Annals of Saudi medicine最新文献

Background: Brucellosis, a common zoonotic disease worldwide, can lead to serious complications in humans. In Oman, the disease occurs most often in the south, but is increasing in the north.

Objectives: Describe brucellosis in children in the Northern Governorate in Oman.

Design: Retrospective, observational.

Settings: Hospitals in the Northern Governorate in Oman.

Patients and methods: We collected data on the demographics, distribution, common clinical presentations, risk factors, laboratory findings, therapy, and complications of confirmed cases of brucellosis. We included all brucellosis cases up to the age of 13 years at the Child Health Department in Royal, Suhar, Al Rustaq and Nizwa Hospitals over a 15-year period.

Main outcome measures: Descriptive findings of brucellosis.

Sample size: 57 confirmed cases.

Results: The 57 confirmed cases of Brucella had a mean age of 6 years. Most of the cases were from Dhakhiliya 21 (36.8%) and Batinah 18 (31.6%). Consumption of raw milk was documented in 75% and 41% had animal contact. From 2010, there was a marked rise of the cases with a maximum rise was noticed in 2019 with a total of 10 cases. The main clinical manifestations were fever (92%, n=52), arthritis (44%, n=25), which involved mainly knees and hips. Forty-two had bacteremia, 41% anemia, 10% osteomyelitis/septic arthritis, one case with congenital brucellosis and one case neurobrucellosis (1.8%). Forty cases had positive serology results of which 19 had positive cultures. Most cases had received cotrimoxazole and rifampin as the primary treatment regimen 22 (40%). Four patients relapsed (7%) after treatment completion.

Conclusion: This study showed the distribution and clinical characteristics of brucellosis in different regions in the Northern Governorate in Oman. Although the numbers of cases remained low, the gradual increase is concerning for public health and preventive strategies. Further studies are needed to compare this data with the Southern region.

Limitation: Retrospective study with small sample size.

Background: Infection is the second-leading cause of death among cancer patients, but there have been few studies on the effectiveness of novel antimicrobial agents to treat carbapenem-resistant Enterobacterales in cancer patients.

Objective: Evaluate the mortality and clinical outcomes of ceftazi-dime-avibactam for OXA-48- and/or New Delhi metallo-β-lactamase (NDM)-producing Enterobacterales infection in cancer patients.

Design: Retrospective observational cohort study.

Setting: Tertiary academic medical center in Riyadh, Saudi Arabia.

Subjects and methods: This study included patients who had cancer and received ceftazidime-avibactam for at least 72 hours for infections caused by OXA-48- and/or NDM-producing Enterobacterales. We excluded patients who died within 72 hours of treatment, patients with polymicrobial infections, and patients who did not receive appropriate antimicrobial therapy.

Main outcomes and measures: Primary outcomes were 30-day mortality and hospital mortality. Secondary outcomes included clinical cure, relapse, and reinfection.

Sample size: 32 cancer patients.

Results: The 30-day mortality among all patients was 15/32 (47%), clinical cure was achieved in 19/32 (59%) of the patients, and the relapse and reinfection rates were 2/19 (10.5%) and 4/17 (23.5%), respectively.

Conclusion: This is the largest study to evaluate clinical outcomes associated with infections caused by OXA-48- and/or NDM-producing Enterobacterales in cancer patients. The mortality rate remains high; however, ceftazidime-avibactam is an encouraging alternative for treating severe infections in cancer patients.

Limitations: Small sample size and single center.

Background: The 30-day period following emergency colorectal surgery (ECRS) is associated with high mortality and morbidity. There is a lack of data assessing factors associated with outcomes of ECRS in the Saudi population.

Objectives: Assess factors associated with 30-day postoperative mortality and complications following ECRS.

Design: Retrospective cohort study.

Setting: Single tertiary care center, Riyadh, Saudi Arabia.

