Spontaneous bilateral superficial femoral artery pseudoaneurysms and a unilateral posterior tibial artery aneurysm in an immunocompromised patient.

Key Clinical Message: The presence of multiple pseudoaneurysms in a patient should prompt investigations for the underlying etiologies including autoimmune and immunosuppressive disease processes. Treatment options include open repair and endovascular stenting. Abstract: Pseudoaneurysms (also known as false aneurysms) are atypical dilatations or outpouchings from a vessel which are not always contained by the three layers of a normal vessel wall, namely the intima, media, and adventitia. These are distinct from a true aneurysm which has a wall comprising all three layers. The underlying etiology for both true aneurysms and pseudoaneurysm can vary. We present the rare case of bilateral superficial femoral artery pseudoaneurysms, of unknown etiology and a concurrent posterior tibial artery saccular aneurysm in a patient with Human Immunodeficiency Virus (HIV) infection and multiple comorbidities. This was managed using a combination of endovascular covered stent grafts and open surgical repair technique. The patient is doing well on follow-up a year later with no post-operative infections. A literature review of the existing reports of superficial femoral artery pseudoaneurysms and posterior tibial artery aneurysms and their management is also reported.

A sepsis treatment algorithm to improve early antibiotic de-escalation while maintaining adequacy of coverage (Early-IDEAS): A prospective observational study.

BACKGROUND: Empiric antibiotic treatment selection should provide adequate coverage for potential pathogens while minimizing unnecessary broad-spectrum antibiotic use. We sought to pilot a sepsis treatment algorithm to individualize antibiotic recommendations, and thereby improve early antibiotic de-escalation while maintaining adequacy of coverage (Early-IDEAS). METHODS: In this observational study, the Early-IDEAS decision support algorithm was derived from previous Gram- negative and Gram-positive prediction rules and models along with local guidelines, and then applied to prospectively identified consecutive adults within 24 hours of suspected sepsis. The primary outcome was the proportion of patients for whom de-escalation of the primary antibiotic regimen was recommended by the algorithm. Secondary outcomes included: (1) proportion of patients for whom escalation was recommended; (2) number of recommended de-escalation steps along a pre-specified antibiotic cascade; and (3) adequacy of therapy in patients with culture-confirmed infection. RESULTS: We screened 578 patients, of whom 107 eligible patients were included. The Early-IDEAS treatment recommendation was informed by Gram-negative models in 76 (71%) patients, Gram-positive rules in 64 (59.8%), and local guidelines in 27 (25.2%). Antibiotic de-escalation was recommended in almost half of all patients (n = 52, 48.6%), with a median of 2 steps down the a priori antibiotic treatment cascade. No treatment change was recommended in 45 patients (42.1%), and escalation was recommended in 10 (9.3%). Among the 17 patients with positive blood cultures, both the clinician prescribed regimen and the algorithm recommendation provided adequate coverage for the isolated pathogen in 12 patients (70.6%), (p = 1). Among the 25 patients with positive relevant, non-blood cultures, both the clinician prescribed regimen and the algorithm recommendation provided adequate coverage in 20 (80%), (p = 1). CONCLUSION: An individualized decision support algorithm in early sepsis could lead to substantial antibiotic de-escalation without compromising adequate antibiotic coverage.

Trends in the mortality, incidence and disability-adjusted life-years of appendicitis in EU15+ countries: an observational study of the Global Burden of Disease Database, 1990-2019.

