Simultaneous Transcatheter Closure of a Ventricular Septal Defect and Pulmonary Valvuloplasty: A Case Report.

BACKGROUND Congenital heart diseases (CHDs) are the most common form of birth defects, affecting the structure and function of neonatal hearts. Pulmonary valve stenosis (PVS) and ventricular septal defects (VSD) are 2 of the more prevalent forms, both of which can lead to significant morbidity if left untreated. The emergence of transcatheter techniques has revolutionized the therapeutic landscape, presenting minimally invasive yet effective alternatives to open-heart surgery and significantly reducing associated patient morbidity and recovery time. CASE REPORT The presented case details the management of a 19-year-old man with complex CHDs, highlighting the nuanced decision-making process that led to a transcatheter approach. The patient's clinical presentation, marked by symptoms reflective of significant cardiac compromise, demanded a tailored approach that utilized the latest advancements in non-surgical intervention. The successful closure of the VSD with an Amplatzer device and the resolution of PVS via balloon valvuloplasty were achieved without complications, showcasing the potential of these techniques in managing similar cases. The post-intervention period was marked by a noteworthy recovery, confirming the procedural efficacy and enhancing the patient's quality of life. CONCLUSIONS The favorable outcome of this case highlights the pivotal role of transcatheter interventions in treating complex CHDs and suggests a shift towards less invasive approaches in cardiac care. This case contributes valuable insights to the existing body of evidence, reinforcing the potential of transcatheter techniques to become the preferred treatment modality. With promising immediate and short-term results, these techniques highlight the need for continued research into their long-term efficacy and application across diverse patient demographics.

Physical accessibility, availability, financial affordability, and acceptability of mobile health clinics in remote areas of Saudi Arabia.

Introduction: Access to primary healthcare (PHC) services is a significant concern, especially for those living in remote areas. Mobile health clinics (MHCs) are a model widely used to enhance access to healthcare in rural areas. In Saudi Arabia, the Ministry of Health has launched mobile clinics to facilitate access to PHC and increase access to healthcare. This study aims to assess the accessibility of MHCs in rural areas of Saudi Arabia measuring four dimensions of access from the patient's perspective: physical accessibility, availability, financial affordability, and acceptability. Methods: A quantitative cross-sectional survey in the form of an interviewer-administered questionnaire was performed on patients who attended mobile clinics between August and October 2020. All these people have been targeted to be interviewed as a nonprobability sample. Data was collected through a survey filled out by the interviewer. Results: Five hundred participants were interviewed in nine mobile clinics in the nine cities of the Kingdom. The majority were men (82.4%) and from Makkah city (13.6%) and 94.2% of the participants were Saudi nationals. In total, 98.3% of the respondents were satisfied with the overall mobile clinic services and 11.4% of the participants had difficulties with the mobile clinics' work schedules. There was a positive correlation between access to mobile clinics and satisfaction. Conclusions: The mobile clinics in rural and remote areas in Saudi Arabia during the study period were accessible to the respondents and met patient satisfaction. Most participants accept the work schedule for mobile clinics. However, it requires further improvements to meet all access dimensions of the study.

Hesitance and Misconceptions about the Annual Influenza Vaccine among the Saudi Population Post-COVID-19.

(1) Background: Vaccination is a cornerstone of public health strategy for mitigating the morbidity and mortality associated with seasonal influenza. However, vaccine hesitancy and misconceptions pose significant barriers to this effort, particularly in the context of the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to investigate the transfer of COVID-19 vaccine hesitancy to the influenza vaccine and to identify misconceptions about the influenza vaccine among the Saudi population in the post-COVID-19 era. (2) Methods: A web-based, cross-sectional study was conducted between February and June 2023 using a questionnaire adapted from the Adult Vaccine Hesitancy Scale (aVHS). The questionnaire was disseminated to 589 Saudi residents, aged 18 and above, with access to digital devices. Data were analyzed via logistic regression analysis to determine the associations between vaccine hesitancy, knowledge of influenza, and baseline characteristics. (3) Results: This study found that 37.7% of respondents exhibited vaccine hesitancy, while 56.7% demonstrated good knowledge about influenza. There was a significant relationship between nationality and vaccine hesitancy (p-value > 0.05), with non-Saudi respondents exhibiting higher hesitancy. Logistic regression analysis revealed significant associations between vaccine hesitancy, age, and nationality. Meanwhile, participants with higher educational qualifications showed greater knowledge about influenza. (4) Conclusions: The findings highlight an important crossover of COVID-19 vaccine hesitancy to influenza vaccines. This study underscores the need for targeted public health interventions to address misconceptions about the influenza vaccine, particularly among certain demographic groups, in order to improve influenza vaccine uptake in the post-COVID era.

