Annals of Saudi Medicine最新文献

Background: Twin reversed arterial perfusion (TRAP) sequence is a rare condition that affects primarily monozygotic monochorionic twin pregnancies in which a normal twin acts as a pump (donor) for an acardiac recipient (perfuse) twin.

Objective: We report our experience over the last 13 years at a tertiary health care center.

Design: Descriptive, retrospective case series SETTING: Tertiary health care center PATIENTS AND METHODS: All TRAP cases managed between the years 2009 and 2022 at our Fetal Diagnosis and Therapy Center were included. Data recorded included demographic and clinical information which was used to generate descriptive data. Patients were managed by a multidisciplinary team with variable interventions.

Main outcome measure: Survival of normal twin SAMPLE SIZE: Eight RESULTS: Eight pregnant women with TRAP syndrome were managed at our center during that period. One was monozygotic monochorionic and the others were monochorionic diamniotic. Median maternal age at presentation was 27 years and median gestational age at diagnosis was 23 weeks. All were diagnosed with ultrasound (US) imaging. Three were managed with bipolar ligation of the cord of the acardiac twin under general anesthesia, one US-guided (single port) and 2 fetoscopic (2 ports) with a median operative time of 39 minutes. The last five cases were managed with US-guided radiofrequency ablation (RFA) under local anesthesia, one needed 2 sessions, 1 week apart. The median duration of the RFA procedure was 23 minutes. There were no complications and all had viable normal babies born at a median of 32 weeks of gestation (6 C-section, 2 spontaneous membrane rupture).

Conclusions: Acardiac twin cord ligation and RFA are feasible and safe options with excellent outcome for TRAP syndrome. RFA may be preferable owing to its less invasiveness under local anesthesia.

Limitations: None, given the rarity of the disease and the study design.

Conflict of interest: None.

Background: An important step in laparoscopic surgery is abdominal access. Several abdominal access techniques have been described to reduce complications. We compare our novel abdominal access technique (MESAD) with other abdominal access techniques, particularly to reduce complications in obese patients.

Objective: Compare the MESAD method and other methods we use for abdominal access in gynecologic laparoscopic surgery of obese patients DESIGN: Retrospective SETTING: Gynecology department in university hospital PATIENTS AND METHODS: Patients who underwent abdominal access by the MESAD technique, the Veress needle technique, and the Hasson technique were included in our study. In addition to demographic data, minor and major complications, number of unsuccessful attempts, conversion to another technique, and abdominal access times were collected from all patient files.

Main outcome measures: Clinical data and complications SAMPLE SIZE: 66 patients, 26 by MESAD technique, 24 by the Veress needle technique, and 16 by the Hasson technique.

Results: There were two major complications (one in the Veress group and one in the Hasson technique group) and 7 minor complications. No significant difference was found between the groups in terms of complications (P=.477, P=.476, respectively). The fastest technique for abdominal access was in the MESAD technique whereas the slowest was in the Hasson (P<.001). The failure of abdominal access and subsequent conversion to another technique was most common in the Veress group. However, no significant difference was found between the groups (P=.092).

Conclusions: The MESAD technique is an easy method to both learn and teach. We think that the low major-minor complication rates in the MESAD technique will allow surgeons to reduce their anxiety at the first entry and to perform a more comfortable operation.

Limitations: Retrospective CONFLICT OF INTEREST: None.

Background: Coronavirus disease 2019 (COVID-19), caused by a novel coronavirus, manifests as a respiratory illness primarily and symptoms range from asymptomatic to severe respiratory syndrome and even death. During the pandemic, due to overcrowding of medical facilities, clinical assessment to triage patients for home care or in-hospital treatment was an essential element of management.

Objectives: Study the demographic features, comorbidities and bio-markers that predict severe illness and mortality from COVID-19 infection.

Design: Retrospective observational SETTING: Single tertiary care center PATIENTS AND METHODS: The study included all patients admitted with a positive PCR test for COVID-19 during the period from March 2020 to September 2020 (7 months). Data on demographics, clinical data and laboratory parameters was collected from medical records every 3 days during hospital stay or up until transfer to ICU.

