Salim Baharoon

Tuberculosis of the breast

Tuberculosis of the breast is an uncommon disease even in countries where the incidence of pulmonary and extrapulmonary tuberculosis is high. Clinical presentation is usually of a solitary, ill-defined, unilateral hard lump situated in the upper outer quadrant of the breast. This disease can present a diagnostic problem on radiological and microbiological investigations, and thus a high index of suspicion is needed. Incorporating a highly sensitive technique like polymerase chain reaction (PCR) may be helpful in establishing the usefulness of such technology and can aid in conforming the diagnosis early. The disease is curable with antitubercular drugs, and surgery is rarely required

In-hospital mortality among a cohort of cirrhotic patients admitted to a Tertiary Hospital

Background/Aim: To determine the mortality rate in a cohort of hospitalized patients with cirrhosis and examine their resuscitation status at admission. Materials and Methods: A retrospective chart review was conducted of patients with cirrhosis who were admitted to a tertiary care hospital in Riyadh, Saudi Arabia, from January 1, 2009, to December 31, 2009. Results: We reviewed 226 cirrhotic patients during the study period. The hospital mortality rate was 35%. A univariate analysis revealed that worse outcomes were seen in patients with advanced age or who had worse child-turcotte-pugh (CPT) scores, worse model for end-stage liver disease (MELD) scores, low albumin and high serum creatinine. Using a multivariate analysis, we found that advanced age (P=0.004) and high MELD (P=0.001) scores were independent risk factors for the mortality of cirrhotic patients. The end-of-life decision were made in 34% of cirrhotic patients, and the majority of deceased patients were “no resuscitation” status (90% vs. 4%, P<0.001). Conclusions: The relatively high mortality in cirrhotic patients admitted for care in a tertiary hospital, Saudi Arabia was comparable to that reported in the literature. Furthermore, end-of-life discussions should be addressed early in the hospitalization of cirrhotic patients.

Histopathology of Middle East respiratory syndrome coronovirus (MERS-CoV) infection – clinicopathological and ultrastructural study

The pathogenesis, viral localization and histopathological features of Middle East respiratory syndrome – coronavirus (MERS‐CoV) in humans are not described sufficiently. The aims of this study were to explore and define the spectrum of histological and ultrastructural pathological changes affecting various organs in a patient with MERS‐CoV infection and represent a base of MERS‐CoV histopathology.

Family Satisfaction in Critical Care Units: Does an Open Visiting Hours Policy Have an Impact?

For critically ill patients, the interaction between health care providers and family members is essential in daily decision making. Improving this relationship has a positive impact on satisfaction with the overall care provided to patients and reduces family member symptoms of depression, anxiety, and posttraumatic stress disorder. In this study, we analyzed the impact of visitation policy (open versus restricted) on family satisfaction using the previously well-validated Critical Care Family Satisfaction Survey (CCFSS) questionnaire. Methods This is a cross-sectional prospective observational study conducted between November 1, 2009, and January 31, 2010, in 2 critical care units with 2 different visiting policy systems, unit A (open visiting hours) and B (restricted visiting hours), comparing family satisfaction in both units using the CCFSS questionnaire. Responses were grouped in 5 satisfaction constructs, namely, the support construct, which assesses the degree of satisfaction with the support of the intensive care staff as perceived by relatives; the assurance construct, which assesses the degree of satisfaction regarding honest answers being given and the responders confidence that the patient is receiving the best care possible; the proximity construct, which assesses the degree of satisfaction with the physical and emotional access to the patient; the information construct, which assesses the degree of satisfaction with the adequacy of information given to relatives; and the comfort construct, which assesses satisfaction with physical comfort and amenities. Results During the study period, 115 questionnaires were distributed in each of the 2 sites. The response rates in units A and B were 92% (106) and 100% (115), respectively. The mean stay time in the intensive care unit was 3.7 days. There were more trauma cases in unit A and more cardiac patients in unit B. There was no significant difference between the 2 units in any of the 5 satisfaction constructs, the support, assurance, proximity, information, and comfort constructs, although there was a nonsignificant trend favoring the unit with the more liberal visit policy regarding amenities (unit A). Conclusions We concluded that family satisfaction to care provided in intensive care as measured by the CCFSS questionnaire was not influenced by frequency of visitation among Saudi families. Factors other than open visiting hours may be important to evaluate.

Medical residents’ burnout and its impact on quality of care

B urnout, the syndrome of depersonalisation, emotional exhaustion and sense of low personal accomplishment, is common among all health care workers. Residents in different medical training programmes are particularly susceptible, with a reported prevalence rate ranging between 25 and 76 per cent. The syndrome can lead to decreased effectiveness at work, reduced job commitment, lower career satisfaction and, more importantly, can adversely affect patients’ care. Burnout differs from depression in that it involves a person’s relationship with work, whereas depression affects life globally. Whether burnout has long-term effects or causes major psychological upsets is not known.