Epidemiology, clinical characteristics, diagnosis, and complications of scrub typhus infection in Nepal: a systematic review.

Introduction: Scrub typhus (ST) is a neglected tropical disease of serious concern in Nepal. This systematic review aims to describe the burden of disease, clinical presentation, and complications of ST infection in Nepal. Methods: A systematic search of PubMed, EMBASE, Google Scholar, and national databases was conducted for any literature published in English between January 2000 and January 2023. Any type of study design (observational studies, case series, and interventional studies) that reported laboratory-confirmed ST and was conducted in Nepal among patients of all age groups was included. The seroprevalence of ST among acute undifferentiated febrile illness (AUFI) cases, geographical distribution, monthly distribution, clinical presentations, complications, and treatment were assessed by the study. Result: A total of 15 studies with 10, 977 participants were included in the review. The seroprevalence of ST among the AUFI cases in Nepal was 19.31%. Young people at or below 20 years of age were mostly affected. The maximum number of cases were reported from Bagmati province (59.46%) and in the month of August (26.33%). Fever, headache, cough, shortness of breath, nausea, and abdominal pain were the clinical characteristics in decreasing order of occurrence. The most common complication was acute kidney injury, followed by respiratory problems, cardiac issues, and neurological manifestations. The case fatality rate of ST in Nepal was 2.56%. Conclusion: The authors findings showed a significant burden of ST among AUFI cases in Nepal. Improved surveillance, general public awareness, and early detection post-calamities could help reduce the disease burden and improve patient outcomes.

Predictors of pregnancy-associated venous thromboembolism: A case-control study.

Background: Venous thromboembolism (VTE), manifesting as pulmonary embolism (PE) or deep vein thrombosis (DVT), is the most common cause of morbidity and death during pregnancy and the postpartum period. We conducted this study to describe the predictors of pregnancy-associated VTE (DVT and PE). Methods: A case-control study was conducted at a tertiary care center in Riyadh. A total of 380 patients were included in this study, 180 of whom were diagnosed with pregnancy-associated thrombosis and 200 of them showed no VTE. Demographic data and data on risk factors of VTE were collected by reviewing the medical charts and the risk assessment tool of the Royal College of Obstetricians and Gynecologists, respectively. The main outcome measures were VTE, manifesting as PE or DVT. Results: The following factors were identified as the predictors of VTE through multivariate analysis: family history [Odds ratio (OR) = 50.47, 95% Confidence Interval (CI): 6.78-375.64, P < 0.0001)], thrombophilia (OR = 21.99, 95% CI: 2.83-170.63, P = 0.003), and presence of gross varicose veins (OR = 17.15, 95% CI: 3.93-74.87, P < 0.0001). Conclusions: The findings of this study showed that family history, thrombophilia, and the presence of gross varicose veins were risk factors for VTE, exceeding other transient risk factors. Hence, prophylaxis is highly recommended for those women who present with any of these factors.

Clinical Characteristics and Management of Ovarian Vein Thrombosis: A Case Series.

Background: Ovarian vein thrombosis (OVT) is an uncommon condition, occurring in ~1 in every 600-2,000 pregnancies. It is associated with various conditions, including thrombophilia, malignancy, sepsis, intra-abdominal and pelvic inflammatory conditions, pregnancy, and the postpartum period, and specific surgical interventions, particularly gynecological surgeries. Thus, this study aims to identify the associated factors for OVT and elaborate on the standard treatment strategies for its management. Methods: Retrospective data collection was used. Our study consists of 18 patients diagnosed with OVT between 2005 and 2016; the data was collected from the Health Information Management system at King Fahad Medical City, Riyadh, Saudi Arabia using a standard format. Results: Our study found that OVT involves the right ovarian vein more often than the left and mainly occurs in women during their postpartum period. These patients other associated factor included hypertension, diabetes, and a higher body mass index (BMI) of above 25 kg/m2. The most frequently presenting complaints were abdominal pain and fever. The most common treatment was the administration of enoxaparin (a low molecular weight heparin) for an average duration of one to three months, which resulted in a low recurrence rate of OVT. Conclusions: Physicians should be vigilant for suspicion of OVT in female patients presenting with lower abdominal pain and fever in their postpartum period. Additionally, it is suggested to use low molecular weight heparin as initial therapy for OVT for one to three months, resulting in a high remission rate.

