The role of arthrography-guided closed reduction in minimizing the incidence of avascular necrosis in developmental dysplasia of the hip

Avascular necrosis of the femoral head is the most serious complication after closed reduction in developmental dysplasia of the hip. Although arthrography has a well-established role in the treatment of developmental dysplasia of the hip, its use is not universal. A prospective study was conducted to compare the incidence of avascular necrosis after closed reduction in developmental dysplasia of the hip performed with and without arthrography in 85 patients, with a minimum of 5 years follow up. Arthrographic criteria were evaluated including lateralization of the femoral head and the type of limbus encountered. Hips treated by closed reduction based on arthrographic evaluation had significantly less incidence of avascular necrosis when compared with those treated by closed reduction without arthrographic guidance. Closed reduction with lateralization of more than 4 mm, and those hips with an inverted limbus were associated with an increased risk of avascular necrosis.     

Outcome of surgery for parotid tumours: 5-year experience of a general surgical unit in a teaching hospital

BACKGROUND: Most of the recent reports on the surgical management of parotid gland disorders come from specialist divisions of otolaryngology, head and neck, or faciomaxillary surgery. The aim of the present study was to evaluate the outcome of surgery for parotid tumours in a general surgical unit of a teaching hospital. METHOD: A prospective clinicopathological study was undertaken over a 5-year period for consecutive patients operated on for parotid gland tumours in the King Saud University Unit of Riyadh Medical Complex. Parameters analyzed were demographic details, clinical presentation, diagnostic work-up, type of surgery, and outcome in terms of early and late morbidity. RESULTS: Thirty seven parotid operations were performed on 36 consecutive patients. All patients presented with parotid gland swelling. Mean age was 51.6 years with a male preponderance. Fine-needle aspiration diagnosed the pathology in 33 out of 37 lesions. Pleomorphic adenoma was the commonest pathology observed in 24 patients (64.9%). Warthin's tumour was more common among male patients and was the only pathology with bilateral involvement. Malignant tumour was found in five patients (13.5%). Superficial conservative parotidectomy was the most frequently performed operation (84%). Overall postoperative morbidity was 13.5%. Transient facial nerve palsy was observed in seven cases (19%). There was no recurrence identified in patients with benign diseases during the mean follow up of 38.5 months. CONCLUSION: Parotid gland surgery can still be performed in a general surgery unit with comparable outcome. However, the operation should be performed in units with special interest and experience in surgery for parotid gland disorders.     

Kaposi’s sarcoma following living donor kidney transplantation: review of 7,939 recipients

Introduction  Kaposi’s sarcoma (KS) is one of the most common tumors to occur in kidney recipients, especially in the Middle East countries. Limited data with adequate sample size exist about the development of KS in living kidney recipients. Methods  Therefore, we made a plan for a multicenter study, accounting for up to 36% (n = 7,939) of all kidney transplantation in Iran, to determine the incidence of KS after kidney transplantation between 1984 and 2007. Results  Fifty-five (0.69%) recipients who developed KS after kidney transplantation were retrospectively evaluated with a median follow-up of 24 (1–180) months. KS occurred more often in older age when compared to patients without KS (49 ± 12 vs. 38 ± 15 years, P = 0.000). KS was frequently found during the first 2 years after transplantation (72.7%). Skin involvement was universal. Furthermore, overall mortality rate was 18%, and it was higher in patients with visceral involvement compared to those with mucocutaneous lesions (P = 0.01). However, KS had no adverse affect on patient and graft survival rates compared to those without KS. Forty-four patients with limited mucocutaneous disease and four with visceral disease responded to withdrawal or reduction of immunosuppression with or without other treatment modalities. Renal function was preserved when immunosuppression was reduced instead of withdrawn in patients with and without visceral involvement (P = 0.001 and 0.008, respectively). Conclusion  The high incidence of KS in this large population studied, as compared to that reported in other transplant patient groups, suggests that genetic predisposition may play a pathogenetic role.     

