The outcome of endovenous intervention for acute iliofemoral deep venous thrombosis with and without inferior vena cava filter.

BACKGROUND: Catheter-directed thrombolysis (CDT) for acute iliofemoral deep venous thrombosis (DVT) is an endovenous interventional therapy that can quickly remove the acute thrombus, thereby improving the clinical outcomes of proximal DVT. However, instrumentation of extensive fresh thrombus may be associated with iatrogenic pulmonary embolism (PE). Therefore, we aimed to compare CDT's safety, complications, and perioperative embolic (PE) insults for acute iliofemoral DVT, with and without an IVC filter. METHODS: One hundred twenty patients having acute proximal DVT for less than 14 days and undergoing endovenous therapy were included and presented to the vascular surgery department of Al-Azhar University Hospitals, Egypt. The patients were randomized into two equal groups, Groups A and B, each having 60 patients. Group A was treated with IVC filter insertion, while Group B was treated without a filter. The anticoagulation and CDT procedures were similar between the two groups. RESULTS: The sample included 96 females (80%) and 24 males (20%), with a mean age of 32.6 ± 7.2 years. Clinically no clinical PE occurred in both groups. However, radiologically, new lesions in multislice CT pulmonary angiogram and V/Q scan were noted in two of 60 patients (3.33%) of the IVC filter group, compared with three patients (5 %) in the non-filtered group. CONCLUSION: Endovenous intervention in the form of CDT for acute iliofemoral DVT without an IVC filter is safe and not associated with an increased risk of pulmonary embolization than filter usage. The routine use of IVC filters should not be used mandatorily during CDT.

Impact of Educational Program on Critical Care Nurses' Knowledge of ICU Delirium: A Quasi-Experimental Study.

Background: Cat Intensive care unit (ICU) delirium is a significant complication that increases the mortality, morbidity, and length of stay for critically ill patient. Objective: The aim of this study was to assess the critical care nurse's knowledge of ICU delirium and the effectiveness of an educational program about the recognition and assessment of ICU delirium on critical care nurse's knowledge. Methods: A quasi-experimental single group pre-test-post-test design was conducted using delirium knowledge assessment questionnaires. Results: The median post test score of overall nurses' knowledge was 76.2 (range 19.1-95.2) compared to the median pre-test score of 38.1 (range 14.3 - 61.9) indicating a significant change in nurses' knowledge after conducting the educational program (p<0.001). Conclusion: Critical care nurses' knowledge of ICU delirium was low before the intervention and increased significantly after delivering an educational program.

Efficacy of Mediastinoscopy in Patients With Isolated Mediastinal Lymphadenopathy.

Background: Since its introduction in 1959 by Carlens (1), Mediastinoscopy has been, for long, used for assessment of the mediastinum (superior and middle) for establishing a histological diagnosis of mediastinal masses of undefined cause, and for Lung carcinomas staging. The use of Mediastinoscopy has been decreasing lately due to the introduction of other less invasive techniques (e.g., endoscopic ultrasound-directed fine needle aspiration cytology), however, it is still a cheap and effective tool that can be utilized in underprivileged centers. Objective: To emphasize how does Mediastinoscopy plays an important role in confirming the clinical diagnosis of isolated mediastinal lymphadenopathy and reviewing its utility. Methods: These are a retrospective analysis of medical charts for patients who underwent diagnostic cervical mediastinoscopy during (2012 - 2018) at a University hospital in Saudi Arabia. The included patients are presented with an isolated mediastinal lymph node enlargement, in the absence of underlying cause and was found to be significant (>1cm in its short axis) by computed tomography. The patient who had a known cause (e.g., Sarcoidosis) or were diagnosed via other tools, was excluded. Results: Mediastinoscopy was performed on 56 patients, 38 of them were males (68%) and 18 females (32%), with a mean age of (37.5 ± 10 years). The patients' most common presenting symptoms were persistent cough (49%), fever of unknown origin (38%) and weight loss (36%) with an average of 2 symptoms per patient, while in 4 patients (7%) lymphadenopathy was discovered incidentally during the CT scan for other reasons. In addition, the histopathological examination of specimens obtained confirmed the most common diagnoses, Sarcoidosis in 17 patients (30%), lymphoma in 12 patients (21%) and TB in 10 patients (18%). The mean hospital stay (calculated from the day of the procedure) was (2.5 ± 4 days) including work up, with only one mortality (2%) and 3 patients (5%) had experienced post-operative complications. Conclusion: The diagnostic Mediastinoscopy is both safe and efficient in the diagnosis of patients with isolated mediastinal lymphadenopathy, requiring a minimal surgical setup and is considered cost-effective. Therefore, it is a valid choice of investigating such cases in other underprivileged centers, as it reaches a tissue-based diagnosis, while other techniques are used for staging purposes.