The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems.

BACKGROUND: Population-based studies from several countries have constantly shown excessively high rates of medication errors and avoidable deaths. An efficient medication error reporting system is the backbone of reliable practice and a measure of progress towards achieving safety. Improvement efforts and system changes of medication error reporting systems should be targeted towards reductions in the likelihood of injury to future patients. However, the aim of this review is to provide a summary of medication errors reporting culture, incidence reporting systems, creating effective reporting methods, analysis of medication error reports, and recommendations to improve medication errors reporting systems. METHODS: Electronic databases (PubMed, Ovid, EBSCOhost, EMBASE, and ProQuest) were examined from 1 January 1998 to 30 June 2020. 180 articles were found and 60 papers were ultimately included in the review. Data were mined by two reviewers and verified by two other reviewers. The search yielded 684 articles, which were then reduced to 60 after the deletion of duplicates via vetting of titles, abstracts, and full-text papers. RESULTS: Studies were principally from the United States of America and the United Kingdom. Limited studies were from Canada, Australia, New Zealand, Korea, Japan, Greece, France, Saudi Arabia, and Egypt. Detection, measurement, and analysis of medication errors require an active rather than a passive approach. Efforts are needed to encourage medication error reporting, including involving staff in opportunities for improvement and the determination of root cause(s). The National Coordinating Council for Medication Error Reporting and Prevention taxonomy is a classification system to describe and analyze the details around individual medication error events. CONCLUSION: A successful medication error reporting program should be safe for the reporter, result in constructive and useful recommendations and effective changes while being inclusive of everyone and supported with required resources. Health organizations need to adopt an effectual reporting environment for the medication use process in order to advance into a sounder practice.

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.

Clinical Predictors of COVID-19 Mortality Among Patients in Intensive Care Units: A Retrospective Study.

OBJECTIVE: The ongoing pandemic of the coronavirus disease 2019 (COVID-19), which originated from Wuhan, China, has been identified to be caused by the novel beta coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 has been spreading rapidly worldwide within just a few months. Our aims were to analyze clinical and laboratory abnormalities in ICU patients with COVID-19, in order to define which predictors can distinguish between those who are at higher risk of developing fatal versus non-fatal forms of the disease. METHODS: A descriptive cross-sectional survey was used; demographics, comorbidities, symptoms, laboratory parameters at ICU admission, and clinical outcomes for the adult patients admitted to ICU were collected from five hospitals in Saudi Arabia. RESULTS: A total of 86 patients with COVID-19 admitted in ICU, 50 patients died, 23 recovered, and 13 were still admitted, with a mortality rate of 58.1%. Septic shock (OR (95% CI): 58.1 (5.97-7812.8), p < 0.001) and acute kidney injury (AKI) (OR (95% CI): 7.279 (1.191-65.43), p = 0.032) had a significant impact on mortality. Cox proportional-hazards regression analysis revealed that septic shock (HR (95% CI): 9.502 (2.958-30.524), p < 0.001) and neutrophil count (HR (95% CI): 1.053 (1.023-1.085), p < 0.001) were significant predictors for mortality. CONCLUSION: Septic shock, AKI, and high neutrophil count were found to be predictive of death in these patients. Further studies are needed to aid efficient recognition and management of severe COVID-19 patients in our population. .

Proton pump inhibitors use and risk of developing spontaneous bacterial peritonitis in cirrhotic patients: A systematic review and meta-analysis.