Main outcome measures: Demographic, comorbidities and biochemical features that might predict severe COVID-19 disease.

Sample size: 372 RESULTS: Of the 372 patients, 72 (19.4%) had severe disease requiring admission to intensive care unit (ICU); 6 (1.6%) died. Individuals over 62 years were more likely to be admitted to the ICU (P=.0001, while a BMI of 40 and higher increased the odds of severe disease (P=.032). Male gender (P=.042), hypertension (P=.006) and diabetes (P=.001) conferred a statistically significant increased risk of admission to ICU, while coexisting COPD, and ischemic heart disease did not. Laboratory features related to severe COVID-19 infection were: leukocytosis (P=.015), thrombocytopenia (P=.001), high levels of C-reactive protein (P=.0001), lactic dehydrogenase (P=.0001), D-dimer (P=.0001) and ferritin (P=.001). With the multivariate analysis, diabetes, high lac-tate dehydrogenase, C-reactive protein and thrombocytopenia were associated with severity of illness.

Conclusions: Particular demographic and clinical parameters may predict severe illness and need for ICU care.

Limitations: Single referral center, several cases of severe COVID-19 could not be included due to lack of consent and or data.

Conflict of interest: None.

Background: Pulmonary embolism (PE) is a condition with high mortality, and determining its etiology is as important as its treatment. There are limited studies in the literature examining the effect of atmospheric pressure (AP) change on PE.

Objectives: Analyze the effect of AP level and the change in AP level on the development of PE according to year, season and months.

Design: Retrospective SETTING: Department of tertiary care center PATIENTS AND METHODS: Patients with diagnosed or presumed PE who were followed up in the Erzurum Atatürk University Medicine Chest Diseases Clinic between 2012 and 2020 (8 years) were retrospectively screened for inclusion in the study by examining hospital records. Daily AP values were obtained electronically through official correspondence with the Erzurum Regional Meteorological Directorate. Patients diagnosed with PE were recorded using the hospital database and anamnesis forms. The dates of admission to hospital were recorded. Risk factors leading to the development of PE were identified using the records.

Main outcome measures: Relationship between AP values and the incidence of PE.

Sample size: 592 RESULTS: AP_min, AP_max, and AP_mean were significantly lower on days with PE cases compared to days without PE cases (P<.001 for all). ΔAP_min, ΔAP_max, and ΔAP_mean values were all negative on days with PE, but only the difference in ΔAP_min was significant (P=.04).

Conclusions: This study showed that lower AP values were significantly associated with the incidence of PE. In particular, a drop in AP_min compared to the previous day seemed to be most associated with PE development.

Limitations: Retrospective design and only applicable to region.

Conflict of interest: None.

Background: ICU and other patients hospitalized with corona-virus disease 2019 (COVID-19) are more susceptible to secondary infections. Undetected secondary infections tend to have a severe clinical impact, associated with prolonged hospitalization and higher rates of inpatient mortality.

Objectives: Estimate the prevalence of secondary infections, determine the frequency of microbial species detected at different body sites, and measure the association between secondary infections and outcomes among hospitalized COVID-19 patients.

Design: Cross-sectional analytical study.

Setting: Tertiary care center in Riyadh PATIENTS AND METHODS: Data were collected through retrospective chart review of hospitalized COVID-19 patients >18 years old from March 2020 until May 2022 at King Saud University Medical City (27 months). Rates of secondary infections among hospitalized COVID-19 patients were described and data on clinical outcomes (intensive care admission, invasive management procedures and mortality) was collected.

Main outcome measures: Features and rates of infection and mortality.

