Modified oral food challenge protocol approach in the diagnosis of Food Protein-Induced Enterocolitis Syndrome.

BACKGROUND: Food Protein-Induced Enterocolitis Syndrome (FPIES) is a non-IgE mediated food allergy most commonly presenting in infants. The most common food triggers include soy, cow's milk and grains. Symptoms may include intractable vomiting, diarrhea, lethargy, pallor, abdominal distention, hypotension and/or shock. Oral food challenges (OFCs) given at food protein dose of 0.06-0.6 g/kg in 3 equivalent doses administered over a few hours are recommended in guidelines to confirm a diagnosis. CASE PRESENTATION: The patient is a 6-month-old girl with a history of severe FPIES symptoms to egg. In our clinic, we perform OFC with 1/100 serving dose on visit 1 and then increase the dose monthly. The patient takes the tolerated dose daily at home between visits. An OFC to baked egg at 1/100 of a serving was performed and was well-tolerated on her initial visit. The patient remained on the same dose upon returning home. Within 1-week, she developed FPIES symptoms including watery diarrhea and severe emesis requiring ondansetron. She required an Emergency Department visit for one of the reactions. CONCLUSIONS: Our patient had severe FPIES symptoms with a small amount of egg. We believe that administration of three large food challenge doses on one clinic visit, as guidelines currently suggest, does not allow adequate time for symptoms to appear. Our patient likely would have suffered a severe reaction. Also, this guidelines protocol does not allow for monitoring of more delayed or chronic FPIES. We propose a modified protocol to OFCs with cautious up-dosing to allow for safer OFCs and monitoring of chronic FPIES. We have implemented an OFC approach where only one food challenge dose (starting with 1/100 of final dose) is given at each visit. The up-titration of the dose is completed every 4-weeks with one dose only. When the serving sized dose is reached and tolerated, the food can be maintained in the diet.

Pulmonary metastasis of head and neck cancer: surgical removal outcomes from a tertiary care center.

PURPOSE: There has been no clear data on the effectiveness of pulmonary metastasectomy on several original cancers, including head and neck. We aim to collect data about the metastasectomies performed in our center for eligible patients and elaborate more on predictors and prognosis. METHODS: A retrospective analysis of 56 patients who underwent metastasectomy from head and neck cancers at our facility between January 2000 and January 2016 (16 years). Statistical analysis was performed based on gender, disease-free interval (DFI), location of the original tumor, and histological subtypes to assess their effect and relevance to the prognosis and disease recurrence. RESULTS: Twenty-nine males and 27 females had lung metastasis from head and neck. The primary lesions of the lung metastasis were more often found in the thyroid (34%), followed by nasopharynx (32%). As for histology, the most common one was papillary cancer (34%), followed by squamous cell carcinomas (29%). The DFI was more than 2 years in 32 patients (57%). The survival rates were 79.5% at 3 years and 71.7% at 5 years. In the univariate analysis, histology was the only independent prognostic factor (p = 0.05). On the other hand, age (p = 0.6), DFI (p = 0.24), and site of the primary tumor (p = .06) showed no effect on the prognosis of head and neck cancers metastasizing to the lungs. CONCLUSION: Pulmonary metastasectomy for lesions originating from head and neck provides good long-term survival. Histological subtype was the only statistically significant prognostic factor.

Surgical treatment of pulmonary metastasis: report from a tertiary care center.

Objective This retrospective analysis aimed to determine the factors influencing prognosis in adult patients who presented to our thoracic surgery service with lung metastases and were eligible for pulmonary metastasectomy. Methods We retrospectively reviewed the data of 296 patients who underwent resection of 575 lung metastases from January 2000 to January 2016. Univariate and multivariate analyses were performed based on age, sex, histology of the primary tumor, disease-free interval, number and size of metastases. Results Sixty-eight (22.97%) patients developed lung metastases from bone sarcoma, 68 (22.97%) from soft-tissue sarcoma, 56 (18.9%) from head and neck cancers, 46 (15.5%) from colorectal cancer, and 58 (19.6%) from other epithelial tumors. The mean size of the lung nodules was 2.48 cm. Open surgical resection was performed in 217 (73.3%) patients. After a mean follow-up of 43 months, 120 (40.7%) patients had died or were lost to follow-up. Univariate analysis confirmed that patients with bone cancer, soft tissue sarcoma, or colorectal carcinoma had a worse prognosis ( p = 0.0003). Moreover, those with a disease-free interval >24 months had a better 5-year survival ( p = 0.0001). The number and size of metastases, age, and sex had no effect on prognosis. The actuarial survival after complete metastasectomy was 71.6% (95% confidence interval: 66-75) at 2 years and 59.3% (95% confidence interval: 56-64) at 5 years. Conclusions Pulmonary metastasectomy provides good long-term survival. The type of primary tumor and disease-free interval are independent prognostic factors for survival.

Perceptions of pre-clerkship medical students and academic advisors about sleep deprivation and its relationship to academic performance: a cross-sectional perspective from Saudi Arabia.

BACKGROUND: The medical student population is believed to be at an increased risk for sleep deprivation. Little is known about students' perceptions towards sleep deprivation and its relationship to academic performance. The aim of study is to explore the perceptions of medical students and their academic advisors about sleep deprivation and its relationship to academic performance. METHODS: The study took place at Alfaisal University, College of Medicine, Riyadh, Saudi Arabia. An online, anonymous, cross-sectional, self-rating survey was administered to first-, third-year students and their academic advisors. Two-tailed Mann-Whitney U test was used to compare the mean 5-point Likert scale responses between students according to gender, academic year and cumulative grade point average (cGPA). RESULTS: A total of 259 students and 21 academic advisors participated in the survey (response rates: 70.6 and 84%, respectively). The vast majority of students agreed that sleep deprivation negatively affects academic performance (78.8%) and mood (78.4%). Around 62.2 and 73.7% of students agreed that the demanding medical curriculum and stress of final exams lead to sleep deprivation, respectively. While 36.7% of students voiced the need for incorporation of curricular separate courses about healthy sleep patterns into medical curriculum, a much greater proportion of students (45.9%) expressed interest in extracurricular activities about healthy sleep patterns. Interestingly, only 13.5% of students affirmed that they were counselled about sleep patterns and academic performance by their academic advisors. There were several statistically significant differences of means of students' perceptions according to gender, academic year and cGPA. Despite almost all academic advisors (95.5%) asserted the importance of sleep patterns to academic performance, none (0%) inquired about sleep patterns when counselling students. Nineteen academic advisors (90.5%) recommended incorporation of sleep patterns related learning into medical curricula; among those, only 1 (n = 1/19; 5.3%) recommended learning as a separate course whereas the majority (n = 18/19; 94.7%) recommended learning in forms of extracurricular activities and integration into relevant ongoing courses. CONCLUSIONS: Our results showed that students had correct conceptions about the negative impact of sleep deprivation on academic performance and mood. Also, our results highlighted the need for curricular/extracurricular education and counseling about healthy sleep patterns.