Risk Factors and Surgical Outcomes of Diabetic Foot in Diabetic Patients at King Fahad University Hospital.

BACKGROUND: Diabetes mellitus affects a large number of the population worldwide. One of the most important complications is diabetic foot ulcers, which are debilitating to the patient and the health care system. OBJECTIVES: To assess the risk factors leading to diabetic foot complications and the surgical outcome of management of patients affected by diabetic foot at King Fahd University Hospital. METHODS: This is a retrospective case series study conducted at King Fahd University Hospital. The study included 52 patients who were admitted from the period 2007 to 2017 with cases of diabetic foot ulcers. The study includes a review of medical charts for diabetic foot patients including demographics, diabetic profile, associated comorbidities, clinical signs, laboratory investigations and surgical outcome. RESULTS: Our study shows that diabetic foot patients had comorbidities like hypertension at 69.2% and hyperlipidemia at 55.8%. Regarding the association between comorbidities and surgical outcomes, we did not find any significance. Furthermore, we found that patients with gangrene were more likely to undergo amputation. Patients who underwent amputation had hemoglobin A1c (HbA1c) of 10.3 ± 2.4% and random blood sugar (RBS) of 259 ±107 mg/dl, indicating poor diabetic control. CONCLUSION: Diabetic foot is the result of poor blood sugar control. Surgical intervention plays an important role in the management of diabetic foot. Depending on the presentation, patients may undergo surgical debridement, revascularization, or amputation. We found that patients who developed gangrene were more likely to undergo amputation.

Common Presentation of Uncommon Disease: Inflammatory myofibroblastic tumor of the lung, case report.

Background: Inflammatory myofibroblastic tumor (IMT) of the lung is a rare lung tumor, accounting for 0.7% of all lung tumors. They are usually benign, but can invade surrounding structures, undergo malignant transformation, recur, or even metastasize. Case report: We report a 44-year-old adult diabetic male from Saudi Arabia who had been suffering from cough with severe sputum and left shoulder pain for 2 weeks. Chest radiography (X-ray and computed tomography (CT)) revealed the presence of a mass lesion in the left lower upper lobe with central cavitation. The diagnosis of inflammatory myofibroblast lung tumor was confirmed by histological and immunohistochemical examination of the CT guided lung biopsy. The patient was successfully treated with surgical resection of the tumor by left limited thoracotomy with safety margin, and IMT was also documented. Conclusion: A high degree of suspicion of a solitary pulmonary mass is required for diagnosis and management of an inflammatory myofibroblastic lung tumor. The clinical and radiologic presentation of an inflammatory myofibroblastic tumor is nonspecific and the diagnosis is rarely made before surgical biopsy. Histologic and immunohistochemical examination is usually required to confirm the diagnosis and prevent recurrence.

Nurses' Knowledge and Practices Regarding the Prevention of Deep Vein Thrombosis in Saudi Arabia: Descriptive Cross-Sectional Study.

