Papillary thyroid microcarcinoma with and without nodal metastasis: A comparative analysis

OBJECTIVES

To assess the demographics and clinical factors of papillary thyroid microcarcinoma (PTMC) patients in Saudi Arabia and compared and analyzed the differences between the patients with and without lymph node metastasis (LNM). Papillary thyroid microcarcinoma (PTMC) is a common thyroid cancer and is not usually detectable clinically but found incidentally after pathologic evaluation of thyroid tissue following surgery for benign thyroid disorders. However, these tumors have a significant risk of LNM.

METHODS

All PTMC patients who underwent surgery at King Abdulaziz University Hospital, King Fahad Medical City, and King Abdulaziz Medical City from 2012 to 2022 were included. The incidence rate of LNM was 9.17%. The patients' average age was 44.05. Most of the patients were female.

RESULTS

Prevalence of LNM among PTMC patients is 9.17% (n=31). The PTMC patients showed the following significant risk factors for LNM: higher Bethesda class, type of pathology, extrathyroidal extension, extracapsular extension, lymphovascular invasion, and residual tumors in patients who had received radioactive iodine. Presence of thyroiditis, multifocality, goitrous thyroid, neural invasion, and tumor size were unrelated to the LNM in the PTMC patients.

CONCLUSION

Higher Bethesda class, pathology type, extrathyroidal extension, extracapsular extension, lymphovascular invasion, and RAI-treated residual tumors were strongly linked to LNM.

Magnetic resonance imaging accuracy in assessing depth of invasion in tongue squamous cell carcinomas and predicting cervical nodal metastasis

OBJECTIVE

The aim of this study was to evaluate magnetic resonance imaging (MRI) accuracy in assessing the depth of invasion (DOI) compared to pathological DOI in oral tongue squamous cell carcinoma (SCC) and to determine whether MRI-measured DOI can predict lymph node metastasis in the cervical region.

PATIENTS AND METHODS

This retrospective study comprised 36 patients diagnosed with oral tongue SCC who underwent head and neck MRI 1-30 days before surgery and were surgically treated at King Fahad Medical City between January 2017 and November 2022. Relevant information was collected from the patients' records, and the data were analyzed to determine the radiological-histopathological correlations for the DOI and ascertain the cutoff point for nodal metastasis.

RESULTS

A value for Pearson's correlation coefficient between MRI-measured and pathological DOI was 0.86, indicating that these measures were highly associated and consistent with each other. The MRI-measured DOI coronal view (CV) was slightly overestimated than the pathological DOI by 1.72 mm. The cutoff values for the MRI-measured DOI CV and pathological DOI that indicated nodal metastasis were 7.08 mm and 9.04 mm, respectively.

CONCLUSIONS

Preoperative MRI is a valuable tool to accurately stage oral tongue SCC by measuring the depth of tumor invasion.

Utilization Pattern and Related Knowledge of Nasal Decongestants Among the General Population in Al-Qunfudah Governorate, Saudi Arabia: A Community-Based Cross-Sectional Study

BACKGROUND

Nasal decongestants, like phenylephrine and pseudoephedrine, are commonly used to relieve nasal obstruction in conditions such as allergic rhinitis. They induce nasal passage dilation through vasoconstriction but can lead to serious side effects like hypertension and rebound congestion. Despite being easily accessible over the counter, their usage patterns and awareness of side effects are not well studied.

OBJECTIVES

The study aimed to assess the utilization pattern and public knowledge of nasal decongestants in Al-Qunfudah governorate, Saudi Arabia, in 2023.

METHODS

This observational cross-sectional study assessed the utilization pattern of nasal decongestants among those who were 10 years of age and older and resided in Al-Qunfudah governorate and its villages. Data were collected in three months, from June to August 2023, using a self-administered survey that was disseminated among the general population at Al-Qunfudah governorate on different electronic platforms like Twitter (X Corp., San Francisco, CA, United States) and Snapchat (Snap Inc., Santa Monica, CA, United States). RStudio (version 4.3.0) was used for the statistical analysis. The knowledge score showed a non-normal distribution (Shapiro-Wilk test p value < 0.001). For normally distributed qualitative variables, the factors related to nasal decongestant use were assessed using Pearson's Chi-squared test. Fisher's exact test was applied when more than 20% of cells had frequencies less than 5. A generalized linear regression model was used to assess the independent predictors of higher knowledge scores. A p-value < 0.05 indicated statistical significance.

RESULTS

Based on 410 responses, nearly 77% (n = 314) of the participants have ever used nasal decongestants. A total of 118 out of 314 (37.6%) used these medications twice daily for less than five days (81.2%, n = 255). A total of 192 (61.1%) participants used nasal decongestants based on physicians' prescriptions. Few respondents (12.9%, n = 53) and (33.2%, n = 136) correctly identified nasal mucosal ulceration and nasal dryness as adverse effects of prolonged nasal decongestants' use. However, 84.6% (n = 347) ignored their contraindications, and 55.1% (n = 226) had no idea about rebound congestion. Overall, participants displayed a moderate level of knowledge regarding nasal decongestants, with a median knowledge score of 5.0. Being a student (beta = 1.12, 95%CI, 0.19 to 2.05, p = 0.019) and being a female were independently associated with better knowledge scores (beta = 0.97, 95%CI, 0.40 to 1.54, p < 0.001). Those who ever used nasal decongestants (beta = 0.71, 95% CI: 0.07 to 1.34, p = 0.030) and those who used them three times a day (beta = 1.05, 95% CI: 0.11 to 1.99, p = 0.029) had higher knowledge scores.