BACKGROUND: Appendicitis places a substantial burden on healthcare systems, with acute appendicitis alone being the most common abdominal surgical emergency worldwide. Further characterisation of the disease burden in EU15+ countries may help optimise the distribution of healthcare resources. The aim of this observational study was to assess the trends in mortality, incidence and disability-adjusted life-years (DALYs) of appendicitis across European Union (EU) 15+ countries between the years 1990 and 2019, Supplemental Digital Content 3, http://links.lww.com/JS9/A589 . MATERIALS AND METHODS: Age-standardised mortality rates (ASMRs), age-standardised incidence rates (ASIRs) and DALYs data for appendicitis in males and females were extracted from the 2019 Global Burden of Disease (GBD) study. Temporal trends within the study period were analysed using Joinpoint regression analysis. RESULTS: The median ASMRs across EU15+ countries in 2019 were 0.08/100 000 and 0.13/100 000 for females and males, respectively. Between 1990 and 2019 the median percentage change in ASMR was -52.12% for females and -53.18% in males. The median ASIRs in 2019 for females and males were 251/100 000 and 278/100 000, respectively, with a median percentage change of +7.22% for females and +3.78% for males during the observation period. Decreasing trends in DALYs were observed over the 30-year study period, with median percentage changes of -23.57% and -33.81% for females and males, respectively, Supplemental Digital Content 3, http://links.lww.com/JS9/A589 . CONCLUSION: Overall, a general trend of decreasing appendicitis ASMRs and DALYs was observed across EU15+ countries, despite small overall increases in appendicitis ASIRs, Supplemental Digital Content 3, http://links.lww.com/JS9/A589 . Variations in both diagnostic and management strategies over the study period are likely contributory to the changing trends.

Foliar Application of Iron Oxide Nanoparticles Promotes Growth, Mineral Contents, and Medicinal Qualities of Solidago virgaurea L.

Goldenrod (Solidago virgaurea L.) is considered for their medicinal properties for humans. These properties are attributed to some volatile compounds that can be extracted from above- and underground organs of plants. More ingredients of medicinal plants are undoubtedly considered by herbal medicine activists. The study aimed to promote Solidago yield and quality under foliar application of Fe2O3 nanoparticles that can be considered as a safe and healthy fertilizer on the basis of US Food and Drug Administration (FDA) regulatory process about color additives. The experiment was performed with concentrations of Fe2O3 nanoparticles (0, 0.5, or 1 mg L-1) and foliar application times (1, 2, 3, 4, or 5 times) on 4- to 5-leaf plants of Solidago virgaurea. Results showed that 4 times foliar application of 1 mg L-1 caused the best plant growth and mineral element contents (nitrogen, phosphorous, potassium, copper, and zinc) except for Fe content that the more the times of foliar application, the more the Fe content increased. However, the flavonoid (rutin and quercetin) and essential oils (caryophyllene, alpha-pinene, camphene, limonene, linalool, myrcene, and terpinene) as biochemical and medicinal qualities of the treated plants were remarkably promoted when 1 mg L-1 of nanoparticles was sprayed 5 times. Furthermore, the more the element contents, the more the ingredients. Finally, based on the goals of herbal medicine activists for the production of the essence, extract, or herb, both 5 and 4 times of foliar applications of ferric oxide nanoparticles are safe and may be economic and recommendable.

Triplet (FOLFOXIRI) Versus Doublet (FOLFOX or FOLFIRI) Regimen as First Line Treatment in Metastatic Colorectal Carcinoma, a Prospective Phase II, Randomized Controlled Trial.

BACKGROUND: The outcomes of treatment of metastatic colorectal cancer (mCRC) is still unsatisfactory. Several trials approved that, the upfront treatment with triplet regimen included fluorouracil, leucovorin, irinotecan and oxaliplatin improved the outcomes of patients with metastatic disease as compared to standard doublet regimen. The objective of our study is evaluating the impact of upfront treatment with triplet (FOLFOXIRI) regimen on both oncological outcomes (response rate and survival) and patients' tolerability in comparison to the standard doublet regimen. METHODS: We randomly enrolled 64 patients with a newly diagnosed unresectable mCRC to receive either FOLFOXIRI (experimental arm) or FOLFIRI or FOLFOX4 (control arm) biweekly up to 12 cycles. The primary endpoints are overall response rate (RR) and patients' tolerability. The secondary endpoints are the progression free and overall survival. RESULT: There was a significantly increase in RR (59% vs 37%) and complete remission rate (CR) (6.3% and 3.1%, respectively (P = 0.045) for the triplet therapy group compared to control group.  Consequently, an increased rate of secondary resection of metastasis (21.9% vs 3.1% respectively; P=0.023). The FOLFOXIRI regimen was associated with higher rate of grade 3/4 toxicity but not statistically significant except febrile neutropenia (6.2%; P=0.03). There was numerical prolongation in the median PFS in the FOLFOXIRI group on compared to control group but not significantly (9 versus 8 months; P=0.11). The median OS was 20 and 22 months in FOLFOXIRI arm and control arm respectively with no statistically significant difference (P=0.57). CONCLUSION: FOLFOXIRI had a higher efficacy and higher conversion rate to secondary resection over the doublet regimen as an upfront treatment option, coupled with a manageable adverse event, but failed to improve the survival outcomes.

