Delayed Irreversible Fanconi Syndrome Associated With Vertebral Fracture After Tenofovir Discontinuation.

The use of tenofovir disoproxil fumarate (TDF) as an antiretroviral agent has been reported to adversely affect both renal tubules and bone health, leading to pathological fractures. While such an effect is largely reversible, substituting TDF with tenofovir alafenamide (TAF) might result in lower rates of adverse events with the preservation of tenofovir effectiveness. We report a case of a 40-year-old lady with HIV infection who had a vertebral fragility fracture secondary to TDF-associated Fanconi syndrome. The syndrome developed four years after TDF cessation and switching to TAF. Other etiologies for decreased bone mass were excluded, and the diagnosis of Fanconi syndrome was established based on her bone mineral density (BMD) and urine parameters. She was treated conservatively with active vitamin D, calcium, and progesterone/estrogen combination, but her phosphate wasting persisted despite switching to TAF; this likely represents a delayed irreversible effect of TDF on the patient's bone remodeling. This case report highlights the chronic sequelae of TDF therapy and the importance of monitoring for and early detection of renal tubulopathy and osteoporotic fractures in this patient population.

Course and predictors of excellent response to therapy in patients with differentiated thyroid cancer at long-term follow-up.

OBJECTIVES: To investigate the long-term outcomes of differentiated thyroid cancer (DTC) and the predictive factors for excellent and incomplete responses to therapy on long-term follow-up of patients. METHODS: A retrospective chart review and analysis was carried out at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Demographic, histological, and therapeutic data were collected from patients older than 13 years at the time of diagnosis, with a minimum follow-up of 18 months. Outcomes were divided into excellent, indeterminate, biochemically incomplete, and structurally incomplete responses. Odds ratios (ORs) for predictors of incomplete response at the last visit were determined. We first tested associations univariately with incomplete responses, and then variables with significant associations were included in a multivariable logistic model. RESULTS: Among 230 patients with DTC, 61.7% had excellent responses to therapy on long-term follow-up, and 24.3% had incomplete biochemical and structural responses. The median follow-up was 4.6 years. Factors significantly associated with incomplete response to therapy in the multivariate analysis (p<0.05) were age >55 years (OR=5) and lymph node (OR=3.4) and distant metastases (OR=29). Older age did not affect the outcome in low-risk patients with DTC but was significantly associated with incomplete responses in those with intermediate risk (p=0.04) and high risk (p=0.003). CONCLUSION: We strongly advocate incorporating age into recurrence risk assessment for patients with DTC.

Accuracy of ultrasound in predicting thyroid malignancy: a comparative analysis of the ACR TI-RADS and ATA risk stratification systems

ABSTRACT Objective: Thyroid nodules are very common in clinical practice, and ultrasound has long been used as a screening tool for their evaluation. Several risk assessment systems based on ultrasonography have been developed to stratify the risk of malignancy and determine the need for fine-needle aspiration in thyroid nodules, including the American Thyroid Association (ATA) system and the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS). The aim of this study was to compare the performance of the ATA and ACR TI-RADS systems in predicting malignancy in thyroid nodules based on the nodules' final histopathology reports. Materials and methods: We performed a retrospective review of medical records to identify patients who underwent thyroid surgery at King Abdulaziz University from 2017 to 2022. The ultrasound features of the nodules with confirmed histopathology (benign versus malignant) were evaluated. Both ATA and ACR TI-RADS scores were documented. Results: The analysis included 191 patients who underwent thyroid surgery and fulfilled the inclusion criteria. Hemithyroidectomy was performed in 22.5% of the patients, and total thyroidectomy was performed in 77.0% of them. In all, 91 patients (47.6%) were found to have malignant nodules on histopathology. We then compared the histopathology reports with the preoperative ultrasonographic risk scores. The estimated sensitivity and specificity in identifying malignant nodules were, respectively, 52% and 80% with the ATA system and 51.6% and 90% with the ACR TI-RADS system. Conclusion: Both ATA and ACR TI-RADS risk stratification systems are valuable tools for assessing the malignancy risk in thyroid nodules. In our study, the ACR TI-RADS system had superior specificity compared with the ATA system in predicting malignancy among high-risk lesions.

A Case of Recurrent Thyrotoxicosis in a Thyroglossal Duct Cyst 18 Years Following Thyroid Surgery.

