Multidrug resistance Acinetobacter species at the intensive care unit,Aseer Central Hospital,Saudi Arabia:A one year analysis

Objective:To identify and to determine the antimicrobial susceptibility of Acinetobacter baumannii(A.baumannii) clinical isolates from ICU at Aseer Central Hospital.Methods:The study was conducted in the Intensive Care Unit,Aseer Central Hospital,Saudi Arabia over 13 months period(2014-2015).Acinetobacter species(n= 105) were isolated from various clinical samples.Isolates were identified using selected phenotypic criteria and confirmed using the Vitek 2 automated system.This system was used to determine the susceptibilities of 21 antimicrobial agents.Patients,isolates and drug data were analyzed using the SPSS statistical software package to determine some epidemiological and microbiological patterns.Results:Of the 105 stains,A.baumannii accounted for 49(46.67%),A.baumannii complex,19(18.09%),A.baumannii/haemolyticus 32(30.47),Acinetobacter haemolyticus 4(3.81%),Acinetobater lwoffii 1(0.95%) and unidentified Acinetobater species 2(1.3%).Of the 105 Acinetobacter strains,103(98.1%) were found multidrug resistant(MDR).A.baumannii strain were 100% sensitive to colistin and 74.5% to trimethoprim + sulfamethoxazole.The remaining 19 antimicrobial agents revealed low or no sensitivities:amikacin 16.3%; ampicillin 7.7%; ceftazidime 7.3%.Distribution of similar sensitivities was shown by other Acinetobacter species.Mean number of isolates from males and females indicates no statistical variation(P=0.867) whereas age groups showed significant differences(P= 0.008) as it is clear from the high percentage of infected individuals more than 60 years followed by those aged 20 to 29 years old(19.05%).Upper respiratory tract(30.48%),lower respiratory tract(47.65%) and subcutaneous tissue(9.5%) were the main sources of Acinetobacter spp.but mean numbers of isolates from these specimens indicate no discrepancy between specimens(P=0.731).Conclusions:Acinetobacterspecies including A.baumannii were found MDR(98.1%) according to the current Acinetobacter spp.antimicrobial categorization.Approximately half of these strains were A.baumannii.All Acinetobacter species were 100% sensitive to colistin and to some extent to trimethoprim + sulfamethoxazole(74.5%).ICU-acquired pneumonia among patients over 60 years of age who spend prolong times at artificial ventilations made up the majority of the cases.

Unilateral Choanal Atresia in Adults: A Case Series

Choanal atresia (CA) is a rare occlusion of the posterior choanae. Unilateral cases have been reported more than bilaterally, and it’s more often right-sided in those patients. According to the literature, mixed bony-membranous atresia is the most common type. There is a high incidence of craniofacial and visceral anomalies associated with congenital choanal atresia. Therefore, investigation for associated congenital anomalies is an important step before the surgery. We report 2 cases of incidental finding of unilateral choanal atresia in a 21- and 17-year-old with nasal discharge being the only complaint in the former and nasal obstruction with headache in the latter. The patients were then scheduled for day-surgery as a case of choanal atresia for transnasal, endoscopic repair and posterior septectomy. The patients were discharged home on the same day with the absence of restenosis or other complications.

Peripheral Central Venous Catheter Induced Supraventricular Tachycardia in a Patient of Acute Lymphoblastic Leukemia

Central venous catheters (CVCs) are used in intensive care units (and, increasingly, in other locations) to administer intravenous fluids and blood products, drugs, parenteral nutrition, and to monitor haemodynamic status. The risk of complication during the insertion or exchange of central venous catheters has been well documented. The majority of complications involve mechanical problems, although rarely it may induce arrhythmias as well [1]. Herein we present a case of peripheral central venous catheter induced supraventricular tachycardia in a young patient of acute lymphoblastic leukemia.