Patients and methods: Demographic characteristics (age, sex, diagnosis, American Society of Anesthesiologists classification, pre-operative septic state, smoking, and comorbidities), operative characteristics (urgency, diverting ostomy, and procedure performed), and postoperative characteristics (length of stay, 30-day mortality, intensive care unit [ICU] admission, ICU length of stay, surgical site infection [SSI], readmission, reoperation, and complications) were collected from electronic medical records. Univariate logistic regression was used to evaluate association with the outcome measures (30-day mortality and postoperative complications). Multivariate logistic regression was applied to evaluate independent variables.

Main outcome measure: Thirty-day postoperative mortality and morbidity.

Sample size: 241 patients.

Results: Among 241 patients, 145 (60.2%) were men, and 80 (33.2%) patients were between 50-64 years of age. The most common indication for surgery was malignancy 138 (57%). The overall complication rate was 26.6% and the 30-day mortality rate was 11.2%. Left hemicolectomy was the most commonly performed procedure, performed in 69 (28.6%) patients. Patients between the age of 65-74 had an increased odds of death within 30 days (OR 5.25 [95% CI 1.03-26.5]) on univariate analysis. Preoperative sepsis was associated with a fourfold increase in the likelihood of 30-day mortality (OR 4.44, 95% CI 1.21-16.24, P=.024) on multivariate analysis. The likelihood of hospital re-admission increased by fivefold in patients who developed a postoperative complication (OR 5.33, 95% CI 1.30-21.78, P=.02).

Conclusion: Preoperative sepsis was independently associated with 30-day mortality in patients undergoing ECRS, while the likelihood of hospital readmission increased in patients with postoperative complications. Expeditious control of sepsis in the emergency surgical setting by both surgical and medical interventions may reduce the likelihood of postoperative mortality. Establishing discharge protocols for postoperative ECRS patients is advocated.

Limitations: Retrospective design, small sample size, and single setting.

Background: The prevalence of inflammatory bowel diseases (IBD), Crohn's (C) and ulcerative colitis (UC) has increased in Saudi Arabia during the past decade. Even though medical treatment is first-line therapy, most patients require surgery during the course of the disease. Stoma creation complications in IBD are underreported in the literature of the Middle East and especially in Saudi Arabia.

Objectives: Report the postoperative, stoma and peristomal complications following stoma creation in (C) versus UC.

Design: Retrospective cohort study.

Settings: Tertiary care center.

Patients and methods: Patients with IBD who underwent stoma creation for either UC or CD between August 2015 and July 2020 were included. The diseases were compared to assess their characteristics and association to postoperative, stoma and peristomal complications. All complications were reported over a 90-day duration from the surgery. Patients younger than 14 years of age were excluded.

Main outcome measures: Postoperative complications, stoma and peristomal complications in IBD patients who underwent stoma creation.

Sample size: 50.

Results: Of 50 IBD patients underwent stoma creation, 32 patients (64%) were diagnosed with CD and 18 patients (36%) with UC. Most of the procedures in both groups were laparoscopic and elective. Low BMI and serum albumin were more prevalent in the CD group. Postoperative complications were higher in the CD patients compared to the UC patients (CD 40.6% vs UC 11.1%, P=.028) with the most common complication being abdominal collection[a]. Stoma complications were comparable between the two groups (UC 16.7% vs CD 15.6%). However, peristomal complications were higher clinically in UC patients in comparison with the CD patients (UC 61.1% vs CD 37.5% P=.095) with the most common complication being skin excoriation (UC 44.4% vs CD 37.5%).

Conclusions: CD has significantly higher postoperative complications compared to UC. Peristomal complications were high in both groups and had a negative impact on quality of life. Therefore, comprehensive stoma education and regular outpatient follow ups are recommended to improve the overall outcomes.

Limitations: Retrospective and conducted in one academic institution with a small sample size.

Background: Neonatal severe hyperparathyroidism (NSHPT) is a rare disease that can be lethal. Most patients require parathyroidectomy.

