Outcomes of Cranioplasty: A Single-Center Experience.

Background Cranioplasty (CP) is a common cranial reconstructive procedure. It is performed after craniectomy due to various causes such as relieving increased intracranial pressure, infection, and tumor infiltration. Although CP is an easy procedure, it is associated with a high rate of complications. We aimed to retrospectively investigate the outcomes of CP at the King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah (KAMC-J). Methods This is a retrospective observational study that included all patients who had CP (first time or redo) at KAMC-J from 1st January 2010 to 31st December 2020. Patients with congenital cranial malformation were excluded.  Result A total of 68 patients underwent CP. Of those, 23 (34%) had complications. The most common complication was infection (10.3%). Twelve of the 23 patients had major complications that necessitated reoperation. Of those 12, six underwent redo CP; three out of these six patients had further complications which were also managed surgically. On bivariate analysis, cranial defects over 50 cm² were associated with a higher rate of both infection and hydrocephalus (p=0.018) while the frontal site was associated with a higher rate of infection (p=0.014). Moreover, traumatic brain injury as an etiology was exclusively associated with post-cranioplasty hydrocephalus (p=0.03).  Conclusion Patients undergoing CP after craniectomy are prone to a considerably high rate of adverse outcomes. The overall rate of complications in this study was 34%, with an infection rate of 10.3% and a 1.5% mortality rate. Consistent with other studies, larger cranial defects as well as frontal sites have a higher rate of infection.

The Outcomes of Diffuse Large B-cell Lymphoma Patients with Synchronous and Early Central Nervous System Involvement: A Single-Center Experience.

BACKGROUND: Diffuse large B cell lymphoma (DLBCL) is the most commonly diagnosed subtype of non-Hodgkin's lymphoma (NHL). R-CHOP has significantly improved clinical outcomes in patients with DLBCL, however, its indication in the prevention of CNS relapse and recurrence is still inconsistent. Moreover, prophylactic methotrexate and/or cytarabine have been used prophylactically for DLBCL patients is at high risk of CNS relapse and to treat CNS DLBCL, however, their efficacy remains unclear. METHODS: The aim of our retrospective study was to determine the incidence of CNS in-volvement in patients with DLBCL and to describe its risk factors and survival outcomes. RESULTS: A total of 406 patients with DLBCL were identified, and 17 (4.2%) of DLBCL patients had CNS involvement i.e. 9 (2.2 %) at diagnosis and 8 (~2%) at relapse. The patients were younger, had advanced stage, high CNS-IPI, and had extra nodal involvement. Seven out of the 17 patients who survived received chemotherapy and a prophylactic methotrexate. Considering the CNS-IPI, of the 146 patients with high CNS-IPI at presentation, 18 received the prophylactic HDMTX and 3 (16.7%) of them had CNS relapse. Two (1.6%) out of 128 who did not receive the prophylactic HDMTX had CNS relapse. On the other hand, of the 223 patients with intermediate CNS-IPI, 25 received the prophylactic HDMTX and 2 (8%) of them had CNS relapse and in 198 patients who did not receive the prophylactic HDMTX, 2 (1.01%) had CNS relapse. The 5-year progression-free survival and overall survival rates for the entire cohort were 73% and 84%, respectively. The median OS for those who had CNS involvement was 17 months and the 2-year OS was 40%. CONCLUSION: CNS involvement in DLBCL has a poor prognosis, thus, aggressive CNS-directed therapy should be considered, especially in young patients.

Approach to Ankle Instability in Patients With a Negative Ankle MRI: A Case Series.

Objectives Injuries to the ankle ligaments are some of the most common musculoskeletal sports injuries. Ankle magnetic resonance imaging (MRI) is the standard diagnostic procedure in today's practice, but its reliability and validity remain controversial. The aim of this study was to explore the approach for patients with negative ankle MRI who continue to have symptoms of ankle instability despite conservative therapy. Methods A total of eight patients who were 14 years or older with negative ankle MRI who continue to have symptoms of ankle instability despite conservative therapy were admitted to our institution from January 1, 2015 to December 31, 2021. Results Eight patients with a mean age of 36, and a mean body mass index (BMI) of 37.7. All patients presented with ankle pain, locking, and giving way in variable severity. All the patients had a radiograph followed by an ankle MRI, which showed normal alignment of ankle joints without abnormality. Initially, all patients were treated conservatively but did not show any improvement. After that, they underwent an operation of lateral ankle ligament reconstruction by modified Brostrom technique, followed by casting and physiotherapy. The symptoms of ankle instability resolved in all patients. The ankle pain resolved completely in six patients, improved in one patient, and did not improve in one patient.  Conclusion Based on our results, we advocate reconstruction surgery by modified Brostrom technique for ligament repair in patients with clinical evidence of chronic ankle instability who have failed a trial of conservative management, even in the context of a normal ankle MRI.

Opioid-induced respiratory depression and risk factors in a tertiary hospital: A retrospective study.