CONCLUSION

More than two-thirds (76.6%) of the Al-Qunfudah general population in Saudi Arabia utilized nasal decongestants. The utilization pattern of nasal decongestants highlighted short-term usage for nasal obstruction. Despite the moderate level of knowledge of the general population about nasal decongestants, many gaps were noted regarding their systemic contraindications, side effects, and the risks of rebound congestion. A focus group discussion is advised to get a full and deep perception of the public regarding this common type of medication. Health education programs are recommended regarding this category of medications, warning them about ineffective self-medication.

Examining the Impact of the COVID-19 Vaccine on Smokers and Diabetic Individuals: Unveiling the Efficacy and Unraveling Side Effects in Al Jouf Region, KSA

BACKGROUND

The assessment of the side effects of the COVID-19 vaccine is crucial to inform individuals about the potential risks and benefits of vaccination and to provide appropriate medical care if necessary. The study aimed to assess the effect of the COVID-19 vaccine on smokers and diabetic individuals and to investigate the occurrence of any side effects in the subpopulation of the Al Jouf region, KSA.

MATERIALS AND METHODS

The questionnaire had three main sections: the first covered basic information including gender, age, general health status, place, socio-economic position, nationality, smoking, and diabetes. Section 2 included the COVID-19 vaccination status and side effects, and the third section dealt with the dental history. Informed consent was obtained from the recruited individuals. Participants completed a Google self-administered questionnaire.

RESULTS

One hundred and twenty participants responded to the survey forms. Similarly, for diabetics versus non-diabetics, there was no statistically significant difference in the type of vaccine received (chi-square value = 3.125, p-value = 0.682). For smokers versus non-smokers, the chi-square test showed a non-significant difference in side effects (chi-square = 2.56, p-value = 0.109), indicating that there was no significant difference in the side effects experienced by smokers and non-smokers. For diabetics versus non-diabetics, the chi-square test showed a non-significant difference in side effects (chi-square = 0.34, p-value = 0.560), indicating that there was no significant difference in the side effects experienced by diabetics and non-diabetics.

CONCLUSION

Smokers and diabetics had higher harmful effects than non-smokers and non-diabetics. These findings need larger, robust trials to support treatment decision-making.

Women's Knowledge and Attitudes Regarding the Risk Factors and Warning Signs of Breast Cancer in the Eastern Province, Saudi Arabia: A Cross-Sectional Study

Introduction Breast cancer is the leading type of cancer in women globally, contributing significantly to cancer-related deaths. In Saudi Arabia, it ranks as the second most common cancer among women. Studies have highlighted a lack of awareness about breast cancer, negatively impacting breast self-examination practices. The Eastern Province has particularly high incidence rates. Knowledge of risk and protective factors can aid in prevention and early detection. While some studies show good awareness, this research aims to assess women's knowledge and attitudes about breast cancer risk factors and warning signs in the Eastern Province. Methodology This is a cross-sectional study conducted in Saudi Arabia's Eastern Province from June to October 2023 to assess breast cancer awareness among adult females. Data were collected via an online survey. Data were cleaned in MS Excel (Microsoft Corporation, Redmond, Washington) and analyzed in IBM SPSS Statistics for Windows, Version 23 (Released 2015; IBM Corp., Armonk, New York). Results Our study assessed breast cancer awareness in 697 participants in Saudi Arabia's Eastern Province. Most were aged 20-24 years (30.3%), married (49.2%), and Saudi nationals (97.6%), with higher education (59.4%). Significantly, 69.2% received education on breast cancer risk factors/signs. Some had personal breast cancer diagnoses (5.0%), and 31.7% had affected family members. Participants showed good awareness of various risk factors and warning signs. Significant associations were found between nationality, personal breast cancer diagnosis, and knowledge and attitudes about risk factors. Age, marital status, occupation, education on breast cancer, and personal breast cancer diagnosis influenced knowledge and attitudes about warning signs. Conclusion Our study findings indicate generally good awareness of breast cancer risk factors and warning signs among participants. Age, marital status, occupation, education on breast cancer, and personal breast cancer diagnosis influenced knowledge and attitudes about risk factors and warning signs. Educational efforts should target lesser-known risk factors to enhance prevention and early detection.

