Muhammad R. Khammash

Acute appendicitis in the elderly: risk factors for perforation

BackgroundAcute appendicitis is the most common surgical emergency and becomes serious when it perforates. Perforation is more frequent in the elderly patients. The aim of this study was to identify the risk factors of perforation in elderly patients who presented with acute appendicitis.MethodologyThe medical records of 214 patients over the age of 60 years who had a pathologically confirmed diagnosis of acute appendicitis over a period of 10 years (2003-2013) were retrospectively reviewed. Patients were grouped into those with perforated and those with nonperforated appendicitis. Comparison was made between both groups in regard to demography, clinical presentation, and time delay to surgery, diagnosis, hospital stay and postoperative complications. Clinical assessment, Ultrasonography and Computerized tomography, in that order, were used for diagnosis. The incidence of perforation was also compared with a previous report from the same region 10 years earlier.ResultsDuring the study period, a total of 214 patients over the age of 60 years had acute appendicitis, 103 males and 111 females. Appendix was found perforated in 87 (41%) patients, 46 (53%) males and 41 (47%) females. Of all patients, 31% were diagnosed by clinical assessment alone, 40% needed US and 29% CT scan. Of all the risk factors studied, the patient’s pre-hospital time delay was the most important risk factor for perforation. Perforation rate was not dependent on the presence of comorbid diseases or in-hospital time delay. Post operative complications occurred in 44 (21%) patients and they were three times more common in the perforated group, 33 (75%) patients in the perforated and 11 (25%) in the nonperforated group. There were 6 deaths (3%), 4 in the perforated and 2 in the nonperforated group.ConclusionAcute appendicitis in elderly patients is a serious disease that requires early diagnosis and treatment. Appendiceal Perforation increases both mortality and morbidity. All elderly patients presented to the hospital with abdominal pain should be admitted and investigated. The early use of CT scan can cut short the way to the appropriate treatment.

BEHÇET'S DISEASE: CLINICAL STUDY OF JORDANIAN PATIENTS

Background. Behçets disease is a chronic, recurrent, inflammatory disorder characterized by the triad of oral and genital ulcers and ocular lesions. The etiology is unknown. This is the first report giving details of the clinical manifestations of Behçets disease in Jordanian patients.

CASE REPORT Concurrent pilomatrix carcinoma and giant pilomatrixoma

A 52‐year‐old man presented with a large, fungating mass on the inner aspect of his left thigh and a smaller hard mass on the inner aspect of his left knee with normal overlying skin. Both lesions had first been noted by the patient 1 year previously and for the first 6 months had a similar appearance until the thigh mass rapidly increased in size and fungated. Pathology of the large thigh lesion showed pilomatrix carcinoma while that of the smaller knee lesion was typical of pilomatrixoma. The pilomatrix carcinoma was widely excised and there has been no evidence of recurrence or metastasis after 3 years. The clinical course of the thigh lesion suggested that pilomatrix carcinoma may arise from a pre‐existing pilomatrixoma. On review of the literature, pilomatrix carcinoma of the lower limb may be more likely to metastasize than those on other sites.

Prevalence of Ischemia in Diabetic Foot Infection

Foot infection is a common problem affecting diabetics. In addition to neuropathy, ischemia is a major factor contributing to the progress and morbidity of the disease. The aim of this study was to determine the prevalence of lower limb ischemia in patients with diabetic foot infection by prospectively measuring the ankle-brachial pressure index (ABI). Over a 21-month period 60 patients were treated in the general surgical ward of Princess Basma Teaching Hospital. Ischemia was present in 35 of the 60 patients (58.4%). Among them 27 had moderate ischemia (ABI 0.5–0.9) and were treated successfully before further vascular workup. The other 8 patients had severe ischemia (ABI < 0.5) and required below-knee amputation because their feet were severely infected and not salvageable. This study confirmed the recommendation for early detection of lower limb ischemia in diabetics, especially those with foot infection, as it should improve the outcome of treatment. In addition to patient education and periodic foot examinations, estimating the ABI is an easy. reliable way to determine foot blood flow and to detect patients who require further vascular workup and treatment.