Background: Deep venous thrombosis (DVT) is a prevalent fatal problem and a major cause of avoidable death among morbid hospitalized patients. It is estimated that up to 900,000 people in the United States are affected each year. Additionally, around 60,000 to 100,000 Americans die annually of DVT. Objective: To assess studied nurses' knowledge and practice regarding Deep venous thrombosis prevention. Methods: A descriptive cross-sectional research design was used in this study at King Fahad Hospital of the University in the Kingdom of Saudi Arabia, using a self-administered questionnaire. A total of 67 nurses from medical and surgical units were included in the study. Data were coded and analyzed using SPSS 23.0 version. Results: According to the results, the knowledge and practice of nurses were found to be high. Total knowledge score regarding prevention of deep venous thrombosis (72.8±9.6), regarding studied nurses, score for each subcategory: general knowledge category (70.6±15.5), deep venous thrombosis risk factors category (66.5±13.1), and deep venous thrombosis prevention category (90.1±10.5). in addition, a statically significance association between nurses' years of experience (p=0.026), previous Deep venous thrombosis education (p=0.012), and total knowledge score regarding the prevention of deep venous thrombosis. Concerning the self-reported practice, the majority of the studied nurses have shown a very high practice score. Yet, there was no statically significant association between the sociodemographic characteristic and practice. Furthermore, a positive association between total knowledge and reported practice score but statically insignificant (p=0.075). Conclusion: Based on the result of the study, most of the studied nurses' level of knowledge and practice concerning the prevention of deep vein thrombosis ranged between high and very high.

Multidisciplinary Approach for a Rare Metastatic Low-Grade Endometrial Stromal Sarcoma to the Inferior Vena Cava and the Right Atrium.

Endometrial stromal sarcoma (ESS) is a rare, malignant tumor of the endometrium. Low-grade endometrial stromal sarcoma (LG-ESS) is a less aggressive subtype of ESS that rarely metastasizes to the heart and large blood vessels. In the present study, we report a case of recurrent LG-ESS after treating the initial mass in the uterus six years ago in a 49-year-old female who presented with a four-month history of dyspnea and easy fatigability. Investigations revealed a right pulmonary embolism, suspicious right psoas muscle mass, and a large inferior vena cava (IVC) thrombus. One month later, she presented with multiple gastrointestinal symptoms and weight loss. Investigations then showed the development of a new right atrial mass, infra-diaphragmatic metastatic lymphadenopathy, progression of the presacral soft tissue component, invasion of the ileal bowel loop, and a tumoral thrombus in the IVC besides new metastatic lymphadenopathy and pulmonary metastasis. Therefore, a multidisciplinary team, which had a crucial role in this complicated case, decided to commence chemotherapy treatment. Such an unusual aggressive metastatic course of LG-ESS is limited in the literature; herein, we recognize a rarely documented disease.

Delayed presentation of massive haemoptysis from aortic aneurysm after aortic coarctation repair (a case report).

INTRODUCTION: Massive haemoptysis refers to coughing and losing a huge amount of blood in a 24-hour period. It's a life-threatening condition with high mortality rate. CASE PRESENTATION: We report a rare case of massive haemoptysis in a 60-year-old female patient who had aortic coarctation repair 30 years ago. Her Computed tomography (CT) angiography showed huge aneurysmal dilatation and dissection of the descending thoracic aorta at the site of the repair. Thoracic endovascular aortic repair (TEVAR) was done, but the patient had recurrent massive haemoptysis due to extension of the aneurysm to the aortic arch. The patient then underwent one stage surgical right to left carotid artery shunt followed by TEVAR to the aortic arch covering the left common carotid artery. The procedure was successful, and haemoptysis was controlled without any complications. DISCUSSION: In this case the high index of suspicion for thoracic aortic aneurysm in patients presenting with haemoptysis and prior history of coarctation repair were demonstrated. CONCLUSION: massive haemoptysis in patients who had aortic coarctation repair is an alarming sign, and surgical intervention is required. TEVAR has become one of the best approaches for managing aortic aneurysm and has replaced open repair.

Aortic valve replacement in a patient with sickle cell disease-Are we justified to perform surgery in the TAVI era?

Not all variants of SCD need the same management and this should be decided on a case-by-case basis. Heterozygous SCD patients can undergo cardiac surgery without the need for intraoperative exchange transfusions with good clinical outcomes.

Renal Impairment After Cardiac Surgery: Risk Factors, Outcome and Cost Effectiveness.