Enhanced Recovery After Surgery (ERAS) in Saudi Arabian Surgical Practice: A Comprehensive Analysis of Surgical Outcomes, Patient Satisfaction, and Cost-Effectiveness

Introduction Surgical procedures present substantial healthcare costs, patient discomfort, and potential adverse outcomes. In response, enhanced recovery after surgery (ERAS) protocols have emerged as comprehensive, evidence-based preoperative care pathways designed to optimize preoperative, intra-operative, and postoperative management. These protocols incorporate various interventions, such as preoperative education, nutritional optimization, minimally invasive techniques, multimodal pain management, early mobilization, and patient engagement. Despite their global success and growing popularity, the adoption and influence of ERAS protocols in Saudi Arabia have not been extensively explored. This study aims to assess the ERAS effects on surgical outcomes and evaluate its relationship with patient satisfaction, considering factors such as cost-effectiveness and compliance in the Saudi context. Methods This cross-sectional study encompassed data collection from 1,452 patients who underwent surgical procedures such as bariatric surgery and cholecystectomy, employing systematic random sampling across multiple healthcare facilities in Saudi Arabia. Data were gathered through structured questionnaires, medical records, and cost-effectiveness analysis within the period spanning from January to August 2023. The relationship between ERAS protocol implementation, surgical outcomes, patient satisfaction, and cost-effectiveness was analyzed using statistical tests, including correlation, regression analysis, and chi-square tests. A statistical significance threshold was set at p < 0.05, and Statistical Product and Service Solutions (SPSS, version 28.0) (IBM SPSS Statistics for Windows, Armonk, NY) was used for data analysis. Results Among the 1,452 respondents, 1,152 (79.3%) reported the implementation of ERAS protocols during their surgical procedures. Those receiving ERAS protocols exhibited significantly lower rates of surgical complications, readmissions, and reduced dependency on pain medication (p < 0.001). Additionally, participants subjected to ERAS protocols reported significantly higher satisfaction levels based on the mean satisfaction scale score, with a p-value of less than 0.001. Conclusion The results highlight substantial improvements associated with the implementation of ERAS protocols, particularly in terms of reduced surgical site infections, shortened hospitalization periods, and decreased pain management-related complications. Moreover, ERAS protocol implementation demonstrated enhanced surgical outcomes, increased postoperative satisfaction, and overall improved recovery experiences. These findings underscore the potential benefits of integrating ERAS protocols into the surgical practices of Saudi Arabia. This research contributes to a better understanding of the advantages offered by ERAS protocols and their potential for enhancing healthcare delivery in the region.

Endovascular Interventions for Peripheral Arterial Disease in Saudi Patients: A Cross-Sectional Study Assessing Efficacy and Economic Impact

Introduction Peripheral Arterial Disease (PAD) is characterized by arterial narrowing or blockage, causing pain and reduced quality of life. Endovascular interventions, like angioplasty and stenting, offer less invasive treatment options with potential benefits. This study, conducted in the Al-Ahsa region of Saudi Arabia from January to August 2023, aims to assess the impact of these interventions on PAD management in Saudi patients. Specifically, we aim to evaluate their effectiveness in improving clinical outcomes, such as symptom relief and quality of life, and their cost-effectiveness in the Saudi healthcare system. By addressing these objectives, our research provides evidence to support informed clinical decisions and healthcare policy in Saudi Arabia, ultimately enhancing patient care. Methods In this study, a cross-sectional design was used to assess the impact of endovascular interventions on PAD management in Saudi patients in the Al-Ahsa region. Data collection took place from January to August 2023. The study focused on a sample of 385 or more Saudi patients who had undergone endovascular interventions. Inclusion criteria involved diagnosed PAD patients who had received these interventions, while non-Saudi patients and those without PAD or interventions were excluded. Data was collected through an online questionnaire distributed in hospitals. The study considered demographic and clinical/economic variables to evaluate intervention effectiveness and cost-effectiveness. Results The findings of this study emphasize the significance of variables such as gender, education level, employment status, and geographic location in shaping perceptions concerning the effectiveness and cost-effectiveness of endovascular interventions for the management of PAD. Participants in the study reported substantial improvements in symptom relief, quality of life, and daily activities following endovascular interventions. Moreover, the study revealed divergent perceptions regarding the cost-effectiveness of these interventions among participants. Conclusion This study highlights a positive association between the use of endovascular interventions and improved clinical outcomes in Saudi patients diagnosed with PAD. The results of this research indicate that endovascular interventions are not only more cost-effective when compared to alternative treatment modalities for PAD management but also lead to significant enhancements in symptom relief, quality of life, and daily activities among patients. The implications of these findings for the Saudi healthcare system are substantial, underscoring the importance of evidence-based decisions in the adoption of endovascular interventions for PAD management.

Validity and Reliability of the Arabic Thyroidectomy-Related Voice and Symptom Questionnaire (A-TVSQ) for Assessing Post-Thyroidectomy Patients

OBJECTIVE

Post-thyroidectomy patients commonly experience voice changes, swallowing symptoms, and neck discomfort, a condition known as post-thyroidectomy syndrome. The Thyroidectomy-Related Voice and Symptom Questionnaire (TVSQ) is a validated tool showing strong correlations with established tools with a potential predictive value for post-thyroidectomy voice outcomes. Our study aims to translate and validate the TVSQ into Arabic.