Imaging in male-factor obstructive infertility

The main purpose of imaging evaluation in male infertility is to identify and treat correctable causes of infertility, such as obstruction of the seminal tract. Various imaging modalities are available to evaluate men with obstructive infertility including scrotal ultrasonography, transrectal ultrasound (TRUS), vasography, magnetic resonance imaging, seminal vesicle aspiration, seminal tract washout, and seminal vesiculography. To date the most reliable and accurate diagnostic technique for obstructive infertility is unclear. In this review article, we report the role of these modalities in diagnosis of obstructive infertility. Scrotal sonography is the initial modality, and if patient results indicate non obstructive azoospermia as varicocele or testicular pathology they will be treated according to standard protocols for management of these pathologies. If the patient findings indicate proximal obstructive azoospermia, they can be managed by vasoepididymostomy. If the scrotal ultrasound is normal, TRUS is the second imaging modality. Accordingly, they are classified into patients with criteria of obstructive infertility without urogenital cysts where TRUS-guided aspiration and seminal vesiculography can be performed and transurethral resection of the ejaculatory ducts (TURED) will be the management of choice. In patients with urogenital cyst, TRUS-guided cyst aspiration and opacification are performed. Ifthe cyst is communicating with the seminal tract, management will be transurethral incision of the cyst. If the cyst is not in communication, the obstruction may be relieved after cyst aspiration. If the obstruction is not relieved, TURED will be the management of choice. Sperm harvested during aspiration may be stored and used in assisted reproduction techniques. If the results of TRUS are inconclusive or doubtful, endorectal magnetic resonance imaging should be performed to serve as a "detailed map" for guiding corrective operative interventions.

Role of color Doppler in differentiation of Graves' disease and thyroiditis in thyrotoxicosis

AIM:To evaluate the role of thyroid blood flow assessment by color-flow Doppler ultrasonography in the differential diagnosis of thyrotoxicosis and compare it to technetium pertechnetate thyroid scanning. METHODS:Twenty-six patients with thyrotoxicosis were included in the study. Clinical history was taken and physical examination and thyroid function tests were performed for all patients. Thyroid autoantibodies were measured. The thyroid glands of all patients were evaluated by gray scale ultrasonography for size, shape and echotexture. Color-flow Doppler ultrasonography of the thyroid tissue was performed and spectral flow analysis of both inferior thyroid arteries was assessed. Technetium99 pertechnetate scanning of the thyroid gland was done for all patients. According to thyroid scintigraphy, the patients were divided into two groups:18 cases with Graves' disease and 8 cases with Hashimoto's thyroiditis. All patients had suppressed thyrotropin. The diagnosis of Graves' disease and Hashimoto's thyroiditis was supported by the clinical picture and follow up of patients. RESULTS:Peak systolic velocities of the inferior thyroid arteries were significantly higher in patients with Graves' disease than in patients with thyroiditis (P = 0.004 in the right inferior thyroid artery and P = 0.001 in left inferior thyroid artery). Color-flow Doppler ultrasonography parameters demonstrated a sensitivity of 88.9% and a specificity of 87.5% in the differential diagnosis of thyrotoxicosis. CONCLUSION:Color Doppler flow of the inferior thyroid artery can be used in the differential diagnosis of thyrotoxicosis, especially when there is a contraindication of thyroid scintigraphy by radioactive material in some patients.

Impact of referral pattern and timing of repair on surgical outcome after reconstruction of post-cholecystectomy bile duct injury:A multicenter study

Background:Bile duct injury(BDI)after cholecystectomy remains a significant surgical challenge.No guideline exists to guide the timing of repair,while few studies compare early versus late repair BDI.This study aimed to analyze the outcomes in patients undergoing immediate,intermediate,and delayed repair of BDI.Methods:We retrospectively analyzed 412 patients with BDI from March 2015 to January 2020.The patients were divided into three groups based on the time of BDI reconstruction.Group 1 underwent an immediate reconstruction(within the first 72 hours post-cholecystectomy,n=156);group 2 underwent an intermediate reconstruction(from 4 days to 6 weeks post-cholecystectomy,n=75),and group 3 underwent delayed reconstruction(after 6 weeks post-cholecystectomy,n=181).Results:Patients in group 2 had significantly more early complications including anastomotic leakage and intra-abdominal collection and late complications including anastomotic stricture and secondary liver cirrhosis compared with groups 1 and 3.Favorable outcome was observed in 111(71.2%)patients in group 1,31(41.3%)patients in group 2,and 157(86.7%)patients in group 3(P=0.0001).Multivariate analysis identified that complete ligation of the bile duct,level E1 BDI and the use of external stent were independent factors of favorable outcome in group 1,the use of external stent was an independent factor of favorable outcome in group 2,and level E4 BDI was an independent factor of unfavorable outcome in group 3.Transected BDI and level E4 BDI were independent factors of unfavorable outcome.Conclusions:Favorable outcomes were more frequently observed in the immediate and delayed reconstruction of post-cholecystectomy BDI.Complete ligation of the bile duct,level E1 BDI and the use of external stent were independent factors of a favorable outcome.

Quantification of epicardial fat:Which method can predict significant coronary artery disease?