Graves' disease (GD) is an immune-mediated condition related to high thyroid-stimulating immunoglobulin levels. Here, we present a rare case of recurrent thyrotoxicosis that developed in a thyroglossal duct cyst (TGDC) and the residual thyroid tissue in a 46-year-old female following subtotal thyroidectomy. In 2005, she was diagnosed with GD causing thyrotoxicosis and treated with subtotal thyroidectomy. In 2022, she was seen at our clinic with a neck swelling gradually growing in size over the last 10 years. On examination, the mass was found to be moving with tongue protrusion. She was on thyroxin 100 mcg daily, and the dose was reduced gradually until she was maintained on no therapy for hypothyroidism and was still thyrotoxic. The combined clinical, laboratory thyroid scintigraphy and ultrasonographic features favored early developing recurrent Graves' disease in the thyroid residual and TGDC. She was started on carbimazole and was referred for surgery. Our case represents a rare occurrence of recurrent GD in the thyroid residual and TGDC.

Accuracy of Four-Dimensional Computed Tomography and Different Imaging Modalities in Primary Hyperparathyroidism.

Background This study aimed to compare the accuracy of different imaging modalities in the preoperative localization of parathyroid pathology in primary hyperparathyroidism. Methodology This prospective study enrolled 70 patients who were biochemically diagnosed with primary hyperparathyroidism between 2021 and 2022 at our center. Patients underwent scanning using three imaging modalities, namely, Tc99m sestamibi scan (sestamibi), parathyroid ultrasonography, and four-dimensional computed tomography (4DCT). A descriptive analysis was performed to determine and compare the respective localizing sensitivities. Results The most common site of parathyroid adenoma (PA) was the left inferior parathyroid gland, seen in 28 (40%) patients. Three patients had false-positive imaging studies with no parathyroid pathology identified surgically or on histological examination. The median levels of parathyroid hormone decreased significantly (p < 0.001) after the surgery, with a median of 24.3 (1.90-121). Furthermore, 4DCT accomplished a sensitivity of 97.14% for diagnosing the side and 94.03% for overall localization of PA. This sensitivity was superior to the sensitivity of ultrasonography and sestamibi scan to detect the side and quadrant of the adenoma. 4DCT was significantly higher in sensitivity when compared to the combination of ultrasound and sestamibi (p < 0.001). Conclusions 4DCT yielded the highest sensitivity in localizing parathyroid pathology from the imaging modalities studied with the lowest false-negative rate. Using ultrasound with 4DCT could be the most cost-effective combination for detecting primary hyperparathyroidism.

Diabetic ketoacidosis in Saudi Arabia: factors precipitating initial admission and readmission.

BACKGROUND: Diabetic ketoacidosis (DKA) is one of the complications of diabetes mellitus (DM), primarily type 1 DM. To our knowledge, only one study explored DKA readmission rates in Saudi Arabia. OBJECTIVES: Identify and analyze precipitating factors for DKA admission and readmission. DESIGN: Medical record review. SETTING: Tertiary care center. PATIENTS AND METHODS: We identified all patients aged 15 years and older admitted with DKA from 2018 to 2020. Descriptive factors and uni-and multivariate analyses are presented for associations with initial admission and readmission. MAIN OUTCOME MEASURES: Relationships between precipitating factors and initial admission and readmission. SAMPLE SIZE: 176 patients. RESULTS: Most of the patients had type 1 DM (n=157). The median (interquartile percentiles) for duration of DM was 6.0 (1.0-12.0) years. The mean (SD) HbA1C (%) was 11.8 (2.6). The factors that precipitated DKA were most commonly treatment nonadherence (55.1%), followed by infections (31.8%) and nonadherence to diet (25.6%). The most common symptoms were nausea and vomiting (87.5%), followed by abdominal pain (72.7%). During the study period, 32.4% of the sample were read-mitted with DKA. The median (interquartile range) duration between the first and second admission was 12 (4-25) weeks. In the multivariate analysis, increased odds of readmission for DKA were associated with type 1 DM and medication nonadherence (P=.038, P=.013, respectively). The severity of the initial DKA and the control of DM were not associated with the readmission rate. CONCLUSION: Treatment nonadherence is the leading precipitating factor of DKA in our region. Patient education and counseling play a major role in addressing this preventable complication and its medical and financial burden. We advocate more efforts dedicated toward patient education and logistic support. LIMITATIONS: Retrospective-single center. CONFLICT OF INTEREST: None.

The long-term impact of neck scar satisfaction among thyroid surgery patients.