METHODS

This validation study was conducted at King Abdulaziz University Hospital and King Khalid University Hospital in Riyadh, Saudi Arabia. Forward and backward translations ensured the conceptual equivalence of the Arabic TVSQ (A-TVSQ) and were reviewed by an expert panel. A pilot test assessed the A-TVSQ's face validity and clarity, leading to necessary cultural adjustments. The final A-TVSQ was preoperatively and postoperatively administered to thyroidectomy patients to evaluate its test-retest reliability.

RESULTS

Data were collected from 116 participants (53 cases [45.6%] and 63 controls [54.3%]). The internal consistency analysis showed strong intercorrelation among the A-TVSQ items, with Cronbach's alpha coefficients (0.951) indicating excellent estimated internal consistency within both domains. Test-retest reliability showed a moderate level of reliability with an intraclass correlation coefficient of 0.696. A-TVSQ item discrimination analysis showed significant associations between the total and domain scores pre- and post-thyroidectomy. External validity analysis showed significant changes in A-TVSQ voice change (P < 0.010) and neck discomfort (P = 0.011) domains and total scores (P < 0.010) between before and 2 weeks after thyroidectomy. However, no significant changes were observed between 2 and 4 weeks after thyroidectomy.

CONCLUSIONS

The translated and validated A-TVSQ showed excellent internal consistency and moderate test-retest reliability, comparable to the original version. Voice change significantly worsened after thyroidectomy, highlighting the need for continued monitoring and management strategies for this complication.

Home infusion services in Saudi Arabia: Where are we standing?

Diseases management has reached the highest level of complexity and cost in history, worldwide, and in Saudi Arabia in particular, which led to prolonged, unnecessary hospital stays. There have been many recent innovative measures to reduce these issues. One is to provide home infusion services. Hence, this narrative review emphasizes the expected benefits and challenges of such services and the applicability of their implementation in Saudi Arabia. A literature search was conducted via PubMed database, involving all published studies from inception until March 24th, 2023. Many studies showed positive impacts of home infusion on reducing the length of hospital stays, increasing cost-saving, and leading to high patient satisfaction.

Adherence to evidence-based guidelines for the management of pneumonia in a tertiary teaching hospital in Riyadh

Background

Adherence to therapeutic guidelines is crucial when treating pneumonia, as it reduces mortality rate, length of hospital stay and duration of antibiotic therapy. However, the high non-adherence rate to treatment guidelines, in general, and to the Infectious Disease Society of America (IDSA) guidelines, are still reported globally. According to our knowledge, no existing data is available regarding the rate of physicians' adherence to the IDSA guidelines for managing pneumonia in Saudi Arabia. Therefore, we aim to assess the adherence rate and the clinical outcomes among patients treated according to the IDSA guidelines, in a tertiary care center in Riyadh.

Methods

A single-centered, retrospective, cross-sectional, observational study was conducted at King Khalid University Hospital, Riyadh, Saudi Arabia. All data were extracted from the hospital's electronic information system, known as Esihi. Adult patients (≥18 years old) diagnosed and treated in the hospital for community-acquired pneumonia, hospital-acquired pneumonia, or ventilator-associated pneumonia from Nov 2019 to Nov 2021 were included.

Results

A total of 148 patients were included in this study, and the management of 50% of them (74 patients) adhered to the guidelines' recommendations. Even though the patients who received guidelines-adhered management were older (70 ± 16 vs 59 ± 22; p = 0.001), and had a higher CURB-65 score for pneumonia severity (1.86 ± 1.03 vs 1.39 ± 1.26; p = 0.026) and an average calculated Charlson comorbidity index (4.62 ± 2.19 vs 3.28 ± 2.80; p = 0.001) than patients who were treated irrespectively of the guidelines, yet they had a better cure rate (95% vs 84%; adjusted OR, 3.9; 95% CI, 0.82-18.58), lower mortality (5% vs 14%; adjusted OR, 0.38; 95% CI, 0.04-4.05) and shorter length of hospital stay (LOS) (6.5 vs 8 days; p = 0.082); compared to patients who were treated irrespectively of the guidelines.

Conclusions

Comparable to previous literature, non-adherence to evidence-based guidelines has been observed in 50% of patients treated for pneumonia. Despite being nonsignificant, higher clinical cure rates, shorter LOS, and lower mortality rates have been observed in patients who were treated based on evidence-based guidelines. Further measures to improve guidelines compliance in pneumonia treatment are needed.

TSH level as a risk factor of thyroid malignancy for nodules in euthyroid patients

Objective

With the increased prevalence of incidental thyroid cancer, determining the predictors of thyroid malignancy has become a source of debate. This study aimed to determine the impact of thyroid stimulating hormone (TSH) levels on rates of thyroid cancer in euthyroid patients.

Methods

A retrospective study included 421 patients who underwent thyroidectomy at a tertiary hospital between 2016 and 2020. Patients' demographics, history of cancer, pre-operative workup and final histology reports were obtained. The study sample was divided into two groups based on the final histopathology (benign vs malignant). The two groups were compared using the appropriate statistical tests to determine the predictors of thyroid cancer in euthyroid patients.