BACKGROUND: Spontaneous bacterial peritonitis (SBP) is one of the most common infectious diseases in patients with cirrhosis and is associated with serious prognosis. A prevailing dogma posits that SBP is exacerbated by the frequent use of proton pump inhibitors (PPIs). AIMS: To re-assess the association between PPIs use and SBP incidence with larger and better-quality data. METHOD: The studies were identified by searching Proquest, Medline, and Embase for English language articles published between January 2008 and March 2020 using the following keywords alone or in combination: anti-ulcer agent, antacid, proton pump inhibitor, proton pumps, PPI, omeprazole, rabeprazole, lansoprazole, pantoprazole, esomeprazole, peritonitis, spontaneous bacterial peritonitis, SBP, ascites, cirrhosis, ascitic and cirrhotic. Three authors critically reviewed all of the studies retrieved and selected those judged to be the most relevant. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was followed. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Sub-group analyses were done to decrease the heterogeneity. RESULTS: A total of twenty-three studies: seven case-control, and sixteen cohorts, involving 10,386 patients were analyzed. The overall results showed a statistically significant association between SBP and PPIs use (pooled odds ratio (OR): 1.80, 95% CI of 1.41 to 2.31). Substantial heterogeneity was observed. On subgroup analysis involving cohort studies, the association was weaker (OR: 1.55 with 95% CI of 1.16 to 2.06 p < 0.00001) but still statistically significant and with high heterogeneity (Chi2p = 57.68; I2 = 74%). For case-control studies, the OR was 2.62 with a 95% CI of 1.94 to 3.54. The funnel plot was asymmetric and Egger's test confirmed asymmetry suggesting publication bias (intercept = - 0.05, SE = 0.27, P = 0.850 two-tailed). CONCLUSION: This meta-analysis sheds light on the conflicting results raised by previous studies regarding the association of SBP with PPIs use. Our meta-analysis showed that there is a weak association, although statistically significant, between SBP and PPIs use. However, the magnitude of the possible association diminished when analysis focused on higher quality data that were more robust. Thus, this updated meta-analysis suggests judicious use of PPIs among cirrhotic patients with ascites.

Safety and Efficacy of Convalescent Plasma for Severe COVID-19: Interim Report of a Multicenter Phase II Study from Saudi Arabia.

OBJECTIVE: To present the interim findings from a national study investigating the safety and efficacy of convalescent plasma (CP) containing detectable IgG antibodies as a treatment strategy for severe coronavirus disease 2019 (COVID-19). TRIAL DESIGN AND PARTICIPANTS: An open label, two-arm, phase-II clinical trial conducted across 22 hospitals from Saudi Arabia. The intervention group included 40 adults (aged ≥18 years) with confirmed severe COVID-19 and the control group included 124 patients matched using propensity score for age, gender, intubation status, and history of diabetes and/or hypertension. Intervention group included those (a) with severe symptoms (dyspnea; respiratory rate, ≥30/min; SpO2, ≤93%, PaO2/FiO2 ratio, <300; and/or lung infiltrates >50% within 24-48 h), (b) requiring intensive care unit (ICU) care or (c) experiencing life-threatening conditions. The control group included confirmed severe COVID-19 patients of similar characteristics who did not consent for CP infusion or were not able to receive CP due to its nonavailability. INTERVENTIONS: The intervention group participants were infused 300 ml (200-400 ml/treatment dose) CP at least once, and if required, daily for up to 5 sessions, along with receiving the best standard of care. The control group only received the best standard of care. OUTCOMES: The primary endpoints were safety and ICU length of stay (LOS). The secondary endpoints included 30-day mortality, days on mechanical ventilation and days to clinical recovery. RESULTS: CP transfusion did not result in any adverse effects. There was no difference in the ICU LOS (median 8 days in both groups). The mortality risk was lower in the CP group: 13% absolute risk reduction (P = 0.147), hazard ratio (95% confidence interval): 0.554 (0.299-1.027; P = 0.061) by log-rank test. There was no significant difference in the days on mechanical ventilation and days to clinical recovery. CONCLUSION: CP containing detectable antibodies is a safe strategy and may result in a decrease in mortality in patients with severe COVID-19. The results of the completed trial with a larger study sample would provide more clarity if this difference in mortality is significant. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04347681; Saudi Clinical Trials Registry No.: 20041102.

Efficacy and Safety of Lopinavir/Ritonavir for Treatment of COVID-19: A Systematic Review and Meta-Analysis.