Objective: Report experience in managing this severe disease.

Design: Retrospective chart review of case series.

Setting: Tertiary health care center.

Patients and methods: We reviewed data on patients managed for NSHPT from June 2001 to January 2023. Demographic, clinical, and follow-up data were collected, and descriptive data were generated.

Main outcome measures: Pre- and postoperative levels of parathyroid hormone (PTH) and serum calcium, and effect of autotransplantation.

Sample size: 19.

Results: The 13 males and 6 females had a a mean age of 46 days at referral. The mean preoperative parathyroid hormone (PTH) and serum calcium levels were 996 ng/L and 4.54 mmol/L, respectively. Twelve patients underwent ultrasonography preoperatively. Of these, six had prominent glands, while no glands were seen in the other six. A Sestamibi scan was done for 15 patients, of which nine showed negative results and six showed positive results, with three glands observed in the neck and three in the sublingual area. Nineteen patients underwent renal ultrasonography, with nine showing nephrocalcinosis. The mean age at surgery was 5.2 months. Total parathyroidectomy (four glands) was performed in 17 patients, and 15 underwent concurrent auto-transplantation. One patient had three glands removed, in addition to auto-transplantation. Another underwent single gland excision as a redo-surgery after previous surgery elsewhere. The mean postoperative follow-up duration was 6 years. The mean postoperative PTH and calcium levels were 25 ng/L and 1.64 mmol/L, respectively. Ultimately, all the patients were required to initiate calcium and vitamin D supplements, except for two patients who had undergone auto-transplantation. Molecular genetic screening of the calcium-sensing receptor gene reported likely pathogenic/pathogenic mutations in 16 of 19 patients (13 were homozygous, two were heterozygous, one was negative, and data was unavailable for the remaining three patients).

Conclusions: Surgical treatment of NSHPT is effective. Preoperative radiological localization studies did not impact the treatment plan. Auto-transplantation proved ineffective in maintaining independence from medical supplements.

Limitations: The retrospective nature of the study may imply inaccuracybut since the data are gathered from electronic medical records, we believe it is highly accurate. The small sample size limits generalizability.

Background: Perinatal fetal mortality and maternal mortality remains relatively high in Saudi Arabia. Antenatal care aims to improve outcomes; however, evidence to demonstrate its impact on outcomes in Saudi Arabia is lacking.

Objectives: Investigate whether booking status for antenatal care impacted outcomes for pregnant women and identify outcomes that predicted booking status.

Design: Retrospective observational cohort study.

Settings: Tertiary care center.

Patients and methods: All Saudi women admitted to the labor or delivery units between January 2011 and December 2019 were included. Outcomes were compared between booked and unbooked women, and logistic regression was used to identify outcomes that predicted booking status, adjusted for age.

Main outcome measures: Booked/unbooked status and perinatal mortality of Saudi women.

Sample size: 10 781 women; 9546 (88.5%) booked, (11.1%) 1192 unbooked.

Results: Unbooked mothers had higher incidences of meconium-stained liquor (P=.040), ruptured uterus (P=.017), and blood loss >1000 mL during cesarean deliveries (P=.003), but a lower episiotomy rate (P<.001). Perinatal fetal mortality and maternal mortality were equivalent between the two groups. Episiotomy, higher birth weight, higher mother age, perinatal death, delivery mode, onset of labor, and use of analgesics were all independent predictors of the mother being booked when adjusted for all outcomes and age.

Conclusions: The rate of perinatal and maternal mortality in this cohort was relatively low and equivalent between booked and un-booked mothers, contrary to our expectations. More analysis of the socioeconomic data may explain this striking result.

Limitations: Retrospective chart-review with incomplete data retrieval that affected the completeness of data retrieved. The results of the multivariate analysis cannot be used to infer causality because the study is observational.