Results

TSH levels were significantly higher in patients with malignant nodules compared to those with benign nodules (1.94 vs 1.62, p = 0.002). It was 1.54 times more likely for thyroid nodules to be malignant when TSH levels were higher (p = 0.038). Meanwhile, larger nodules (> 4 cm) were significantly more prevalent in benign nodules (43.1%) than in malignant nodules (21.1%). Larger nodules decreased the possibility of thyroid cancer by 24% (OR = 0.760, p-value = 0.004).

Conclusions

High TSH levels in euthyroid patients were significantly correlated with the risk of thyroid malignancy. In addition, as Bethesda category proceeded toward malignancy, TSH levels increased. High TSH levels and small nodule diameters can be used as additional parameters in predicting thyroid cancer in euthyroid patients.

Ventral Hernia in the Al-Ahsa Region, Saudi Arabia: Risk Factor Knowledge Assessment

Introduction A ventral hernia is defined as a non-inguinal, non-hiatal defect in the fascia of the abdominal wall. Approximately 350,000 ventral hernia procedures are performed each year. Ventral hernia can have a negative impact on a person's quality of life and, in severe situations, lead to hospitalization and even death. Aim This study aimed to assess the knowledge of the general population living in the Al-Ahsa region regarding the risk factors of ventral hernia. Subjects and methods This is a cross-sectional study conducted among the general population living in the Al-Ahsa region of Saudi Arabia. A self-administered questionnaire was distributed among the population using an online platform. The questionnaire includes basic demographic characteristics (age, gender, and body mass index (BMI)) and a nine-item questionnaire to assess the knowledge of risk factors of ventral hernia. Results Of the 803 respondents involved, 42.1% were aged between 22 and 28 years old, and 44.4% were either overweight or obese. According to participants' knowledge, the most common risk factor of ventral hernia was heavy weight lifting (87.4%), and pregnancy and labor (64.1%). The overall mean knowledge score was 5.78 (standard deviation (SD): 2.68) out of 12 points. Nearly half (49.4%) were considered to have poor knowledge levels, 40.2% were considered to have moderate knowledge levels, and only 10.6% were considered to have good knowledge levels. Increased knowledge was seen more frequently in younger participants, males, and respondents with normal or underweight BMI. Conclusion The knowledge of the general population regarding the risk factors of ventral hernia was insufficient. Of all the population, male respondents who were younger and had a normal body mass index demonstrated a better understanding of the ventral hernia's risk factors compared to the rest of the subjects. Further research is needed to establish the knowledge of the general population regarding the risk factors of ventral hernia in our region.

Erythrodermic Psoriasis Managed with Risankizumab

Erythrodermic psoriasis (EP) is a severe, often refractory, variant of psoriasis. Due to the high morbidity and mortality rate associated with EP and other causes of erythroderma, they are often classified as dermatologic emergencies. EP is usually a therapeutic challenge, where topical and conventional systemic therapies have yielded a less than satisfactory result in several patients. Furthermore, there are a limited number of studies evaluating other therapeutic modalities, such as biologic agents, with no clear treatment guidelines. In this case report, we present a patient who was diagnosed as a case of EP and showed an impressive response to risankizumab.

The Biological and Mechanical Effect of Using Different Irrigation Methods on the Bond Strength of Bioceramic Sealer to Root Dentin Walls

Objectives This study aimed to evaluate the biological and mechanical effect of different irrigation methods on the bond strength of Bioceramic (BC) sealer to root canal dentin walls. Material and Methods Forty-Five single-rooted teeth were decoronated and then prepared using rotary instrumentation. Teeth were randomly divided into three groups. Group 1: using the conventional syringe method; Group 2: using the ultrasonic (US) activation method; and Group 3: using the Nd:YAG laser activation method. The BC sealer (TotalFill® BC Sealer™, FKG Dentaire, Switzerland) was used for obturation according to the manufacturer's recommendation. The bond strength was evaluated using the push-out test, and the adaptation of the sealer/dentin interface was assessed using Scanning Electron Microscope (SEM). Data were analyzed by Welch's ANOVA analysis of variance and Games-Howell for pairwise comparison. The level of statistical significance was set at 95% (p-value ≤ 0.05). Results The push-out bond strength values of the Nd:YAG (6.46 ± 0.5) laser group were statistically significant than both conventional (3.33 ± 1.8) and US groups (4.21 ± 2.2). The mean gaps that were formed between the root walls and GP/BS sealer interface were statistically significant only between the Nd:YAG laser group (25.54 ± 13.8) compared to both conventional (62.00 ± 15.3) and US groups (58.82 ± 23.8) (p ≤0.05). No significant difference was found between the conventional and US groups in both rested parameters (p >0.05). Conclusion The method protocol of RC system irrigation affects the adhesion and bond strength of BS sealers to the root canal dentin walls.