Background: Opioids are potent analgesics used for the treatment of moderate to severe acute and chronic cancer and non-cancer pain. However, opioid usage may be limited by negative side effects, such as potentially life-threatening respiratory depression. Objectives: The aim of our study is to investigate the prevalence of opioid-induced respiratory depression (OIRD) and its predictors at King Abdulaziz Medical City in Jeddah (KAMC-JD). Method: This is a retrospective cross-sectional (chart review) study conducted from January 1, 2016, to December 31, 2020. Results: A total of 15,753 patients received opioids during admission to KAMC-JD, and only 144 (0.915%) of them received naloxone from January 1, 2016 to December 31, 2020. Only 91 patients (0.57%) developed opioid-induced respiratory depression (OIRD), which was more frequently reported among young and middle-aged adults. OIRD was significantly associated with receiving a daily morphine milligram equivalent (MME) dose of ≥150 MME and with having a low urea concentration at the baseline and at admission under surgery. Also, fentanyl use remained a significant risk factor for OIRD. Conclusion: In conclusion, monitoring patient receiving opioids with a daily MME dose of ≥150 MME, prescribed Fentanyl, low urea concentration at the baseline, and patients' admissions to the surgery department may mitigate the risk of developing OIRD.

The Utilization of Lumbar MRI for Lower Back Pain at National Guard Hospital, Jeddah: A Retrospective Cohort Study.

Introduction Magnetic reasoning imaging (MRI) is the imaging modality of choice for detecting spinal pathologies. The study of the appropriateness of MRI utilization in Saudi Arabia is lacking. As a result, this research aims to assess the use and misuse of lumbar MRI in lower back pain (LBP) at the National Guard Hospital (NGH) in Jeddah city. Methods This is a retrospective cohort study that included all adult patients who had lumbar MRI for LBP at NGH in 2019. A total of 1,225 patients were included. Patients with extreme ages, trauma, recent lumbar spine surgery, spine or spinal canal tumors, and infection were excluded, leaving a number of 805 patients. Specific MRI findings were obtained and assessed in association with history and physical examination. Results LBP with radiculopathy was the most common complaint (82.9%) followed by LBP without radiculopathy (12.8%), with the lowest being limb pain alone (2.6%). Overall, 72% of patients had negative MRI findings, which did not explain their symptoms, and 28% had positive MRI findings that were not associated with their symptoms (p < 0.001). A complete physical examination was performed on 27.5% of patients, of which only 12% had positive findings. MRI was ordered for 72.5% of patients without a complete physical examination. Finally, 88.2% of patients who had MRI were managed conservatively, while only 6.7% were managed with surgery (p < 0.04). Conclusion The number of patients who had proper assessment prior to the ordering of MRI was significantly low. The decision to request MRI was not based on any scientific basis. This study has demonstrated that without proper and strict guidelines, MRIs will continue to be overutilized, which, in turn, will have negative consequences on the waiting time for an MRI and the cost of all the unnecessary MRIs. Furthermore, a good number of patients nowadays who do not have any indications for an MRI keep asking their physicians for it, and if the physician refuses, they transfer to another physician who will order the MRI.

The The Impact of Surgical Revascularization on Cardiac Function and Mitral Regurgitation in Patients with Coronary Artery Disease: An Intermediate-Term Single-Center Experience.

INTRODUCTION: Ischemic heart disease is the most common cause of death worldwide. Coronary artery bypass grafting (CABG) is the most performed cardiac surgical procedure. Studies have shown that CABG can have a beneficial effect on left ventricular ejection fraction (LVEF) and ischemic mitral regurgitation (IMR) without intervention on the mitral valve. This study aims to assess changes in LVEF and IMR after CABG in our population. METHODS: We retrospectively reviewed charts of patients who underwent only CABG at King Faisal Cardiac Center in Jeddah between January 2016 and December 2019 (N = 298). Pre- and postoperative echocardiography data were evaluated. Changes in cardiac function and mitral regurgitation were analyzed. RESULTS: CABG was performed on 298 patients. The median age was 61 years (interquartile range (IQR)= 54-68), and 78.5% of the patients were male. The median body mass index was slightly higher in females (32.9 vs. 28.6 kg/m2, P = 0.089). Approximately 81% of patients had diabetes and hypertension, but only 24% were active smokers. The median time between pre- and postoperative echocardiography was 8 months (IQR= 3-17). The median preoperative LVEF was 51% (IQR= 44.1-57.9), and 75% of patients had normal-to-mild MR. The median postoperative EF was not different among patients who underwent echocardiography within or after 6 months (53.1% and 50.3%, respectively, P = 0.454). None of the patients progressed to severe MR after surgery, and only 2.7% had moderate-to-severe MR at follow up. Postoperative in-hospital mortality was 0.7%. CONCLUSION: Based on international guidelines and the best evidence, surgical revascularization is sufficient for patients with coronary artery disease (CAD) with moderate IMR and is not associated with LVEF worsening or MR progression. Complete revascularization might have an influence on ventricular recovery that might improve or stabilize IMR. Our results are consistent with larger studies reporting very low postoperative mortality of this high-risk patient group.