Continuous Mandatory Onsite Consultant Intensivists in the ICU: Impacts on Patient Outcomes.

Objective The aim of this study was to compare the impacts on patient outcomes of continuous versus on-demand access to certified consultant intensivists in the intensive care unit (ICU). Methods Two general adult ICUs within the same health-care organization were compared in terms of patient outcomes. One unit featured continuous mandatory presence of a consultant intensivist (unit A), whereas the other had continuous access to a consultant intensivist during daytime hours but only on-demand access during the night-time hours (unit B). The data collected from these 2 units over the same 12-month period included sex, age, APACHE II score, disease category (medical, surgical, or traumatic), ICU mortality, and length of stay. A subgroup analysis was undertaken to assess the impact of disease severity, age, sex, and disease category on mortality. Results When adjusted for disease severity, mortality was significantly lower in unit A with continuous mandatory 24-hour presence of a consultant intensivist compared with unit B with on-demand access to a consultant intensivist after working hours. Old age, female sex, and a higher APACHE II score were associated with poorer outcomes at both sites. The subgroup analysis revealed that the difference in mortality was only significant among medical patients but not among surgical or trauma patients. Conclusions An improved survival rate was observed only among medical patients admitted to the ICU with mandatory continuous access to a consultant intensivist, despite the presence of greater disease severity in the population admitted to this unit.

Tuberculous myocarditis is not always fatal: Report of three confirmed cases with uneventful outcome

Tuberculosis (TB) is a leading cause of death worldwide. It can affect any organ. However, cardiac involvement is extremely rare. Anti-TB therapy has been proved to be effective and curative in majority of TB cases except TB myocarditis, where it is found to be fatal. We describe three cases with confirmed TB with impaired left ventricular systolic function and low ejection fraction. All three cases improved clinically and left ventricular function returned to normal within a few weeks after the commencement of TB therapy.

Eosinophilic pneumonia: experience at two tertiary care referral hospitals in Saudi Arabia.

BACKGROUND AND OBJECTIVE Eosinophilic lung diseases are a diverse group of disorders characterized by pulmonary opacities associated with tissue or peripheral eosinophilia. DESIGN AND SETTING A retrospective study conducted at two tertiary care hospitals from January 1999 to December 2009. METHODS All cases with the diagnosis of pulmonary eosinophilia were reviewed over a period of 10 years. Data on demographic, clinical, and radiologic characteristics were collected. RESULTS Thirty-five patients with a mean age of 33.9 (16.2) years, of which 20 (57.1%) were male and meeting the criteria of eosinophilic lung disease were identified. Cough and dyspnea were the most frequent symptoms at presentation in 29 (82.9%) and 27 (77.1%) patients, respectively. Reticulonodular and airspace patterns were the most common radiographic findings in 17 (48.6%) and 15 (42.9%) patients, respectively. Peripheral eosinophilia was present in 33 (94.3%) patients. Twenty-four patients (68.6%) were labeled as having idiopathic pulmonary infiltrate with eosinophilia. Complete remission was achieved in 13 (54.2%) of 24 patients, while 10 (41.7%) patients relapsed within a few months of discontinuation of therapy. Specific therapy for a specific disease was administered in 8 patients: 2 patients for pulmonary tuberculosis, 2 for Churg–Strauss syndrome, 1 for lymphoma, 1 for schistosomiasis, 1 for acute eosinophilic pneumonia, and 1 for Wegener granuloma; 3 patients were treated as allergic bronchopulmonary aspergillosis. CONCLUSIONS Pulmonary eosinophilia remains rare but challenging, and it can have the same diverse clinical and radiographic presentations seen with other common pulmonary conditions. Clinicians should be alert to these syndromes and must think of them in any lung disease differential diagnoses.

Combination antifungal therapy for invasive pulmonary aspergillosis.

A 58-year-old man with a history of AIDS and recurrent non-Hodgkins lymphoma had 1-week complaint of fever, productive cough and chest pain 2 weeks after chemotherapy. He was on antiretroviral triple therapy and antibiotics, but with no response. Physical examination was significant for tachyponea and bilateral crepitations. Chest x-ray showed right middle lobe hazy infiltrates and scattered small nodular lesions (figure 1). Laboratory data showed white cell count of 16.2×109/l with neutropenia, and CD4 count of 70 cells/µl. Bronchoscopy was performed (see video 1) and showed discrete, white coloured ulcerations of the airways. The transbronchial biopsy showed …