Prevalence and predictors of seizure in patients with Alzheimer’s disease at a tertiary care center in Riyadh, Saudi Arabia

Purpose: To assess the prevalence and predictors of seizures in patients with Alzheimer’s disease (AD) at a Saudi tertiary hospital.Methods: A retrospective, matched case-control study was conducted using the electronic medical records of patients with AD who had an unprovoked seizure, from October 2015 to May 2018.Results: Nineteen cases and 195 controls were identified. Statistically significant risk factors for an unprovoked seizure in patients diagnosed with AD were hypertension (p = 0.001), autoimmune disease, stroke and TIA (p = 0.001). The multivariate logistic regression analysis identified hypertension (OR = 2.89; p = 0.009) and autoimmune disease (OR = 19.6; p = 0.045) as predictors of unprovoked seizure in AD patients.Conclusion: The occurrence of unprovoked seizures is more likely in severe cases of AD. In addition, the risk of seizure in patients with AD increases with two co-morbid conditions, hypertension, and autoimmune disease. However, further studies are required to determine the underlying mechanism of the association between the two risk factors and AD.

Characteristics of Patients Presented With Metastases During or After Completion of Chemoradiation Therapy for Locally Advanced Rectal Cancer: A Case Series

PURPOSE

Locally advanced rectal cancer (LARC) is managed by chemoradiotherapy (CRT), followed by surgery. Herein we reported patients with metastases during or after CRT.

METHODS

Data of patients with LARC who received CRT from 2008 to 2017 were reviewed. Patients with metastases after CRT were included. Those with metastatic tumors at the initial diagnosis were excluded.

RESULTS

Fourteen patients (1.3%) of 1,092 who received CRT presented with metastases. Magnetic resonance circumferential resection margin (mrCRM) and mesorectal lymph nodes (LNs) were positive in 12 patients (85.7%). Meanwhile, magnetic resonance extramural vascular invasion (mrEMVI) was positive in 10 patients (71.4%). Magnetic resonance tumor regression grade (mrTRG) 4 and mrTRG5 was detected in 5 and 1 patient respectively. Ten patients (71.4%) underwent combined surgery and 3 (21.4%) received palliative chemotherapy.

CONCLUSION

Patients with metastases after CRT showed a higher rate of positive mrCRM, mrEMVI, mesorectal LNs, and poor tumor response. Further studies with a large number of patients are necessary for better survival outcomes in LARC.

Neorectal Mucosal Prolapse After Intersphincteric Resection for Low-Lying Rectal Cancer: A Case Report

Radical resection for low rectal cancer is the mainstay among the treatment modalities. Intersphincteric resection (ISR) is considered a relatively new but effective surgical treatment for low-lying rectal tumor. As the sphincter preserving techniques get popularized, we notice uncommon complication associated with it in the form of rectal mucosal prolapse. We presented 2 rare cases that developed neorectal mucosa prolapse after ISR a complication following low rectal cancer surgery. Although ISR is a safe and effective surgical technique for low rectal cancer, it should be considered to correct modifiable possible risk factors. Also, Delorme procedure is good option for management of neorectal mucosal prolapse.

Efficacy of clotrimazole for the management of oral candidiasis: A meta-analysis of randomized clinical trials

Purpose

To assess the efficacy and safety of topical application of clotrimazole versus others in the treatment of oropharyngeal candidiasis (OPC).

Method

Four electronic databases, registries of ongoing trials, and manual search were used to identify randomized controlled trials (RCTs) that compared the efficacy of clotrimazole to other antifungal agents in patients who were clinically diagnosed with oral candidiasis up to November 1st, 2019. Primary outcomes were clinical response and mycological cure rates. Secondary outcomes include relapse rate, incidence of systemic infections, and compliance. Adverse effects were also evaluated.

Results

Sixteen RCTs with a total of 1685 patients were included. Half of the eligible studies were considered at high risk of performance bias and more than a third, at high risk of reporting bias. Our analysis showed no significant difference in clinical response between clotrimazole and all other antifungal agents. However, clotrimazole was less effective in terms of mycologic cure and relapse rate. Sensitivity analysis comparing clotrimazole to other topical antifungal agents only showed no differences in clinical response, microbiologic cure or relapse. Further sensitivity analysis showed significant efficacy of fluconazole over clotrimazole.

Conclusion

This meta-analysis indicated that clotrimazole is less effective than fluconazole but as effective as other topical therapies in treating OPC. Well-designed high-quality RCT is needed to validate these findings.

Utilization of adjusted body weight for dosing unfractionated heparin in obese patients with venous thromboembolism: A retrospective matched cohort study

