeding Practices among Children below Two Years of Age in Southwestern Saudi Arabia.

Growing evidence suggests that feeding practices in early childhood play a major role in the occurrence of childhood diarrhea. However, there is a lack of information regarding feeding practices and its relationship with occurrences of diarrhea in young children from Saudi Arabia. The present study is aimed to measure the prevalence of diarrhea and assess its relationship with feeding practices among children between two months and two years of age in Saudi Arabia. A cross-sectional study was carried out in two large cities in the Aseer region in southwest Saudi Arabia. A total of 302 mothers attending well-baby clinics across six primary health centers were included. A structured questionnaire was used to collect data. Factors associated with diarrheal disease were identified by multivariable logistic regression analysis. The prevalence of diarrhea among children during the study period was 56.3% (95% CI: 50.7%-61.8%). Only 15.9% of children in our study were exclusively breastfed. The occurrence of diarrhea was significantly associated with age 7-12 months (aOR = 2.64, 95% CI: 1.42-4.91). We found that diarrhea was prevalent among children between two months and two years of age, and that exclusive breastfeeding was not a common practice in this region. Health education programs should be directed towards mothers to improve rates of breastfeeding, weaning practices, food hygiene, and childcare. Special attention and support should be provided for working mothers.

An Intriguing Case of Eosinophilia with FIP1L1/PDGFRA Rearrangement Who Presented as Thrombotic Thrombocytopenic Purpura.

Myeloid neoplasm with eosinophilia and FIP1-like-1-platelet-derived growth factor receptor-alpha (FIP1L1-PDGFRA) rearrangement is a multi-organ disease with diverse clinical presentation. Thrombotic thrombocytopenic purpura (TTP) is characterized by the concomitant occurrence of often severe thrombocytopenia, microangiopathic hemolytic anemia, and a variable degree of ischemic organ damage. To our knowledge, only one case of eosinophilia with FIP1L1-PDGFRA rearrangement presented as a case of thrombotic thrombocytopenic purpura reported in the literature. We herein report a case of a young male patient with hypereosinophilic syndrome and FIP1L1-PDGFRA rearrangement who presented with asthma, transient ischemic attacks (TIA), and confusion. He had an acquired TTP that was successfully treated with plasma exchanges (PLEX), corticosteroids, rituximab, and later with the addition of imatinib mesylate (Gleevec, Novartis). He remains in complete remission on imatinib 100 mg daily for more than 28 months of follow-up.

Knowledge, attitude, and performance of primary healthcare physicians in Aseer Region, Saudi Arabia about attention deficit hyperactivity disorder.

BACKGROUND: Attention-deficit hyperactivity disorder (ADHD) is one of the most common psychiatric disorders. This study aimed to assess the knowledge, attitude, and practice of primary health-care (PHC) physicians on diagnosis and management of ADHD. MATERIALS AND METHODS: This was a cross-sectional study included 340 PHC physicians in Aseer Region, Saudi Arabia. A self-administered questionnaire was used to collect data on personal characteristics, knowledge, attitude, and practice of the diagnosis and management of ADHD. RESULTS: Nearly 47.6% of the PHC physicians were aged <30 years, 60.3% were male, 79.1% were Saudi nationals, and 84.1% had completed MBBS. Only 13.2% had attended continuing medical education courses on ADHD, 63.2% had read about ADHD; Internet was the main source of information (30.7%). Participants' attitude toward ADHD was mainly positive, while 32.1% had poor knowledge and 17.6% had diagnosed ADHD cases in the last year, but 73.3% had referred the diagnosed cases to specialists. Participants' knowledge differed significantly according to their age, gender, and nationality. CONCLUSIONS: PHC physicians' knowledge about ADHD was suboptimal, but they had a positive attitude toward their role with regard to ADHD. PHC physicians should focus on the clinical and diagnostic aspects of ADHD. Awareness and interest of undergraduate medical students and newly graduated physicians in ADHD should be raised. The Ministry of Health should encourage attendance at extracurricular courses and workshops.

Bilateral peritonsillar abscess: A case report and pertinent literature review.

INTRODUCTION: The peritonsillar space is defined as the area between the palatine tonsillar capsule medially and the superior pharyngeal constrictor muscle laterally. Unilateral peritonsillar abscess (PTA) is more common than the bilateral condition. To the best of our knowledge, only 13 cases of bilateral PTA have been reported worldwide; this is the first case reported from Saudi Arabia. PRESENTATION OF CASE: We present a case involving a 16-year-old boy who presented to the emergency department with a5-day history of sore throat, dysphagia, trismus, drooling, and a muffled "hot-potato" voice, but with no symptoms of airway compromise. After several examinations, we diagnosed bilateral PTA. We performed an incision and drained the pus from both sides, which was positive for Streptococcus pyogenes. Postoperatively, the patient improved dramatically, and tonsillectomy was scheduled for 6 weeks later. DISCUSSION: The difficulty in diagnosing bilateral PTA stems from the fact that it does not present with the usual clinical characteristics as unilateral PTA. These symptoms include asymmetry of the tonsils and palate, deviation of the uvula, and unilateral otalgia. As these cases carry the risk of impending airway compromise, we recommend airway management as the first step in treating such cases. CONCLUSION: Based on our case and literature review, we recommend airway management as the first step, followed by further examinations, especially contrast-enhanced computed tomography, in cases of bilateral PTA. This condition lacks the hallmark of unilateral disease and may mimic many conditions, which will have different management approaches.