(Background) Lopinavir-ritonavir (LPV/RTV) is a human immunodeficiency virus (HIV) antiviral combination that has been considered for the treatment of COVID-19 disease. (Aim) This systematic review aimed to assess the efficacy and safety of LPV/RTV in COVID-19 patients in the published research. (Methods) A protocol was developed based on the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) statement. Articles were selected for review from 8 electronic databases. This review evaluated the effects of LPV/RTV alone or in combination with standard care ± interferons/antiviral treatments compared to other therapies, regarding duration of hospital stay, risk of progressing to invasive mechanical, time to virological cure and body temperature normalization, cough relief, radiological progression, mortality and safety. (Results) A consensus was reached to select 32 articles for full-text screening; only 14 articles comprising 9036 patients were included in this study; and eight of these were included for meta-analysis. Most of these studies did not report positive clinical outcomes with LPV/RTV treatment. In terms of virological cure, three studies reported less time in days to achieve a virological cure for LPV/RTV arm relative to no antiviral treatment (-0.81 day; 95% confidence interval (CI), -4.44 to 2.81; p = 0.007, I2 = 80%). However, the overall effect was not significant (p = 0.66). When comparing the LPV/RTV arm to umifenovir arm, a favorable affect was observed for umifenovir arm, but not statically significant (p = 0.09). In terms of time to body normalization and cough relief, no favorable effects of LPV/RTV versus umifenovir were observed. The largest trials (RECOVERY and SOLIDARITY) have shown that LPV/RTV failed to reduce mortality, initiation of invasive mechanical ventilation or hospitalization duration. Adverse events were reported most frequently for LPV/RTV (n = 84) relative to other antivirals and no antiviral treatments. (Conclusions) This review did not reveal any significant advantage in efficacy of LPV/RTV for the treatment of COVID-19 over standard care, no antivirals or other antiviral treatments. This result might not reflect the actual evidence.

Perception of dental professionals towards dental management of patients using antithrombotic medications in Saudi Arabia: A cross-sectional survey.

OBJECTIVES: To assess dental professionals' perception and knowledge about dental management of patients on antithrombotics and determine if the treatment approach is according to the international guidelines. METHODS: This cross-sectional survey was conducted in Saudi Arabia during January 2014-December 2015 and included licensed dentists and hygienists from different dental institutions and Saudi's annual dental conference attendees. Data were collected by using a self-administered questionnaire, with questions about dental management of patients on antithrombotics. Data analysis was done using Statistical Package for Social Sciences statistical software, version 22. RESULTS: Of the 305 participants, 302 completed the survey (dentists: 94.7% and dental hygienists: 5.3%). For traditional antithrombotics, familiarity was higher for Warfarin and Aspirin compared to Clopidogrel. However, for new oral anticoagulants (NOACs), familiarity was significantly less for Rivaroxaban (P = 0.042). A significant number of participants responded that they were unsure as to how to treat patients [Enoxaparin (P < 0.001), Rivaroxaban (P < 0.037), and Dabigatran (P < 0.027)]. Furthermore, the management of patients on traditional or NOACs was not under guidelines (ranging: 8.2%-42.2%). CONCLUSION: Dental professionals have limited familiarity with antithrombotics, especially NOACs. Therefore, awareness about NOACs and their impact on dental procedures is needed among dentists in primary healthcare settings, to facilitate proper and timely management.

Safety and Efficacy of Convalescent Plasma to Treat Severe COVID-19: Protocol for the Saudi Collaborative Multicenter Phase II Study.

