Gall stone ileus: Unfamiliar cause of bowel obstruction. Case report and literature review.

INTRODUCTION: Gallstone ileus is a rare sequela of cholelithiasis. The pathology occurs as a result of bilioenteric fistula due to erosion by the offending gallbladder stone. It is most commonly encountered in elderly females and CT imaging is diagnostic in the majority of cases. Surgical intervention aims to promptly relief the obstruction by removing the gallstone and dealing with the fistula. Morbidity and mortality are usually high since it usually occurs in elderly patients. PRESENTATION OF CASE: An 88-year-old lady with multiple chronic medical problems and no history of biliary manifestation presented with acute small bowel obstruction. Abdominal CT imaging revealed a bilioenteric fistula and an impacted gallstone in the jejunum causing occlusion. Laparotomy was performed and the stone was removed via enterolithotomy. Manipulation of the cholecystoduodenal fistula was not attempted due to severe inflammatory adhesions. The patient had uneventiful postoperative course and remained symptom free on one year follow-up. DISCUSSION AND CONCLUSION: Management of gallstone ileus is mainly surgical. Delay in detection and treatment of gallstone ileus may result in significant morbidity and mortality. The choice of surgical option is influenced by the preoperative medical status of the patient. A literature review generally supports the employment of enterolithotomy in high-risk patients and reserving cholecystectomy and resection of the fistula for less comorbid patients with feasible anatomy.

Evaluation of modified Alvarado scoring system and RIPASA scoring system as diagnostic tools of acute appendicitis.

BACKGROUND: Acute appendicitis is the most common surgical condition presented in emergency departments worldwide. Clinical scoring systems, such as the Alvarado and modified Alvarado scoring systems, were developed with the goal of reducing the negative appendectomy rate to 5%-10%. The Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) scoring system was established in 2008 specifically for Asian populations. The aim of this study was to compare the modified Alvarado with the RIPASA scoring system in Kuwait population. METHODS: This study included 180 patients who underwent appendectomies and were documented as having "acute appendicitis" or "abdominal pain" in the operating theatre logbook (unit B) from November 2014 to March 2016. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic accuracy, predicted negative appendectomy and receiver operating characteristic (ROC) curve of the modified Alvarado and RIPASA scoring systems were derived using SPSS statistical software. RESULTS: A total of 136 patients were included in this study according to our criteria. The cut-off threshold point of the modified Alvarado score was set at 7.0, which yielded a sensitivity of 82.8% and a specificity of 56%. The PPV was 89.3% and the NPV was 42.4%. The cut-off threshold point of the RIPASA score was set at 7.5, which yielded a 94.5% sensitivity and an 88% specificity. The PPV was 97.2% and the NPV was 78.5%. The predicted negative appendectomy rates were 10.7% and 2.2% for the modified Alvarado and RIPASA scoring systems, respectively. The negative appendectomy rate decreased significantly, from 18.4% to 10.7% for the modified Alvarado, and to 2.2% for the RIPASA scoring system, which was a significant difference (P<0.001) for both scoring systems. CONCLUSION: Based on the results of this study, the RIPASA score is a simple scoring system with better sensitivity and specificity than the modified Alvarado scoring system in Asian populations. It consists of 14 clinical parameters that can be obtained from a good patient history, clinical examination and laboratory investigations. The RIPASA scoring system is more accurate and specific than the modified Alvarado scoring system for Kuwait population.

Acute appendicitis as a rare cause of mechanical small bowel obstruction case report.

Acute appendicitis is the most common surgical condition with which patients present in emergency departments worldwide. It is also a rare cause of intestinal obstruction. Here, we report a case of a 53-year-old man who presented with a clinical picture of mechanical small bowel obstruction. Leucocytosis was not demonstrated on the routine blood investigation in our case, in contrast to the findings for most patients with acute appendicitis. Acute appendicitis, as the cause of the intestinal obstruction, was diagnosed by computed tomography of the abdomen. The patient was treated using diagnostic laparoscopy and laparoscopic appendectomy. This case was compared with those previously reported in the medical literature to determine the frequency of the case and the surgical management.