Effectiveness of stapedotomy in improving hearing sensitivity for 53 otosclerotic patients: retrospective review.

BACKGROUND: Otosclerosis is a common cause of progressive hearing impairment that causes fixation of the stapes. Surgical intervention is the preferred treatment approach to ameliorate the conductive hearing loss associated with stapedial otosclerosis. However, given that it is a difficult and delicate procedure, the surgery may fail for a number of reasons. Therefore, it is very important to evaluate the success rate of the surgical approach used in each regional center. OBJECTIVE: To examine the effectiveness of stapedotomy in improving hearing sensitivity for otosclerotic patients at King Abdul Aziz University Hospital in Riyadh. DESIGN: Retrospective chart review with an analysis of pre- and postoperative surgical treatment. SETTING: Tertiary referral otolaryngology clinic. PATIENTS AND METHODS: All cases who underwent stapedotomy between 1997 and 2009 were retrospectively reviewed. Preoperative and postoperative audiometric assessments were conducted using conventional pure tone audiometry. Differences were analyzed by two-way repeated measures ANOVA. MAIN OUTCOME MEASURE(S): Pre- and postoperative pure tone thresholds for air and bone conduction. RESULT: Fifty-three patients underwent stapedotomy. Stapedotomy yielded significant improvements in mean (SD) postoperative air-conduction thresholds of about 18.7 (11.7) dB (P < .0001) and mean (SD) post.operative bone-conduction thresholds of about 2 (7.2) dB (P < .05). Additionally, a significant correlation was found between improvement in air-conduction thresholds and the size of preoperatve air-bone gap (P < .01) About 70%of patients achieved an air-bone gap of 20 dB or better. None of the cases examined in this study exhibited sensorineural hearing loss or adverse complications following stapedotomy. CONCLUSIONS: Stapedotomy is a safe and effective treatment option for patients with otosclerosis. Given that the majority of participants in this study exhibited mixed hearing loss preoperatively, the results further suggest that stapedotomy can also be effective in improving thresholds for these patients. LIMITATIONS: The sample size was relatively small.

Modified Baha Punch Technique: Least Invasive, Shortest Time and No Suturing.

To describe a new Baha surgical procedure (Modified Punch Technique) with a smaller punch hole, a minimal incision and the use of the hydroxyapatite-coated abutment (BIA400). Retrospective chart review. Patients were implanted between 2012 and 2013 at King Abdulaziz University Hospital (Kingdom of Saudi Arabia). Eligible for initial or replacement bone-anchored hearing system; includes six patients (four adults, two children). Baha surgery using the Punch Method is described. The mean surgical time was 12.33 min (range 6-30), without the single outlier, it was 8.8 min. Bleeding was significant but easily controlled in two patients only. Depending on the postauricular subcutaneous thickness, the sizes of abutment used were 6, 8, 10 or 12 mm. None of the patients experienced severe pain. The postoperative follow-up period was 7 months for one patient, 5 months for three patients, and 3 months for two patients. First report of combined Modified Punch Technique with the BIA400 abutment is minimally invasive, reduces surgical time and results in faster healing and reduced likelihood of postoperative numbness.

Hair tourniquet syndrome: Successful management with a painless technique.

Hair tourniquet syndrome is a clinical phenomenon that involves hair or thread becoming so tightly wrapped around an appendage that pain, swelling and occasionally ischemia result. We report two cases of hair tourniquet syndrome that affected the digits and were treated with hair removal cream, which was an easy, effective and less invasive treatment method compared with standard managements such as incision or blunt probe cutting techniques.

Impedance cardiography: noninvasive assessment of hemodynamics and thoracic fluid content during bariatric surgery.

BACKGROUND: The effects of pneumoperitoneum (ppm) on hemodynamic parameters during bariatric surgery were investigated using the impedance cardiography monitor. METHODS: 11 patients with BMI 46.5+/-10 kg/m2 (range 38.9-60.8 kg/m2) underwent laparoscopic adjustable gastric banding under general anesthesia. Besides routine monitoring, the impedance cardiography (ICG) monitor was used to monitor cardiac output (CO), cardiac index (CI), systemic vascular resistance (SVR), and thoracic fluid content (TFC). Data were recorded at three stages: A) before ppm, B) during ppm, and C) after gas deflation. One-way analysis of variance (ANOVA) was used to analyze differences of the data before, during and after ppm, and post-hoc (Bonferoni test) for multiple comparisons of the data obtained. For all comparisons, P<0.05 was considered significant. RESULTS: There were significant low mean values of heart rate (HR), CO and CI at stage B compared to stage A (P<0.05). The mean values of TFC at stages A, B, and C were 30.48 +/- 4.69, 29.74 +/- 2.86 and 31.72 +/- 4.93 k/Ohm respectively, with a non-significant relationship (P>0.05). The mean values of SVR during the same stages A, B and C were 1299.18 +/- 374.40, 1873.64 +/- 276.26 and 1669.36 +/- 537.92 dynes sec cm(-5) respectively, with significant high mean values at stages B and C compared to mean value at stage A (P<0.05). CONCLUSIONS: Morbid obesity and pneumoperitoneum have significant effects on hemodynamics. However, it appears that these changes were of marginal clinical significance.