Sample size: 260 RESULTS: In total, 24.2% of the study population had secondary infections. However, only 68.8% of patients had secondary infection testing, from which 35.2% had a confirmed secondary infection. These patients had a significantly higher prevalence of diabetes mellitus (P<.0001) and cardiovascular diseases (P=.001). The odds of ICU admissions (63.3%) among secondarily infected patients was 8.4 times higher compared to patients with only COVID-19 infection (17.3%). Secondarily infected patients were more likely to receive invasive procedures (OR=5.068) and had a longer duration of hospital stay compared to COVID-19 only patients. Overall mortality was 16.2%, with a predominantly higher proportion among those secondarily infected (47.6% vs 6.1%) (OR=14.015). Bacteria were the most commonly isolated organisms, primarily from blood (23.3%), followed by fungal isolates, which were mostly detected in urine (17.2%). The most detected organism was Candida albicans (17.2%), followed by Escherichia coli (9.2%), Klebsiella pneumoniae (9.2%) and Pseudomonas aeruginosa (9.2%).

Conclusion: Secondary infections were prevalent among hospitalized COVID-19 patients. Secondarily infected patients had longer hospital stay, higher odds of ICU admission, mortality, and invasive procedures.

Limitation: Single-center study, retrospective design and small sample size.

Conflict of interest: None.

Background: Antenatal assessment of maternal risk factors and imaging evaluation can help in diagnosis and treatment of placenta accreta spectrum (PAS) in major placenta previa (PP). Recent evidence suggests that magnetic resonance imaging (MRI) could complement ultrasonography (US) in the PAS diagnosis.

Objectives: Evaluate the incidence, risk factors, and maternal morbidity related to the MRI diagnosis of PAS in major PP.

Design: A 10-year retrospective cohort study.

Setting: Tertiary care hospital.

Patients and methods: We report on patients with major PP who had cesarean delivery in Abha Maternity and Children's Hospital (AMCH) over a 10-year period (2012-2021). They were evaluated with ultrasonography (US) and color Doppler for evidence of PAS. Antenatal MRI was ordered either to confirm the diagnosis (if equivocal US) or to assess the depth of invasion/extra-uterine extension (if definitive US).

Main outcome measures: Risk factors for PAS in major PP and maternal complications.

Sample size: 299 patients RESULTS: Among 299 patients, MRI confirmed the PAS diagnosis in 91/299 (30.5%) patients. The independent risk factors for MRI diagnosis of PAS in major PP included only repeated cesarean sections and advanced maternal age. The commonest maternal morbidity in major PP with PAS was significantly excessive intraoperative bleeding.

Conclusion: MRI may be a valuable adjunct in the evaluation of PAS in major PP; as a complement, but not substitute US. MRI may be suitable in major PP/PAS patients who are older and have repeated cesarean deliveries with equivocal results or deep/extra-uterine extension on US.

Limitation: Single center, small sample size, lack of complete histopathological diagnosis.

Conflict of interest: None.

Background: The effect of maternal infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on the fetus is unclear, and there is no data from Saudi Arabia.

Objective: Assess the effect of maternal SARS-CoV-2 infection on fetal growth.

Design: Retrospective case-control SETTING: Tertiary care hospital, Riyadh, Saudi Arabia PATIENTS AND METHODS: We selected pregnant women who underwent an obstetric growth scan and umbilical artery Doppler ultra-sound examination between 28 and 41 weeks of pregnancy. Women with multiple pregnancy, fetal abnormalities, maternal body mass index >30, maternal hypertension, any other chronic diseases that might affect fetal growth or pregnant women suffering from cancer were excluded. Fetal growth parameters assessed included fetal biometry (biparietal diameter, head circumference, abdominal circumference and femur length). We also did an umbilical artery Doppler assessment, which includes the umbilical artery pulsatility index, resistive index and the systolic/diastolic ratio.

Main outcome measure: Fetal biometry and biophysical profile SAMPLE SIZE: 48 SARS-CoV-2; 98 non-SARS-CoV-2 RESULTS: More women who had recovered from SARS-CoV-2 infection had small for gestational age fetuses compared with the control group (P=.001).

Conclusion: Maternal SARS-CoV-2 infection during pregnancy was associated with a higher prevalence of small for gestational age (SGA) fetuses.

Limitations: Retrospective, middle cerebral artery and uterine artery Doppler data were not included nor were the effect of tobacco use and socioeconomic status, the relationship between the date of infection with the date of conceiving or the relationship between the severity of infection in the mother and fetal biometry and growth.