This study evaluated scar satisfaction in Arabic patients who underwent thyroidectomy surgery using validated assessment tools. We aimed to assess the relationship between scar length and scar satisfaction, and validate Arabic versions of the universally used scar satisfaction questionnaires. In this retrospective cohort study, 60 patients who underwent thyroidectomy at King Abdulaziz University Hospital were enrolled. Scars were evaluated in two stages: firstly, by a clinician, and secondly, by a naïve observer. Ratings of disfigurement were measured using the validated Patient and Observer Scar Assessment Scale (POSAS) that was translated into Arabic. Results: The Arabic version of the POSAS showed good or excellent reliability. Average POSAS scores were 12.88, 18.02, and 7.53, respectively, indicating that most patients were satisfied. Incision size and POSAS scores (but not Patient and Naïve Observer scores) were positively correlated, and larger incisions resulted in greater dissatisfaction. Fitzpatrick Skin Type score and Observer scores were positively correlated, but there were no significant correlations between Patient and Naïve Observer scores with skin type. In conclusion, this study validated the Arabic version of universally used questionnaires for scar satisfaction. Most patients were satisfied with their neck scars regardless of scar length. Our findings pave the way for further research into patient postoperative scar satisfaction in Arabic-speaking populations.

Neoadjuvant lenvatinib for inoperable thyroid cancer: A case report and literature review.

BACKGROUND: Poorly differentiated thyroid cancer (PDTC) is now classified as a separate thyroid tumor entity. It has male predominance and poor prognosis compared to differentiated TC. CASE: We report a case of a patient with PDTC who was previously deemed inoperable. A trial of neoadjuvant lenvatinib therapy was given to the patient after that the tumor become operable and the surgery went successfully. CONCLUSIONS: Lenvatinib is a feasible option in patients with inoperable TC and can stabilize the lesion size or even reduce it, leading to a more favorable surgical outcome.

Diabetes and driving safety: A survey among health care professionals in Saudi Arabia.

AIMS: Diabetes mellitus may impair an individual's fitness to drive. In this study, we explore health care providers' (HCPs) knowledge of problems associated with diabetes and driving, and evaluate the consistency of counseling on driving safety for patients with diabetes. METHODS: We conducted a cross-sectional survey-based study among HCPs in Saudi Arabia. We designed a web-based questionnaire to collect demographic data, assess HCPs' knowledge of driving and diabetes and their compliance with driving safety regulations, and meet Diabetes Canada's and the British Driver and Vehicle Licensing Agency's recommendations. Data were analyzed using descriptive statistics and chi-square analysis. RESULTS: We received 389 responses to the questionnaire. The majority of the respondents were consultants (38.8%), worked in governmental institutes (72.2%), and managed more than 30 patients weekly (34.4%). Only 5.7% of HCPs correctly answered all the driving safety questions. Diabetes educators and general practitioners had the fewest correct answers (p-value 0.03). About 12.6% of HCPs stated that they always counseled their patients about driving safety strategies. CONCLUSION: HCPs' education in problems associated with diabetes and driving should be improved to ensure quality counseling for their patients.

Frequency of Preoperative Localization Techniques of Parathyroid Adenoma at King Abdulaziz University Hospital, Saudi Arabia.

Background Accurate preoperative radiological localization of parathyroid pathologies paves the way to enable less invasive surgical procedures. Results on the accuracy of the different diagnostic measures are conflicting. Also, little is known about the most common location of parathyroid lesions. This paper aims to determine the most common location of parathyroid adenoma and evaluate the diagnostic performance of radiological modalities such as ultrasonography, sestamibi scintigraphy/single-photon emission computerized tomography (SPECT), magnetic resonance imaging (MRI), and computed tomography (CT) scan for the preoperative localization of parathyroid pathologies. Methods This is a retrospective study. Data were collected from patients who underwent total or partial parathyroidectomy at King Abdulaziz University Hospital between January 2000 and March 2020. The parathyroid adenoma site was detected preoperatively by a radiological method and confirmed postoperatively by the histopathology report. The performance of each preoperative localizing radiological method was evaluated based on the accuracy in localizing parathyroid pathology. Results A total of 73 patients were included in the analysis, with females being the most common gender in the study at 64%. Only complete data files were included and incomplete data files were excluded. The most frequent mode of detecting parathyroid adenoma was a sestamibi/SPECT scan (62.5%) followed by a CT scan (50%), ultrasound (34.6%), and MRI (25%). The most common location of a parathyroid adenoma was the left side. Conclusion Sestamibi/SPECT is a frequent radiological method for detecting the parathyroid lesion site as compared with CT, MRI, and ultrasonography.

Effect of COVID-19 Pandemic on the Cardiac Outpatients' Perception of Seeking Medical Advice.