Safe use of segmental liver grafts from donors after cardiac death (DCD) in children with acute liver failure

Emergency liver transplantation is a life-saving procedure in selected subset of children with acute liver failure (ALF), when most recipients receive a segmental graft from a living or heart-beating deceased donor. The increased use of full-liver grafts from donors after cardiac death (DCD) has had a beneficial impact on elective liver transplantation in adults. These grafts however are more susceptible to poor initial function, and most centres are reluctant to consider their use as segmental grafts, let alone in the situation of ALF where good initial function is imperative. In this short article, we describe the use and successful outcome in two children aged 6 weeks and 6 years with acute liver failure who received reduced-size DCD liver grafts.     

Epidemiology of varicocele

Varicocele is a common problem in reproductive medicine practice. A varicocele is identified in 15% of healthy men and up to 35% of men with primary infertility. The exact pathophysiology of varicoceles is not very well understood, especially regarding its effect on male infertility. We have conducted a systematic review of studies evaluating the epidemiology of varicocele in the general population and in men presenting with infertility. In this article, we have identified some of the factors that can influence the epidemiological aspects of varicoceles. We also recognize that varicocele epidemiology remains incompletely understood, and there is a need for well-designed, large-scale studies to fully define the epidemiological aspects of this condition.     

Persistent renal and extrarenal immune changes after severe ischemic injury

BACKGROUND: Renal ischemia/reperfusion (I/R) injury is associated with delayed graft function and decreased long-term allograft function. However, most experimental studies evaluating renal I/R injury have focused on acute events after ischemia. T cells are potential candidates to link preservation injury, alloimmunity, and fibrosis. We hypothesized that severe renal I/R injury would generate long-term kidney damage and immune changes. METHODS: C57BL/6 mice underwent 60 minutes of warm unilateral I/R injury or sham surgery and were studied for 6 weeks. Serum creatinine, renal histology, and albumin excretion were measured. Phagocyte infiltration, CD4+ infiltration, renal cytokine expression, and splenic lymphocyte intracellular cytokine production were also measured in mice at 6 weeks. RESULTS: Serum creatinine levels rose following 60 minutes of unilateral I/R injury compared to sham mice. Histologic analysis of ischemic kidneys at 6 weeks revealed a pronounced loss of tubular architecture and infiltration of inflammatory cells. Phagocyte and CD4+ T-cell infiltration were significantly increased in ischemic kidneys. This was accompanied by a significant increase in interleukin (IL)-1beta and regulated upon activation, normal T-cell expressed and secreted (RANTES) expression. Despite similar splenic CD4 and CD8 numbers, intracellular cytokine staining of T cells revealed a significant increase in interferon-gamma (IFN-gamma) in I/R injury mice compared to sham mice. CONCLUSION: Persistent renal and extrarenal immune responses occur after a single episode of severe I/R injury. These immune processes resulting from injury could in turn have long-term consequences on progression of renal disease in transplanted and native kidneys.     

Paediatric palliative care at home: a single centre’s experience

INTRODUCTION

There is increased awareness of paediatric palliative care in Malaysia, but no local published data on home care services. We aimed to describe the paediatric experience at Hospis Malaysia, a community-based palliative care provider in Malaysia.

METHODS

We conducted a retrospective case note review of patients aged up to 21 years who were referred to Hospis Malaysia from 2009 to 2013.

RESULTS

A total of 137 patients (92 male, 45 female) with a median age of 140 (3–250) months were included in this study. The majority (71.5%) had malignancies. At referral, 62 patients were still in hospital and 17 died prior to discharge. A total of 108 patients received home visits. At the first home visit, 89.8% of patients had at least one physical symptom. Pain was the most common (52.5%) symptom. Patients had various supportive devices: 39 were on feeding tubes, ten had tracheostomies, five were on bilevel positive airway pressure and ten had urinary catheters. 66 families discussed the preferred location of care at end-of-life. Among those who died, 78.9% died at home, as they preferred (p < 0.001). Regression analysis showed no statistically significant association between a home death and age, diagnosis and number of home visits. Bereavement follow-up occurred for 93.3% of families.