BACKGROUND: The COVID-19 pandemic is expected to cause significant morbidity and mortality. The development of an effective vaccine will take several months to become available, and its affordability is unpredictable. Transfusion of convalescent plasma (CP) may provide passive immunity. Based on initial data from China, a group of hematologists, infectious disease specialists, and intensivists drafted this protocol in March 2020. OBJECTIVE: The aim of this study is to test the feasibility, safety, and efficacy of CP in treating patients with COVID-19 across Saudi Arabia. METHODS: Eligible patients with COVID-19 will be recruited for CP infusion according to the inclusion criteria. As COVID-19 has proven to be a moving target as far as its management is concerned, we will use current definitions according to the Ministry of Health (MOH) guidelines for diagnosis, treatment, and recovery. All CP recipients will receive supportive management including all available recommended therapies according to the available MOH guidelines. Eligible CP donors will be patients with COVID-19 who have fully recovered from their disease according to MOH recovery criteria as detailed in the inclusion criteria. CP donors have to qualify as blood donors according to MOH regulations except for the history of COVID-19 in the recent past. We will also test the CP donors for the presence of SARS-CoV-2 antibodies by a rapid test, and aliquots will be archived for future antibody titration. Due to the perceived benefit of CP, randomization was not considered. However, we will compare the outcome of the cohort treated with CP with those who did not receive CP due to a lack of consent or lack of availability. In this national collaborative study, there is a likelihood of not finding exactly matched control group patients. Hence, we plan to perform a propensity score matching of the CP recipients with the comparator group patients for the major characteristics. We plan to collect demographic, clinical, and laboratory characteristics of both groups and compare the outcomes. A total sample size of 575 patients, 115 CP recipients and 460 matched controls (1:4 ratio), will be sufficient to detect a clinically important hospital stay and 30-day mortality difference between the two groups with 80% power and a 5% level of significance. RESULTS: At present, patient recruitment is still ongoing, and the interim analysis of the first 40 patients will be shared soon. CONCLUSIONS: In this paper, we present a protocol for a national collaborative multicenter phase II study in Saudi Arabia for assessing the feasibility, safety, and potential efficacy of CP in treating patients with severe COVID-19. We plan to publish an interim report of the first 40 CP recipients and their matched comparators soon. TRIAL REGISTRATION: ClinicalTrials.gov NCT04347681; https://clinicaltrials.gov/ct2/show/NCT04347681. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/23543.

Prolonged Survival of a Patient with Chronic Myeloid Leukemia in Accelerated Phase with Recurrent Isolated Central Nervous System Blast Crisis.

BACKGROUND Chronic myeloid leukemia (CML) is usually a tri-phasic myeloproliferative neoplasm, characterized by the presence of the BCR-ABL1 fusion gene, derived from a balanced translocation, t(9;22)(q34;q11). BCR-ABL tyrosine kinase inhibitors (TKI) are used to treat patients with CML. The addition of pegylated interferon-alpha2b to imatinib or dasatinib results in promising deep molecular responses. Because imatinib shows poor penetration into the central nervous system (CNS), the CNS may become a sanctuary site in patients on prolonged imatinib therapy for CML. It is extremely rare for the blast phase in patients with chronic phase CML to affect the CNS without concomitant bone marrow involvement. CASE REPORT This report describes a 57-year-old woman who was diagnosed with accelerated phase (AP) CML and failed high dose imatinib therapy. Despite achieving an excellent molecular response to dasatinib in 6 months, she developed recurrent isolated CNS blast crisis. Survival was prolonged after treatment with intrathecal chemotherapy and whole-brain radiation therapy combined with dasatinib. After achieving long and deep molecular remission with dasatinib and a few months of pegylated interferon-alpha2a, she lived for 18 months in treatment-free-remission (TFR). At age 65 years, she died of progressive rectal carcinoma with septic shock, cancer-related venous thromboembolism, and a possible autoimmune disorder. CONCLUSIONS This patient with accelerated phase CML and 2 isolated CNS blast crises died in TFR 8.5 years after her initial diagnosis and 7.5 years after her first isolated CNS blast crisis. Survival resulted from tailoring of therapies around her comorbidities.

Association of Mondor's disease with oral contraceptive pills.

Mondor's disease (MD) is a rare disease characterised by thrombophlebitis of superficial veins in the body. We describe a case of a 28-year-old woman with a painful cord-like lesion of the right breast (3 cm) overlying the right upper quadrant. The patient was recently prescribed metformin and oral contraceptive pills for symptomatic polycystic ovarian syndrome. Right breast ultrasound showed a tubular anechoic structure with several areas of narrowing, resembling a beaded appearance. The patient was diagnosed with MD associated with use of oral contraceptive pills. We recommended the patient to discontinue oral contraceptive because discontinuation of the causative drug is important. The patient was started on topical non-steroidal anti-inflammatory drugs and a therapeutic dose of enoxaparin. The patient showed significant clinical improvement after 5 days. At 6-week outpatient follow-up, complete resolution of the disease was noted.