Purpose: To evaluate the effectiveness of adjusted body weight (AjBW)-based dosing of unfractionated heparin (UFH) in obese patients vis a vis actual body weight (ABW)-based dosing in non-obese patients with venous thromboembolism (VTE).Methods: A retrospective chart review was conducted for obese and non-obese patients initiated on UFH for treating VTE from September 2013 to December 2014. Patients were excluded from the study if they were under 18 years old, developed heparin-induced thrombocytopenia during treatment, received thrombolytic therapy prior to UFH, or received UFH at a dose that did not follow the institution’s protocol. The primary objective was to assess the efficacy of dosing UFH based on AjBW in achieving a therapeutic activated partial thromboplastin time (aPTT) within the first 24 h in obese patients, in comparison to the standard ABW-dosing for non-obese.Results: Of the 57 patients included in the study, 27 patients (47.4 %) were obese, and 30 patients (52.6 %) were non-obese; 16 (59.25 %) of the obese patients achieved a therapeutic aPTT within the first 24 h of AjBW-based dosed UFH, while 18 (60 %) of the non-obese patients achieved a therapeutic aPTT within the first 24 h of ABW-based dosed UFH (p = 0.45).Conclusion: AjBW-based dosing of UFH in obese patients demonstrates comparable efficacy to ABWbased dosing in non-obese patients. Keywords: Obesity, Unfractionated heparin, Venous thromboembolism, Adjusted body weight, Ideal body weight

Does the timing of protective ileostomy closure post-low anterior resection have an impact on the outcome? A retrospective study

BACKGROUND

The optimal timing for ileostomy closure remains controversial, most of the surgeons are closing ileostomy after two to three months, although ileostomy closure considered a simple procedure, it can cause significant morbidity; this study aims to clarify any relation between the post-closure complications rate and the time from its creation to the repair.

METHOD

From January 2010 to December 2017, data retrieved for a 405 patients who had protective ileostomy closure after rectal cancer surgery, our sample has been enrolled into two arms, the first arm includes whose ileostomies closed at or before three months, and the second arm involved whose ileostomies closed after three months from the index surgery, statistical analysis was performed and compared in both arms, RESULT: The overall post-closure complications in our hospital was 23.7%, there was no significant difference between the overall complications rate for both early and late closure groups (26.8% and 22.7%) respectively (P = 0.499), The majority of the complications were intestinal obstruction, and superficial surgical site infection, there was no significant association between the interval to ileostomy reversal and the intestinal obstruction although it was higher in the late closure group, in the other hand the surgical site infection complication found to be significantly higher in the early closure group than the late closure group (15.4% Vs 5.1%) with (P = 0.002).

CONCLUSION

The duration between the creation of protective ileostomy and its reversal was not a significant independent predictor of post-closure complications rate.

Factors associated with facial weakness following surgery for benign parotid disease: a retrospective multicenter study

BACKGROUND

Facial nerve weakness is the most common and most concerning complication after parotidectomy. Risk factors for this complication following surgery for benign diseases remain controversial.

OBJECTIVE

Review the frequency and prognosis of facial nerve weakness after parotidectomy and analyze potential risk factors.

DESIGN

Retrospective review of medical records.

SETTINGS

Two tertiary care centers.

PATIENTS AND METHODS

We included all parotidectomies performed for benign diseases from January 2006 to December 2018. Details about the development and recovery of postoperative facial weakness were recorded. Patient, disease and surgery-related variables were analyzed using bivariate and multivariate analyses to identify risk factors.

MAIN OUTCOME MEASURES

Frequency, recovery rates and risk factors for facial nerve weakness SAMPLE SIZE: 191 parotidectomies, 183 patients, 61 patients with facial weakness.

RESULTS

The frequency of postoperative facial weakness was 31.9% (61/191 parotidectomies). Among patients with temporary weakness, 90% regained normal facial movement within 6 months. Steroid therapy was not associated with a faster recovery. Postoperative weakness was not associated with age, diabetes, smoking, disease location, use of an intraoperative facial nerve monitor or direction of facial nerve dissection. Risk factors for temporary weakness were total parotidectomy and surgical specimens larger than 60 cubic centimeters. Revision surgery was the only identified risk factor for permanent weakness.

CONCLUSION

Larger parotid resections increase the risk of temporary facial nerve weakness while permanent weakness is mainly influenced by previous surgeries.

LIMITATIONS

Retrospective nature, underpowered sample size, selection bias associated with tertiary care cases.

CONFLICT OF INTEREST

None.

Comparing the efficacy and safety of faecal microbiota transplantation with bezlotoxumab in reducing the risk of recurrent Clostridium difficile infections: a systematic review and Bayesian network meta-analysis of randomised controlled trials

OBJECTIVES

The risk of recurrent Clostridium difficile infections (RCDIs) is high when treated with standard antibiotics therapy (SAT) alone. It is suggested that the addition of faecal microbiota transplantation (FMT) or bezlotoxumab after SAT reduces the risk of RCDI. In the absence of head-to-head randomised controlled trials (RCTs), this review attempts to compare the efficacy and safety of bezlotoxumab with FMT in reducing the risk of RCDI in hospitalised patients.

DESIGN

A systematic review and Bayesian network meta-analysis.

DATA SOURCE

A comprehensive search from inception to 30 February 2019 was conducted in four databases (Medline/PubMed, Embase, Scopus, ClinicalTrials.gov).

ELIGIBILITY CRITERIA

RCTs reporting the resolution of diarrhoea associated with RCDI without relapse for at least 60 days after the end of treatments as the primary outcome.

DATA EXTRACTION AND SYNTHESIS

We extracted author, year of publication, study design and binomial data that represented the resolution of diarrhoea or adverse events of monoclonal antibodies and FMT infusion. Random-effects models were used for resolution rate of RCDI and adverse events. The Cochrane Risk of Bias tool was used to assess the quality of included RCTs.