Introduction Acute kidney injury (AKI) is considered one of the serious complications in the medical field. It has a large impact on patients' life medically, socially and economically. It also has a financial burden on governments and hospitals regardless of which part of the world is considered. On the other hand, AKI is a common complication of cardiac surgery, which alone has a tremendous burden and implications on patients and governments. In this study, we will discuss the various risk factors, outcomes and financial burden of renal impairment associated with cardiac surgery. Methods This is a retrospective case-control study, which included 144 adult patients who underwent open cardiac surgical procedures at King Fahad University Hospital in the Eastern Province of Saudi Arabia over a period of five years from January 2015 till the end of December 2019. We included all types of cardiac surgeries performed such as coronary artery bypass grafting (CABG), valve surgery and aortic dissection repair and excluded patients with end-stage renal disease (ESRD) requiring dialysis preoperatively and pediatric patients. Two control groups were defined, those who developed renal impairment (group A) and those who did not develop it (group B). Results The mean age of the patients was 58.59 ± 12.6 years (range: 42 to 77 years). Mean serum creatinine level in the postoperative period was 1.95 ± 1.5 mg/dL in group A compared to group B of 1.0 ± 0.32 mg/dL (P-value<0.01). Mean serum blood urea nitrogen (BUN) in group A was 26.45 ± 19.9 mg/dL compared to group B of 16.79 ± 16.2 mg/dL in group B (P-value < 0.01). Diabetic were more likely to develop renal impairment than non-diabetic (P-value = 0.049, OR 2.73; 95% CI: 0.97-7.66). Obese patients were two times more likely to develop renal impairment than non-obese (P-value = 0.056, OR 2.6; 95% CI: 0.94-7.1). The average cost for each patient with renal impairment who required dialysis was 110,000 Saudi Riyal (~ 29,000 $) compared to other patients. Conclusion Serum creatinine, BUN, diabetes and obesity are strong indicators in developing AKI in cardiac surgery. In addition, the financial burden was almost doubled in patients developing AKI.

Efficacy of Precise Foot Massage Therapy on Pain and Anxiety Following Cardiac Surgery: Pilot Study.

BACKGROUND: Pain is the most pervasive distressing symptom following cardiac surgery. Forty percent of postoperative cardiac patients report inadequate pain management. Undertreated acute pain results in increased anxiety, delayed wound healing, and increased chance of persistent chronic pain. Foot massage is a safe, visible complementary approach to manage acute pain following surgery. AIM: The aim of this study is to evaluate the efficacy of integrating foot massage therapy for managing postcardiac pain. METHOD: A randomized placebo controlled single blinded trial comparing foot massage to placebo was conducted at a large hospital in Saudi Arabia. Thirty-one patients who had undergone cardiac surgery (16 in experimental and 15 in placebo group) participated in the study. Ten-minute foot massage was delivered to the experimental group by a nurse researcher, twice during one day, within 30 minutes after receiving an opioid pain medication. RESULTS: The findings of this study indicate that foot massage significantly (p < .05) decreases pain intensity and anxiety in patients who have undergone cardiac surgery compared with a placebo control group. CONCLUSION: Providing non-pharmacologic interventions for pain is the responsibility of the nursing staff. Foot massage is within the scope of nursing practice and is a safe and effective manner of improving patient care. Foot massage in conjunction with pharmacological interventions is effective in improving pain and anxiety. Future studies should consider focusing on frequency, dose, feasibility, acceptability, and participants' satisfaction.

Unusual Presentation of Aspergillus Pericarditis: A Case Report.

Cardiac aspergillosis is a rare fungal infection that affects the heart and/or pericardium of immunocompromised patients. Here, the authors report a rare case of a 36-year-old female with aspergillus pericarditis. The patient was diagnosed with infective endocarditis and splenic infarction and treated with emergency splenectomy and double-valve replacement surgery. During the surgery, a fibropurulent pericardial tissue was found and excised. The culture report of the tissue confirmed the diagnosis of aspergillus pericarditis. The patient was successfully managed with intravenous voriconazole. Aspergillus do not usually infect the pericardium and such infections are rarely detected premortem, especially during a cardiac surgery. In this report, the infection was accidentally detected during the double-valve surgery. The authors conclude that because of its nonspecific clinical manifestations, a high degree of clinical suspicion is required for the early diagnosis and treatment of aspergillus pericarditis.