Conflict of interest: None.

Background: Enhanced recovery after surgery (ERAS) protocols have improved treatment outcomes and have standardized patient care.

Objectives: Identify the benefit of introducing the ERAS protocol for feeding after gastrostomy insertion with or without Nissen fundoplication, the effects on the time of reaching the full feeds the length of stay single-center experience, and complications associated with early feeding protocols.

Design: Retrospective cohort study SETTING: Tertiary hospital METHODS: The study review included cases performed between 2015 and 2021 by four surgeons, and cases performed in 2022 by all surgeons using ERAS feeding protocol (P) in a tertiary hospital.

Main outcome measures: Comparison the mean and mode of the length of stay (LOS) and the time until the patient reached full feed (TFF).

Sample size: 224 patients; 181 by the four surgeons and 43 cases by the ERAS protocol group.

Results: The difference in the ERAS protocol from the four surgeons in TFF and LOS was statistically significant (P<.001). There was no noticeable difference in postoperative complications after introducing the ERAS protocol.

Conclusion: ERAS improved the TFF and decreased the LOS without any increase in procedure complications. Increasing bed utilization and reducing costs were two benefits of reducing LOS at our hospital.

Limitations: Single-center study, which may not be generalizable. Multiple comorbidities. Travel time from different parts of the country could impact LOS. Retrospective and thus dependent on the accuracy of the information in file notes.

Conflict of interest: None.

Background: Coronavirus disease 2019 (COVID-19) is a devastating pandemic that causes disease with a variability in susceptibility and mortality based on variants of various clinical and demographic factors, including particular genes among populations.

Objectives: Determine associations of demographic, clinical, laboratory, and single nucleotide polymorphisms in the ACE2, TMPRSS2, TNF-α, and IFN-γ genes to the incidence of infection and mortality in COVID-19 patients.

Design: Prospective cohort study SETTINGS: Various cities in the Kurdistan Region of Iraq.

Patients and methods: This prospective cohort study compared laboratory markers (D-dimer, tumor necrosis factor-alpha [TNF-α], interferon-gamma [IFN-γ], C-reactive protein [CRP], lymphocyte and neutrophil counts) between COVID-19 patients and healthy controls. DNA was extracted from blood, and genotypes were done by Sanger sequencing.

Main outcome measures: Single nucleotide polymorphisms of the ACE2, TMPRSS2, TNF-α, and IFN-γ genes and demographic characteristics and laboratory markers for predicting mortality in COVID-19.

Sample size: 203 (153 COVID-19 patients, 50 health control subjects).

Results: Forty-eight (31.4%) of the COVID-19 patients died. Age over 40 and comorbidities were risk factors for mortality, but the strongest associations were with serum IFN-γ, the neutrophil-to-lymphocyte ratio (NLR), and serum TNF-α. The AA genotype and A allele of TMPRSS2 rs2070788 decreased while the GA genotype and A allele of TNF-α increased susceptibility to COVID-19. Patients with the GA genotype of TNF-α rs1800629 had shorter survival times (9.9 days) than those carrying the GG genotype (18.3 days) (P<.0001 by log-rank test). The GA genotype versus the GG genotype was associated with higher levels of serum TNF-α. The GA genotype increased mortality rates by up to 3.8 fold. The survival rate for COVID-19 patients carrying the IFN-γ rs2430561 TT genotype (58.5%) was lower than in patients with the TA and AA genotypes (80.3%). The TT genotype increased the risk of death (HR=3.664, P<.0001) and was linked to high serum IFN-γ production. Olfactory dysfunction was a predictor of survival among COVID-19 patients.

Conclusions: Age older than 40, comorbidities, the NLR and particular genotypes for and the IFN-γ and TNF-α genes were risk factors for death. Larger studies in different populations must be conducted to validate the possible role of particular SNPs as genetic markers for disease severity and mortality in COVID-19 disease.

Limitations: Small sample size.

Conflict of interest: None.