AIM:To compare the predictive value of three methods of epicardial fat(EF) assessment for presence of significant coronary artery disease(CAD) [i.e.,epicardial fat volume(EFV),EFV indexed with body surface area(EFV/BSA) and EFV indexed with body mass index(EFV/BMI)].METHODS:The study was performed on 170 patients(85 women and 85 men) with clinical suspicion of CAD.They aged 26-89 years with a median age of 54 years.The patients were classified into three groups:Group 1:58 patients with normal coronary arteries; group 2:48 patients with non-significant CAD and group 3:64 patients with significant CAD.The three methods for assessment of epicardial fat were retrospectively studied to determine the best method to predict the presence of significant CAD.RESULTS:The three methods for epicardial fat quantification and measurements,i.e.,EFV,EFV/BSA and EFV/BMI with post- hoc analysis showed a significant difference between patients with significant coronary artery disease compared to the normal group.Receiver operating characteristic curve analysis showed no significant difference between the three methods of epicardial fat measurements,the area under curve ranging between 0.6 and 0.62.The optimal cut-off was 80.3 cm3 for EFV,2.4 cm3/m2 for EFV indexed with BMI and 41.7 cm3/(kg/m2) for EFV indexed with BSA.For this cut-off the sensitivity ranged between 0.92 and 0.94,while specificity varied from 0.31 to 0.35.CONCLUSION:Any one of the three methods for assessment of epicardial fat can be used to predict significant CAD since all have the same equivalent predictive value.

Abscess of the caudate lobe of the liver, a rare disease with a challenging management: a case report

We reported a rare case of abscess of the caudate lobe of the liver in a 60-year old man. We first tried computed tomography （CT） guided percutaneous drainage of the abscess but failed to eradicate the infection. Deterioration of the general condition of the patient necessitated open surgical drainage, which resulted in cure of the abscess. The peculiar anatomical location of caudate lobe abscess introduces a great challenge for the surgeon in plan- ning the appropriate management and paucity of patients with caudate lobe abscess has led to lack of guidelines for management. The non-operative interventional radiology approach has become the therapeutic choice for pyo- genic liver abscess, but is it applicable also for caudate lobe abscess？

Myocardial bridging analysis by coronary computed tomographic angiography in a Saudi population

AIM: To assess the incidence, location, morphology and clinical association of myocardial bridging in a Saudi population using coronary computed tomographic angiography(CCTA). METHODS: A total of 350 CCTA of Saudi patients were included in this study(236 men, 114 women) with a mean age of 56.3 years. All patients were examined for appropriateness criteria of CCTA indications(typical chest pain, recent onset cardiomyopathy, left bundle branch block, etc.). The scans were retrospectively reviewed for the presence of myocardial bridging and any other pathological association. RESULTS: Myocardial bridging was found in 89 of 350(22.5%) patients. Most of the intramuscular segments were of the superficial type and found in the mid left anterior descending(LAD)(24.6%), followed by distal LAD(3.7%), diagonal branches(2%), ramus intermedius artery(1.4%) and obtuse marginal artery(0.8%). No myocardial bridging was detected in the right coronary or circumflex arteries. No significant differences were found between males and females(P = 0.14). Coronary artery atherosclerosis was found in 51 of 89(57.3%) patients with MB. Atherosclerotic plaques were not detected in the intramuscular or distal segment of bridging arteries. Dynamic compression was observed in 35(94.5%) patients with full encasement. No evidence of myocardial hypoperfusion was found in the territories supplied by the bridging arteries. CONCLUSION: CCTA is excellent in analyzing myocardial bridging in a Saudi population and the results are comparable to other populations. However, finding the real incidence may need a large multicenter study.

Percutaneous cecostomy in the management of organic fecal incontinence in children

AIM:To assess the effectiveness and safety of imagingguided percutaneous cecostomy in the management of pediatric patients with organic fecal incontinence.METHODS:Twenty three cecostomies were performed on 21 children with organic fecal incontinence(13 males,8 females),aged from 5 to 16 years(mean 9.5 years).Thirteen patients had neurogenic fecal incontinence and 8 patients had anorectal anomalies.Procedures were performed under general anesthesia and fluoroscopic guidance.Effectiveness and complication data were obtained for at least 1 year after the procedure.RESULTS:Cecostomy was successful in 20 patients(primary technical success rate 95).Cecostomy failed in one patient due to tube breakage(secondary technical success rate 100).The tubes were in situ for an average of 18 mo(range 12-23 mo).Eighteen patients(87) expressed satisfaction with the procedures.Resolution of soiling was achieved in all patients with neurogenic fecal incontinence(100) and in 5 of 8 patients with anorectal anomalies(62.5).Eleven patients(52) experienced minor problems.No major complications were noted.CONCLUSION:Percutaneous cecostomy improves the quality of life in children with organic fecal incontinence.A satisfactory outcome is more prevalent in patients with neurogenic fecal incontinence than anorectal anomalies.