Evaluation of modified Alvarado scoring system and RIPASA scoring system as diagnostic tools of acute appendicitis / 世界急诊医学杂志（英文）

@#BACKGROUND: Acute appendicitis is the most common surgical condition presented in emergency departments worldwide. Clinical scoring systems, such as the Alvarado and modified Alvarado scoring systems, were developed with the goal of reducing the negative appendectomy rate to 5%–10%. The Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) scoring system was established in 2008 specifically for Asian populations. The aim of this study was to compare the modified Alvarado with the RIPASA scoring system in Kuwait population. METHODS: This study included 180 patients who underwent appendectomies and were documented as having "acute appendicitis" or "abdominal pain" in the operating theatre logbook (unit B) from November 2014 to March 2016. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic accuracy, predicted negative appendectomy and receiver operating characteristic (ROC) curve of the modified Alvarado and RIPASA scoring systems were derived using SPSS statistical software. RESULTS: A total of 136 patients were included in this study according to our criteria. The cut-off threshold point of the modified Alvarado score was set at 7.0, which yielded a sensitivity of 82.8% and a specificity of 56%. The PPV was 89.3% and the NPV was 42.4%. The cut-off threshold point of the RIPASA score was set at 7.5, which yielded a 94.5% sensitivity and an 88% specificity. The PPV was 97.2% and the NPV was 78.5%. The predicted negative appendectomy rates were 10.7% and 2.2% for the modified Alvarado and RIPASA scoring systems, respectively. The negative appendectomy rate decreased significantly, from 18.4% to 10.7% for the modified Alvarado, and to 2.2% for the RIPASA scoring system, which was a significant difference (P<0.001) for both scoring systems. CONCLUSION: Based on the results of this study, the RIPASA score is a simple scoring system with better sensitivity and specificity than the modified Alvarado scoring system in Asian populations. It consists of 14 clinical parameters that can be obtained from a good patient history, clinical examination and laboratory investigations. The RIPASA scoring system is more accurate and specific than the modified Alvarado scoring system for Kuwait population.

Sports injuries among professional male athletes in Kuwait: prevalence and associated factors.

OBJECTIVES: To assess a 12-month period and the lifetime prevalence of sports injuries among male athletes according to type of sport, type of injury and its seriousness, and to examine the association of injuries with sociodemographic, lifestyle and preventive factors. SUBJECTS AND METHODS: In this cross-sectional study, we approached 475 professional athletes participating in ball sports, aged 15 years and older, from 5 sports clubs in Kuwait. Of them, 452 responded. Four ball games--football (soccer), basketball, handball and volleyball--were included. Data were collected through a self-administered questionnaire. Bivariate and multivariate relationships between associated factors and experience of injury were tested by using χ(2) and logistic regression. RESULTS: The overall 12-month and lifetime prevalence of sports injuries were 73.8 and 89.8%, respectively. Prevalence was highest among volleyball athletes (79%) and lowest among football (soccer) athletes (69%). Lower limbs (73.1%) were the most common site of injuries and joint injuries (43.6%) were the most common type. For the most recent injury, 138 (42%) of athletes took more than 10 days off practice. Compared to volleyball, football (soccer) and handball athletes were 2.9 times (95% CI: 1.3-6.3) and 3.4 times (95% CI: 1.5-7.8) more likely to take more than 10 days off practice. Athletes who sometimes wore protective gears were 3.1 times (95% CI: 1.7-5.8) more likely to report an injury compared with those who never wore protective gears (p < 0.001). CONCLUSIONS: Sports injuries are highly prevalent among professional athletes in Kuwait. Future studies are needed to provide guidelines for interventions that may reduce such injuries.

The first pilot study on characteristics and practice patterns of Kuwaiti breast cancer patients.