Colorectal adenocarcinoma in a defined Jordanian population from 1990 to 1995

PURPOSE: This study aims to evaluate cancer of the large bowel as it occurred in a defined Jordanian population, with special reference to its epidemiologic aspects. Second, this study was undertaken to compare these results with those of other countries and those previously reported from Jordan. METHODS: Records of patients diagnosed as having colorectal adenocarcinoma during a six-year period in Irbid province, Jordan, were reviewed. The material was analyzed retrospectively with respect to various epidemiologic features, and the results were compared with those of other countries and those previously published about the Jordanian population. RESULTS: Between January 1990 and December 1995, 109 new patients with colorectal adenocarcinoma were managed, an incidence of 3.8/100,000/year. Male to female ratio was 1∶1.05 for colonic cancer and 1.36∶1 for rectal cancer. The maximum incidence was seen in the sixth and seventh decades. A total of 12.8 percent of the patients were younger than 40 years of age. The rectum was the most common site involved in 30.3 percent of the patients, followed by the sigmoid, right colon, and the rest of the colon. When compared with previous Jordanian figures, a shift toward the western figures was noted. The delay in diagnosis was noted from the 8.2 months of delay before diagnosis and the advanced stage of the disease at the time of diagnosis. A total of 49.5 percent of the cases were in Dukes B stage, 30.3 percent in Dukes C, and 19.3 percent in Dukes D. Only one patient was in Dukes A stage. A total of 13.8 percent of the cases were mucinous adenocarcinoma. A total of 26.5 percent of the patients presented with complications. CONCLUSIONS: As for colorectal adenocarcinoma, we still share the epidemiologic characteristics of developing countries, but there is a shift toward those of western communities. Flexible sigmoidoscopy is encouraged for evaluation of lower gastrointestinal symptoms, and education of the public and medical staff about colorectal diseases is needed to improve the outcome.

Skin cancer trends in northern Jordan.

Background  The Jordan Cancer Registry was established in 1996, since which time all cases of cancer have been reported and registered. We have used this registry to perform the first analysis of skin cancer in northern Jordan and to compare our findings with those of published reports from other regions.

Peripheral arterial disease in diabetic Jordanian patients and the agreement between ankle brachial index and toe brachial index

This study aims to screen patients with type 2 diabetes mellitus for peripheral arterial disease (PAD) and to determine the agreement between ankle brachial index (ABI) and toe brachial index (TBI). A total of 182 diabetic patients at 40 years of age or older were assessed using both ABI and TBI. Mean age was 60.5 (SD ±8.1) years. PAD was present in 28.9% and 5.4% of patients according to TBI and ABI definitions respectively. The prevalence of high ABI (ABI > 1.3) was 16.5%. The agreement between TBI and ABI results was fair. Current smoking was associated with low ABI whereas age was inversely associated with TBI. We strongly suggest using both the ABI and TBI as screening tests for PAD because the agreement between these tests was fair, they complement each other in most instances and they detect PAD at different anatomical levels.

Changing Pattern of Intestinal Obstruction in Northern Jordan

BackgroundObstructed abdominal wall hernias have been reported to be the leading cause of mechanical intestinal obstruction (MIO) among adults in developing countries. In the developed countries, postoperative adhesions are the commonest cause. With the worldwide improvements in health services and education, especially in developing countries, we aimed to determine the effects of these improvements on the patterns and outcomes of management of MIO in JordanMethodsThe records of all patients who were treated for MIO between the years 2005 and 2010 were reviewed retrospectively. Causes of MIO, presenting symptoms, the main imaging study performed, and the results of management are described. The pattern was compared with that in a previous 1993 report from Jordan.ResultsA total of 88 patients were treated for MIO. Postoperative adhesions in 52.5%, gastrointestinal tumors in 21.0%, and obstructed abdominal wall hernias in 9.5% were the three major causes of MIO. Three patients developed surgical-site infections (3.3%), and one developed a minor anastomotic leak that was treated accordingly (1.1%). There were no mortalities. In 1993, obstructed hernias accounted for 30% of the MIOs followed by postoperative adhesions and tumors (27 and 14%, respectively). There was a 7% mortality rate.ConclusionsOur data confirmed that improved health education programs and services changed the pattern of causes improved the outcomes of management of MIO in Jordan.