Background: Rebound pain is characterized by sudden, significant acute postoperative pain occurring after the resolution of inter-scalene block (ISB); it affects the quality of recovery postoperatively. Dexamethasone increases ISB resolution time and decreases opioid consumption and the incidence of rebound pain.

Objective: Evaluate whether multimodal analgesia including intravenous dexamethasone administration with preoperative ISB reduces the incidence of rebound pain.

Design: Prospective, randomized, controlled trial.

Setting: Tertiary university hospital.

Sample size: 60 patients.

Patients and methods: Patients who underwent shoulder surgery under general anesthesia were assigned randomly to two different multimodal analgesia protocols. Thirty patients received 5 mg IV dexamethasone with non-steroid, paracetamol, and ISB with 15 mL 0.5% bupivacaine, while the control patients received the same regimen and ISB with 15 mL 0.5% bupivacaine without dexamethasone. Postoperative opioids were given to any patient on demand.

Main outcomes measures: Effect of IV dexamethasone on pain score and incidence of rebound pain after ISB resolution and postoperative opioid consumption at 0-48 hours, numerical pain rating scale (NPRS) scores, sleep scale scores, and quality of recovery-15 scores (QoR-15).

Results: The incidence of rebound pain was lower in the dexamethasone group than in the control group (73.3% and 30%, respectively, P=.001). NPRS scores after ISB resolution were lower in the dexamethasone group (5 ([4-7]), 8 ([5.75-8]), P<.001, respectively). Those who received IV dexamethasone had less sleep disturbances (P<.001) and higher QoR-15 on day 1 (P<.001) and day 7 (P=.020) postoperatively.

Conclusions: IV dexamethasone added to the ISB block resulted in a lower incidence of rebound pain. In addition, better results were obtained in postoperative sleep quality and QoR-15.

Limitations: Single-center study.

Background: Although transanal minimally invasive surgery (TAMIS) for rectal neoplasia has gained wide acceptance, the mid-term and long-term outcomes are not widely reported in the literature.

Objective: Describe the mid-term outcomes of patients who underwent TAMIS for benign and malignant rectal lesions in a single center.

Design: Retrospective cohort study.

Settings: Tertiary referral center.

Patients and methods: Demographic, clinical, and oncological outcomes of patients who underwent TAMIS between January 2015 and December 2022 were prospectively collected. The indication for TAMIS was based on the National Comprehensive Cancer Network guidelines. The follow up for the cancer patients included clinical examination, tumor markers every 6 months and MRI rectum at the end of one year. In addition, colonoscopy and CT scan at years one and three and a final CT scan and colonoscopy at year five.

Main outcome measures: Mid-term oncological and clinical outcome.

Results: Thirty elective TAMIS procedures included adenocarcinoma for 33.3% (n=10) of the patients, 20% (n=6) neuroendocrine tumor and the 40% (n=12) were adenomatous lesions. Negative resection margins were achieved in all malignant lesions. Perioperative complications occurred in 2 patients (6.6%), one patient had breaching into the peritoneal cavity, and postoperative hypotension occurred in another patient. The median follow-up time was 23 months (range: 5-72 months). Two patients with adenoma and positive margins developed recurrent adenoma (6.6%) and one patient with initial polypectomy biopsy of adenocarcinoma, had TAMIS with histopathology of adenoma and distant metastasis had developed.

Conclusions: TAMIS for local excision of rectal neoplasia is a valid option with favorable mid-term outcomes provided there is adherence to careful selection criteria.

Limitations: Retrospective nature and small number of the patients.

Background: Hernia recurrence is one of the most common complications after inguinal herniotomy (IH) in children. We describe a novel approach that involves adding anterior annuloplasty (AAP) during IH for selective high recurrence-risk children.

Objectives: Evaluate the initial safety and effectiveness of selective AAP during IH in boys.

Design: Retrospective SETTING: Tertiary care center.

Patients and methods: The study included boys younger than 15 who were selected to undergo either IH with or without AAP between January 2011 and January 2022. The preoperative recurrence risks were compared for the two groups. Cases who underwent other forms of hernia repair were excluded.