Is laterality in breast Cancer still worth studying? Local experience in Bahrain.

BACKGROUND: Laterality in breast cancer means an increased frequency of left-sided breast cancers compared to right-sided breast cancers ranging between 1.05 and 1.26. It was first described in 1935 by Fellenberg, Sweden. The explanation of this phenomenon is not clear, but the association with other factors was found. This study aimed to explore the laterality of breast cancer in Bahrain as a model for Arabian countries. The association of laterality with the clinicopathological characteristics of the tumor was also analyzed to explore any applied clinical value. METHODS: This is a cross-sectional, retrospective review of a particular ethnic population to study laterality of breast cancer versus a number of clinicopathological factors, as well as prognosis. The study analyzed 228 breast cancer patients treated in Arabian Gulf University facilities in Bahrain between 1999 and 2020. Three bilateral breast cancer and two malignant phyllodes patients were excluded. The following variables were analyzed: laterality ratio (Lt/Rt) and the association between laterality and clinicopathological characteristics (age at diagnosis, family history of malignancy, size of the tumor, tumor grade, histological type, hormonal receptors and HER2, axillary lymph node status, tumor stage, five-year survival rate, nulliparity, and multifocality). RESULTS: The laterality ratio (Lt/Rt) was 1.06 and was 0.97 for patients below 50 years of age, and 1.19 for patients 50 years of age and above. Analysis of our data showed a statistically significant association between laterality and tumor stage (p. value =0.025) at presentation, and laterality and family history of malignancy (p. value =0.052). Right-sided breast cancer was associated with a higher positive family history of malignancy and an increased ratio of locally advanced and metastatic disease, and a reduced 5-year survival in relation to size and stage. Left-sided breast cancer was associated with higher early tumor stage. CONCLUSION: This is the first study exploring the issue of breast cancer laterality in a defined Arabian population. The laterality ratio in this study was 1.06, which is consistent with the globally published range (1.05 to 1.26) and is increasing with increasing age. The association between breast cancer laterality, and the hormonal and HER2 is still not widely addressed in the available literature, although other clinicopathological characteristics were extensively analyzed.

SARS-CoV-2 in peritoneal swabs from asymptomatic patients undergoing emergency abdominal surgery.

This is a case series of five patients with acute abdomen requiring surgery who tested positive for coronavirus disease 2019 (COVID-19) and were asymptomatic, with the purpose of detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in peritoneal fluid. Nasopharyngeal swab was done as a prerequisite for admission or prior to admission as part of random testing. Two methods of viral testing were employed: Xpert® Xpress SARS-CoV-2 (rapid test) and real-time reverse transcription polymerase chain reaction (RT-PCR). Either or both tests were done, with the former performed for patients requiring surgery immediately. Surgery was performed within 24-36 h from admission. Peritoneal fluid swabs were obtained for the detection of SARS-CoV-2 using RT-PCR test. Swabs were immediately placed in viral transfer media and delivered to the public health laboratory in an ice bag. SARS-CoV-2 was not detected in peritoneal swabs. Due to the limited number of patients, further studies are required; yet, protective measures should still be taken by surgeons when dealing with COVID-19 cases.

Epidemiological and clinical presentations of hospitalized COVID-19 patients in Libya: An initial report from Africa.