OBJECTIVES: During this unprecedented time of COVID-19 pandemic, it was noticed a decline in cardiovascular cases presentation to the Emergency rooms in many countries, raising many speculations about the reasons and its ramifications. 1 - Identify the reasons during this pandemic that refrain patients from seeking medical care and its impact on stress level and medication adherence. 2 - Emphasize the new role of virtual medicine. METHODS: A quantitative descriptive cross-section survey study of 388 patients. It has been done in the cardiac outpatient department and conducted virtually through telemedicine. RESULTS: Despite this pandemic and its consensuses, the majority of cardiac outpatients will still seek medical advice in case of experiencing symptoms. Nevertheless, the fear of contracting COVID-19 infection, which can alter patient's decisions from visiting the emergency room and the increase in stress level during these challenging times, is genuine and no more an element of guessing. CONCLUSION: The majority of cardiac outpatients will wisely seek medical advice in case of serious cardiac symptoms and are adherent to their medications during this pandemic. Nevertheless, they face many concerns which need to implement a preventive and helping measures to fight the consensuses of COVID-19 such as, patient educations, establishing a hotline to all patients, telemedicine, new phone applications, and delivering medications to patients are essential in such circumstances to ensure continuity of care.

Predictors of persistent disease following initial thyroid cancer management.

OBJECTIVES: To study which factors increase the risk of persistent disease in differentiated and poorly differentiated thyroid carcinoma. Methods: A retrospective chart review of all consecutive differentiated and poorly differentiated thyroid cancer patients from King Abdulaziz University Hospital, Jeddah, Kingdom of  Saudi Arabia, a tertiary care center, between 2004 and 2018. Logistic regression analysis was performed to predict factors associated with less than excellent response to treatment. Results: We included 186 patients with complete data records; 81.1% were females. Papillary thyroid carcinoma comprised 88.1% of the neoplasms. In total, 55.9% of patients attained an excellent response to treatment by the end of the first year following treatment. All patients with distant metastasis had persistent disease. On univariate analysis, female gender was associated with excellent response (p=0.002). Lymph node metastasis, extrathyroidal extension, vascular invasion, and cancer multifocality were all found to be inversely related to excellent response (p less than 0.05 for all). On multivariate analysis only lymph node metastasis was associated with a decreased adjusted odds of an excellent response (p=0.007). Conclusion: Patients with lymph node metastasis are at high risk for persistent disease following initial thyroid cancer management. Careful monitoring of these patients is warranted.

Clinicopathological Characteristics of Thyroid Cancer in a Saudi Academic Hospital.

Background The global incidence of thyroid cancer (TC) has increased significantly over the past decades. In Saudi Arabia, it is the third most common cancer among adults. This study aims to review the clinical and histopathological characteristics of TC in Saudi Arabia and analyze the size trend over the years. Methods We conducted a retrospective chart review of all differentiated and poorly differentiated TC patients following up at a tertiary care center in the Western region of Saudi Arabia. All patients 11 years and older, diagnosed between 2004 - 2018, and with sufficient histopathological data were included. Follicular and poorly differentiated TC were categorized and tumor stage was allocated. We performed descriptive and size trend analysis. Results We had a total of 285 patients who qualified for inclusion. The mean age at diagnosis was 40.6 years, and 81.05% of patients were females. Papillary TC comprised 88.07% of these neoplasms, and most patients (89.12%) were at Stage I. Only papillary TC showed a gender difference in the age of the diagnosis. In men, the mean age at diagnosis of papillary TC was 46.98 ± 15.4 years, while in female patients, it was 39.02 ± 12.8 years (p-value = 0.0001). We did not find a trend toward smaller tumours in the more recent years in comparison to the early years (r = -0.083, p-value = 0.168). Conclusions TC is diagnosed at a younger age and larger sizes in Saudi Arabia in comparison to other countries. A gender difference was only noted with papillary TC in regard to the age of diagnosis. There was no trend toward smaller sizes of TC over the years.

Epidemiology and clinical consequences of occupational exposure to blood and other body fluids in a university hospital in Saudi Arabia.

OBJECTIVES: To describe the epidemiological characteristics, clinical impact, and adequacy of post-exposure management of occupational exposure to blood and body fluids (BBFs).  METHODS: Retrospective chart review of individuals reporting exposure to BBFs from 2007 to 2013 at King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia.  RESULTS: The total number of exposures reported was 326 exposures, of which 302 (92.6%) exposures were percutaneous, 21 (6.5%), mucocutaneous, and 3 (0.9%), bites. Nursing staff/students had the highest rate of exposure (149, or 45.6%), followed by physicians (57, or 17.5%). Surgeons were found to have a significantly higher risk for sharp injuries compared with other physicians (26.3%, or 15 exposures, p less than 0.005). Most (216, or 72.5%) percutaneous injuries were caused by hollow-bore needles. Majority of exposures (124, or 42.6%) occurred after using the needle/sharp item and before disposal. Two-thirds (219, or 67%) of exposed individuals were immune to hepatitis B at the time of exposure. With appropriate post-exposure management, none of exposed individuals seroconverted to HIV, hepatitis B or C virus infections.  CONCLUSION: Occupational exposure to BBFs remains a concern among healthcare workers. Educational programs targeting high-risk groups entailing reinforcement of prevention and adherence to post-exposure management guidelines are needed.