Main outcome measures: The frequency of recurrence and other postoperative complications and the distribution of high recurrence-risks.

Sample size: 315 boys; 143 underwent IH and AAP, while 172 had IH only.

Results: Among all the cases, only one recurrence was reported (0.3%). Other complications were hydrocele in 29 (9.2%), scrotal hematoma/inflammation in 9 (2.9%), and wound infection in 8 (2.6%), which resolved spontaneously in all cases. Compared to IH only, those selected for an additional AAP were significantly younger (3 [16%] vs. 12 [46%] months, P=.038) and more likely to be premature (35 [24.5%] vs. 15 [8.7%], P<.0001), frequently had extensive cremasteric adhesions (39.2% versus 3.5%, P<.0001) and had a higher rate of incarcerated hernia at presentation (6.3% versus 1.2%, P=.026). The high-recurrence risk group was almost twice as likely to be selected for an additional AAP compared to the low-risk group (143 vs. 75, P<.0001).

Conclusion: Adding simple AAP to conventional hernia repair for high-recurrence risk boys can be a safe and effective step to reduce the overall risk of recurrence without increasing the incidence of other postoperative complications.

Limitations: The study lacked a control group of patients to whom selective AAP would not be offered despite a high-recurrence risk. A prospective, controlled trial with a longer follow-up would lead to a stronger conclusion.

Background: Hepatitis C virus (HCV) can cause chronic liver disease, hepatic cirrhosis, hepatocellular carcinoma, liver transplantation, and death. Early diagnosis and treatment are thus vital.

Objectives: We aimed to investigate the sustained virological response (SVR) rates in chronic hepatitis C patients infected with different genotypes, receiving different direct-acting antiviral treatments (DAAs).

Design: Retrospective, observational SETTING: Clinic for infectious diseases and clinical microbiology PATIENTS AND METHODS: Patients diagnosed with chronic hepatitis C who applied to our outpatient clinic between January 2016 and November 2022 and were treated with a DAA were included in the study. Treatment responses were evaluated after each patient was treated with either ledipasvir plus sofosbuvir (LDV/SOF), LDV/SOF + ribavirin (RBV), SOF+RBV, ombitasvir/paritaprevir/ritonavir plus dasabuvir (OBV/PTV/r±DSV) ±RBV, or glecaprevir plus pibrentasvir (GLE/PIB).

Main outcome measures: Sustained virological response (SVR) rates at 12 weeks (SVR12) post-treatment.

Sample size: 360 patients.

Results: Of 360 patients who met the inclusion criteria, 218 (60.6%) were male and 142 (39.4%) were female with no statistically significant differences in SVR between sexes (P=.252). Nearly all had a SVR (n=353, 98.1%). The median (IQR) age of the patients was 56 (30.3) years. There were 42 (11.7%), 199 (55.3%), 4 (1.1%), 106 (29.4%), 8 (2.2%) and 1 (0.3%) patient with genotypes 1a, 1b, 2, 3, 4 and 5, respectively, and SVR12 did not differ significantly between genotypes (P=.066). SVR12 response was higher in 246 (68.3%) non-injecting drug users compared to 114 (31.7%) injecting drug users (P=.005). The SVR12 response was achieved in 100% of patients with genotypes 1a, 2, 4, and 5. SVR12 response could not be obtained in 1 of 199 genotype 1b patients and 6 of 106 genotype 3 patients. The common feature of 6 reinfection patients with genotype 3 was that they were using intravenous drugs. These 6 patients were reinfected due to their continued intravenous drug use.

Conclusion: In conclusion, DAAs provide high SVR12 rates in cirrhotic/non-cirrhotic, pegylated interferon-naive/experienced patient groups and in patients infected with all genotypes. DAAs have a high SVR12 rate in patients with chronic hepatitis C.

Limitations: Retrospective, single-center.