BACKGROUND: The first case of the novel coronavirus disease 2019 (COVID-19) in Libya was diagnosed in March 2020. We aimed to determine the epidemiological, clinical, and laboratory characteristics of COVID-19 in Libya. METHOD: In this retrospective descriptive study, we analyzed the demographics, initial clinical presentation, history, comorbidities, laboratory findings, complications, and outcomes of hospitalized patients with COVID-19 at several centers in the Western part of Libya between March 24, 2020, and December 3, 2020. RESULTS: The study included 811 (67.2%) men and 396 (32.8%) women. The median (interquartile range [IQR]) age was 56 (40-64). A total of 173 (14.3%) patients developed respiratory distress syndrome, while 70 (5.8%) developed circulatory shock and hypotension; 190 (15.7%) were admitted to the intensive care unit. Acute cardiac injury occurred in 27 (2.2%) patients, and 45 (3.7%) developed arrhythmia. Acute kidney injury occurred in 44 (3.6%) patients. Of the patients admitted during the study period, 149 (12.3%) died. The predominant comorbidities ordered in a descending manner were as follows; diabetes mellitus, presented 490 (40.6%), hypertension in 414 (34.3%), chronic kidney disease in 114 (9.4%), and lung diseases in 103 (8.5%). The total white blood cell, neutrophil; monocyte; D-dimer; creatinine kinase; creatine kinase-MB; creatinine; total bilirubin; alanine and aspartate aminotransferase; and hypersensitive troponin were increased among non-survivors, whereas lymphocyte and platelet counts were decreased among non-survivors. CONCLUSION: This is the first report of the clinical presentations and laboratory findings in patients hospitalized with COVID-19 in Libya. Libyan authorities must implement several restrictions to control the pandemic. However, incoming international travelers pose a challenge to the local authorities, especially with the recent discovery of new variants.

Successful management of H1N1 related severe acute respiratory distress syndrome with noninvasive positive pressure ventilation.

Acute respiratory distress syndrome (ARDS) is a life threatening complication of H1N1 pneumonia. According to the Berlin conference guidelines, severe ARDS requires management with early invasive mechanical ventilation. Whether noninvasive positive pressure ventilation (NIPPV) should be attempted in patients with H1N1 pneumonia is still a matter of debate. We report the case of one patient with severe ARDS without other organ failure. The patient was managed successfully using NIPPV. Endotracheal intubation was avoided and the patient was discharged from the intensive care unit (ICU) after 10 days with a successful outcome. NIPPV can be useful in patients with isolated severe H1N1 ARDS provided early improvement of the oxygenation parameters is achieved. Patients with multiple organ failure or with persistent severe hypoxemia under noninvasive ventilation should be electively intubated and started on invasive mechanical ventilation.

Design-of-experiment approach for HPLC analysis of 25-hydroxyvitamin D: a comparative assay with ELISA.

Although high-performance liquid chromatography-mass spectrometry (HPLC-MS) is adopted as the method of choice for the determination of vitamin D and its metabolites in plasma, yet the unavailability of this expensive detection technique in many clinical laboratories makes ultraviolet (UV) detection the alternative of choice in many places worldwide. In this regard, determination of parameters affecting HPLC separation of vitamins D2, D3 and their hydroxyl metabolites in plasma in a systematic way would put an end to irrelevant trials for more optimization. A new robust HPLC-UV was developed, optimized using DryLab(®)2000 and validated for the determination of vitamins D2 and D3 and their 25-hydroxyl metabolites in plasma to achieve best resolution and least runtime where the metabolites elute in <10 min, where vitamin D2 is considered a feasible internal standard. Chromatographic parameters affecting resolution of the four peaks were specifically defined by a two-dimensional resolution map. Forty-six plasma samples were analyzed by the optimized method as well as by an ELISA kit to compare results and to judge validity of ELISA as a technique of clinical importance. Statistical analyses proved that the investigated assays were incomparable. Variation among subjects was detected by HPLC but not ELISA, concluding that HPLC-UV is the better tool in determining vitamin D status than ELISA.