Late onset ilio-psoas abscess due to stump appendicitis： a case report

We describe a case of right ilio-psoas abscess caused by stump appendicitis 14 years after open appendectomy.Stump appendicitis is a rare complication of appendectomy. Right ilio-psoas abscess was diagnosed in an immunecompetent patient and treated by ultrasound guided percutaneous drainage twice without identifying the cause of the abscess. The patient did not improve until diagnostic laparoscopy was performed revealing a long stump appendicitis to be the origin of infection. It was treated by completion appendectomy. Surgical exploration may be necessary in persistent or recurrent ilio-psoas abscesses. We identified 4 reported cases of post-appendectomy ilio-psoas abscess but without recognizing the cause of the abscess and its relation to appendectomy. This is the first reported case of ilio-psoas abscess that developed as a complication of stump appendicitis.

Percutaneous imaging-guided interventions for acute biliary disorders in high surgical risk patients

AIM:To evaluate the efficacy of percutaneous imagingguided biliary interventions in the management of acute biliary disorders in high surgical risk patients.METHODS:One hundred and twenty two patients underwent 139 percutaneous imaging-guided biliary interventions during the period between January 2007 to December 2009.The patients included 73 women and 49 men with a mean age of 61 years(range 35-90 years).Fifty nine patients had acute biliary obstruction,26 patients had acute biliary infection and 37 patients had abnormal collections.The procedures were performed under computed tomography(CT)-(73 patients),sonographic-(41 patients),and fluoroscopic-guidance(25 patients).Success rates and complications were determined.The χ2 test with Yates' correction for continuity was applied to compare between these procedures.A P value < 0.05 was considered significant.RESULTS:The success rates for draining acute biliary obstruction under CT-,fluoroscopy-or ultrasoundguidance were 93.3,62.5 and 46.1,respectively with significant P values(P = 0.026 and 0.002,respectively).In acute biliary infection,successful drainage was achieved in 22 patients(84.6).The success rates in patients drained under ultrasound-and CT-guidance were 46.1 and 88.8,respectively and drainage under CT-guidance was significantly higher(P = 0.0293).In 13 patients with bilomas,percutaneous drainage was successful in 11 patients(84.6).Ten out of 12 cases with hepatic abscesses were drained with a success rate of 83.3.In addition,the success rate of drainage in 12 cases with pancreatic pseudocysts was 83.3.The reported complications were two deaths,four major and seven minor complications.CONCLUSION:Percutaneous imaging-guided biliary interventions help to promptly diagnose and effectively treat acute biliary disorders.They either cure the disorders or relieve sepsis and jaundice before operations.

Surviving a Catastrophic Upper Gastrointestinal Bleeding Caused by Esophageal-Subclavian Fistula: Case Report

Arterio-esophageal fistula (AEF), whether congenital or acquired, is a rare condition which can lead to fatal upper gastrointestinal bleeding. We report here a young man who developed a subclavian-esophageal fistula (SEF) secondary to chicken bone impaction in the upper esophagus. The diagnosis was reached by urgent upper endoscopy and Computed Tomography of the chest which showed pseudo-aneurysmal changes at left subclavian artery with leaked contrast through the fistula towered the esophagus. Urgent endo-vascular angiography confirmed the subclavian arterio-esophageal fistula that was managed uneventfully using covered 6mm Viban stent-graft. The patient survived this serious condition and was discharged home in good condition.

Case Report: Post Lumbar Discectomy Acute Iliac Arteriovenous Fistula;Endovascular Management and Literature Review

Posterior approach lumbar disc surgeries (LDS) can be associated with serious iatrogenic vascular complications which could be a serious life threatening condition. We report a rare case of right sided acute iliac vessels iatrogenic arteriovenous fistula (IAVF) which was diagnosed and managed in 24 hours duration in a 45 years old healthy female who underwent surgical posterior approach L4-5 discectomy. Intraoperative, she developed sudden hypotension, tachycardia, wide pulse pressure and acute drop of hemoglobin level without obvious operative site bleeding which raise the index of suspicion of vascular injury and urge the team for doing emergency CT angiography (CTA), vascular and endovascular team consultation for digital subtraction angiography (DSA) and endovascular management. Endovascular stenting is nowadays the modality of choice of intervention. We provide case report with literature review.