Three Rare Structural Anomalies: Right Aberrant Subclavian Artery, Kommerell's Diverticulum, and Isolated Left Vertebral Artery All Associated with Type B Aortic Dissection.

INTRODUCTION AND BACKGROUND: Right aberrant subclavian artery accounts for 0.5-1.8% of the population as the most frequently encountered aortic arch anomaly, while the prevalence of an isolated left vertebral artery ranges from 3 to 8%. Despite the low prevalence and the asymptomatic presentation of these structural anomalies, the development of cardiovascular complications and aneurysmal formation could happen as in Kommerell's diverticulum in a complicated right aberrant subclavian artery, which can undergo aneurysmal degeneration and dissection. Depending on the severity and the degree of the symptoms, the management of the patient can be determined. CASE PRESENTATION: A 51-year-old male hypertensive Pakistani patient was admitted complaining of chest and back pain; a CT of the aorta was done and showed type B aortic dissection associated with a right aberrant subclavian artery with an isolated left vertebral artery. A thoracic endovascular aneurysmal repair was done, and the patient improved afterward. CONCLUSION: The prevalence of these structural anomalies, the right aberrant subclavian artery, Kommerell's diverticulum, and isolated left vertebral artery with type B aortic dissection, is uncommon. Therefore, the earlier the diagnosis, the better the treatment. This is the first case report explaining the occurrence of these vascular anomalies together in Saudi Arabia.

Management of Primary Spontaneous Pneumothorax: A Single-center Experience.

BACKGROUND: The prevalence of primary spontaneous pneumothorax is high in the Arab region. There is a lack of studies from the Eastern Province of Saudi Arabia highlighting the associated risk factors and demonstrating the effectiveness of surgical management. OBJECTIVES: To identify risk factors associated with primary spontaneous pneumothorax and to correlate the effectiveness of surgical management with the rate of disease recurrence. SUBJECTS AND METHODS: This retrospective chart review included adult patients who presented with primary spontaneous pneumothorax and were managed at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia, from January 1, 2005, to December 31, 2014. The results are presented as arithmetic mean for quantitative data, and chi-square test was used for statistical analysis. P ≤0.05 was considered statistically significant. RESULTS: In total, 151 patients with primary spontaneous pneumothorax were included, with the majority being male (98.7%) and Saudis (88.7%). The mean age was 24 ± 6 years (range: 13-49 years), mean height 171 ± 8 cm (range: 144-193 cm) and mean body mass index 19.2 ± 3.8 kg/m2 (range: 13.3-39.0 kg/m2). About 62% of the patients were smokers. Ten patients had an ipsilateral recurrence of primary spontaneous pneumothorax after the first episode was successfully managed. Surgical exploration after the first episode itself was found to significantly reduce the recurrence rate. The study found that in the management of these patients, there was a shift from conventional open thoracotomy to the minimally invasive video-assisted thoracoscopic surgery method. CONCLUSIONS: The risk factors for primary spontaneous pneumothorax in this study were consistent with the current literature. Surgical exploration after the first episode of primary spontaneous pneumothorax significantly reduces the recurrence rate and there is a paradigm shift toward a less invasive surgical approach in managing these patients.

Aortic Valve Myxoma Presenting with a Stroke: A case report and review of the literature.

Myxomas originating from the aortic valve are rare. We report a 40-year-old male patient who presented to the King Fahd Hospital of the University, Khobar, Saudi Arabia, in 2017 with a stroke. Transoesophageal echocardiography indicated a mobile mass measuring 6 × 2 mm attached to the right coronary cusp of the aortic valve and a mobile interatrial septum with a small patent foramen ovale (PFO). The patient underwent surgical excision of the mass and direct closure of the PFO. Histopathology confirmed the mass to be a myxoma. Despite their rarity, the recognition and treatment of valvular myxomas is very important; moreover, clinicians should be aware that affected patients may present with an embolic stroke.