CONCLUSION

Community care referrals tend to occur late, with 25.5% of patients dying within two weeks of referral. At referral, patients often had untreated physical symptoms. The majority of families preferred and had a home death.     

Long-stay patients in pediatric intensive care units: Five-years, 2-points,cross-sectional study

Objectives:To explore the changing patterns of long-stay patients (LSP) to improve the utilization of pediatric intensive care units (PICUs) resources.Methods:This is a 2-points cross-sectional study (5 years apart; 2014-2019) conducted among PICUs and SCICUs in Riyadh, Saudi Arabia. Children who have stayed in PICU for more than 21 days were included.Results:Out of the 11 units approached, 10 (90%) agreed to participate. The prevalence of LSP in all these hospitals decreased from 32% (48/150) in 2014 to 23.4% (35/149) in 2019. The length of stay ranged from 22 days to 13.5 years. The majority of LSP had a neuromuscular or cardiac disease and were admitted with respiratory compromise. Ventilator-associated pneumonia was the most prevalent complication (37.5%). The most commonly used resources were mechanical ventilation (93.8%), antibiotics (60.4%), and blood-products transfusions (35.4%). The most common reason for the extended stay was medical reasons (51.1%), followed by a lack of family resources (26.5%) or lack of referral to long-term care facilities (22.4%).Conclusion:A long-stay is associated with significant critical care bed occupancy, complications, and utilization of resources that could be otherwise utilized as surge capacity for critical care services. Decreasing occupancy in this multicenter study deserves further engagement of the healthcare leaders and families to maximize the utilization of resources.     

Risk stratification and utilisation of thrombo-embolism prophylaxis in a medical-surgical ICU: a hospital-based study

To assess the risk for venous thrombo-embolism (VTE) and the utilisation of VTE prophylaxis in an open medical-surgical intensive care unit (ICU), patients were admitted and enrolled to the ICU at a multispecialty, tertiary care teaching hospital in Mumbai, for an observational study during a 3-month period. Risk factors for VTE and methods of VTE prophylaxis used were noted. Risk stratification was done, and the consultants attending the ICUs filled a questionnaire about VTE awareness, preferences and usage of VTE prophylaxis methods and reasons for not using thromboprophylaxis. Of 580 admissions, 488 were included in the study. As per the risk stratification, thromboprophylaxis was indicated in 466 (95%). The study group had an average VTE risk of 5.74, with a mean risk of 6.48 in medical patients and 5.0 in surgical patients. The most common risk factors in medical patients were bed rest >72 hours (56%), age >60 years (49.6%) and age 40-60 years (38.4%). Among surgical patients, the most common risk factors were major surgery (80.25%), central venous access (59.24%) and age 40-60 years (46.6%). Overall, VTE prophylaxis was used in 229 patients (47%), with 127 (55%) medical and 102 (45%) surgical patients. The most common methods of VTE prophylaxis used were elastic stockings (24.2%), low molecular weight heparin (15%) and low molecular weight heparin and stockings both (9.6%). Fear of bleeding was the commonest reason cited for the underutilisation of VTE prophylaxis. Almost half of all high-risk patients admitted to the ICU didn't receive any thromboprophylaxis. Consistent practice patterns of ICUs, and continuing medical education programmes addressing VTE prophylaxis will help improve the usage of VTE prophylaxis.     

Fucosidosis and anesthesia

Fucosidosis is a rare, autosomal recessive lysosomal storage disorder caused by a severe deficiency of a-L-fucosidase. Patients usually have some problems with glycoprotein storage in the brain and other organs, and some structural abnormalities that need special consideration in anesthesia. It has 2 types, the early onset or infantile, and the juvenile. Here we present an 8-year old girl with deformities in the maxillofacial region, with big tongue, small and retracted chin, saddle nose, and short neck that could not be extended, causing difficult intubation, and congenital cardiac problems requiring a special anesthetic strategy.