Nongenetic breast cancer risk factors have never been evaluated in Kuwait. Accordingly, we aimed at examining these factors as well as the immune profile of the patients. Fifty stage I breast cancer patients and 50 age group-matched normal controls were assessed for the level of their peripheral blood lymphocyte subsets and for risk factors associated with their demographic and reproductive characteristics and with diet. The percentages of CD4+ T lymphocytes, CD4+:CD8+ ratio, and CD19+ B lymphocytes were significantly higher in the patients as compared to controls, while the percentages of CD8+ T lymphocytes and natural killer (CD56+) cells were significantly reduced. Risk factors associated with the disease included higher BMI, lack of regular exercise and physical activity in the past 5 years, early age at menarche, late age at first pregnancy, lack of previous information about breast cancer, hormonal therapy, and presence in Kuwait during the invasion/liberation. Other parameters included significantly more frequent consumption of carbohydrate, sweets, animal fat, and vegetable oil (margarine) and less frequent consumption of fresh vegetables and olive oil. This is the first study to highlight the environmental risk factors associated with breast cancer among the Kuwaiti women. We recommend introducing a nationwide campaign to further investigate these factors and to address them accordingly.

Melanoma immunotherapy: past, present, and future.

The incidence of cancer and its related morbidity and mortality remain on the increase in both developing and developed countries. Cancer remains a huge burden on the health and social welfare sectors worldwide and its prevention and cure remain two golden goals that science strives to achieve. Among the treatment options for cancer that have emerged in the past 100 years, cancer vaccine immunotherapy seems to present a promising and relatively safer approach as compared to chemotherapy and radiotherapy. The identification of different tumour antigens in the last fifteen years using a variety of techniques, together with the molecular cloning of cytotoxic T lymphocytes (CTLs)- and tumour infiltrating lymphocytes (TILs)-defined tumour antigens allowed more refining of the cancer vaccines that are currently used in different clinical trials. In a proportion of treated patients, some of these vaccines have resulted in partial or complete tumour regression, while they have increased the disease-free survival rate in others. These outcomes are more evident now in patients suffering from melanoma. This review provides an update on melanoma vaccine immunotherapy. Different cancer antigens are reviewed with a detailed description of the melanoma antigens discovered so far. The review also summarises clinical trials and individual clinical cases in which some of the old and current methods to vaccinate against or treat melanoma were used. These include vaccines made of autologous or allogenic melanoma tumour cells, melanoma peptides, recombinant bacterial or viral vectors, or dendritic cells.

Diagnosis of abdominal hydatid cyst disease: the role of ultrasound and ultrasound-guided fine needle aspiration cytology.

OBJECTIVE: To retrospectively analyze the role of ultrasound (US) imaging and US-guided fine needle aspiration cytology in the diagnosis and management of abdominal hydatid cyst disease (HCD). SUBJECTS AND METHODS: The medical records of 55 diagnosed cases of HCD seen between January 1986 and December 2000 at Mubarak Al-Kabeer Hospital and Al-Amiri Hospital in Kuwait were reviewed for demographic and clinical data, including radiology and serology. The US findings of the patients were classified into four types as follows: type I: single or multiple well-defined cysts, with or without detached or collapsed wall and with or without echogenic contents; type II: single or multiple cysts with peripheral cysts, with or without echogenic contents; type III: solid or semisolid lesions, and type IV: cysts with calcified walls. RESULTS: The overall accuracy of US in the diagnosis of HCD was 80% (44/55 cases). US examination was suggestive of HCD type I, 16/19 (84%), type II, 21/23 (91%), type III, 3/8 (38%), and type IV, 4/5 (80%). For the 11 remaining undiagnosed cases, US was useful for localizing the lesions for US-guided fine needle aspiration cytology. It established the diagnosis in all the 11 cases, without precipitating complications. CONCLUSION: US alone was valuable for diagnosing and localizing HCD in the abdomen except for solid-type lesions. US-guided fine needle aspiration cytology was useful in localizing and establishing the diagnosis of HCD in the cases where US alone was ineffective.