RESULTS

Out of 1003 articles identified, seven RCTs involving 3043 patients contributed to the review. No difference was reported between single or multiple infusions of FMT and bezlotoxumab in resolving RCDI, (OR 1.53, 95% credible interval (CrI) 0.39 to 5.16) and (OR 2.86, 95% CrI 1.29 to 6.57), respectively. Patients treated with SAT alone or bezlotoxumab with SAT showed significantly lower rates of diarrhoea than FMT (OR 0, 95% CrI 0 to 0.09) and (OR 0, 95% CrI 0 to 0.19), respectively. There was no difference in terms of other adverse events.

CONCLUSIONS

This is the first network meta-analysis that has compared the recently Food and Drug Administration-approved monoclonal antibody bezlotoxumab with FMT for resolving RCDI. The quality of the included RCTs was variable. The findings of this study suggested no difference between single or multiple infusions of FMT and bezlotoxumab. However, FMT was associated with a higher rate of non-serious diarrhoea as opposed to SAT used alone or in combination with bezlotoxumab.

Trends in thyroid carcinoma among thyroidectomy patients: a 12-year multicenter study

BACKGROUND

Thyroid malignancy, the most diagnosed cancer of the endocrine system, represents 2% of all malignancies worldwide. The increasing incidence of thyroid cancer has been linked to the increasing sensitivity of modern diagnostic methods which overdiagnosis small thyroid tumors.

OBJECTIVES

Assess the distribution and trends in thyroid cancer among thyroidectomy patients.

DESIGN

Descriptive, based on medical record review.

SETTINGS

Two tertiary care centers in Riyadh.

PATIENTS AND METHODS

We included patients who underwent thyroid surgery from January 1, 2004 to December 31, 2016 who ranged in age from 9-90 years regardless of initial diagnosis.

MAIN OUTCOME MEASURES

Distribution of thyroid carcinomas by type, age and sex and trends over the time period.

SAMPLE SIZE

979 patients.

RESULTS

Of 979 patients, 84.5% were <55 years old, with the majority being female. Thyroid malignancy ranked second to benign tumors, and the most common type of thyroid cancer was papillary thyroid carcinoma (91% of malignant tumors), followed by follicular thyroid cancer (4.7% of malignant tumors). After thyroid microcarcinomas were isolated from the sample and studied separately, we found the overall trend for thyroid cancer to be stable, and that the annual increases in rates were due to increased diagnosis of thyroid microcarcinoma in the period from 2010 to 2016.

CONCLUSION

Our study shows that increases in thyroid cancers may be attributed to a rise in the rates of diagnosis of thyroid microcarcinomas.

LIMITATIONS

The main limitation is the retrospective nature of this design. Also, a multicenter collaboration would prove beneficial in evaluating the trends of thyroid cancer in Saudi Arabia on a much larger scale.

CONFLICT OF INTEREST

None.

Multiple Weekly Dalbavancin Dosing for the Treatment of Native Vertebral Osteomyelitis Caused by Methicillin-Resistant Staphylococcus Aureus: A Case Report

Patient: Male, 58

Final Diagnosis: Vertebral osteomyelitis

Symptoms: Back pain

Medication: Dalbavancin

Clinical Procedure: —

Specialty: Infectious Disease

Early prediction of oral calcium and vitamin D requirements in post-thyroidectomy hypocalcaemia

OBJECTIVE

To optimize and individualize post-thyroidectomy hypocalcemia management.

STUDY DESIGN

A multicenter prospective cohort study.

SETTING

Two tertiary care hospitals.

SUBJECTS AND METHODS

parathyroid hormone (PTH) was measured preoperatively, then at 1 and 6 hours after surgery. The required doses of calcium and vitamin D were defined as those maintaining the patients asymptomatic and their cCa ≥ 2 mmol/L. They were used as an endpoint in a generalized linear mixed effect model (GLIMMEX) aiming to identify the best predictors of these optimal required doses. Models were evaluated by goodness of fit and Receiver Operating Characteristic (ROC) curves.

RESULTS

One hundred and sixty-eight patients were analyzed; 85.1% were female, 49.3% had BMI > 30, and 64% had vitamin D deficiency. Post-thyroidectomy hypocalcemia was found in 25.6%, of whom 18 (41.9%) were symptomatic and received intravenous calcium. First hour percentage of drop in PTH correlated positively with the severity of hypocalcemia (P < .0001). The GLIMMIX prediction model for oral calcium requirement was based on first-hour percentage change from preoperative PTH level, preoperative actual PTH, BMI, and thyroid function. The same predictors were identified for vitamin D, except that thyroid function was replaced with vitamin D status. These factors were used to build predictive equations for calcium and vitamin D doses.

CONCLUSION

Our findings help to optimize management of post-thyroidectomy hypocalcemia by assisting in the early identification of those who are not at risk of hypocalcaemia and by guiding early effective management of those at risk. This may reduce complications and medical cost.