Dual natural orifice per luminal endoscopic repair of vesico-vaginal fistula: A case report.

Vesico-vaginal fistula (VVF) is a dreaded complication of gynaecologic and obstetric procedures with many approaches and techniques described for its repair. We present a novel technique of dual natural orifice transluminal endoscopic repair of VVF.

Rectus abdominis detrusor myoplasty (RADM) for acontractile/hypocontractile bladder in spinal cord injury patients: Preliminary report.

BACKGROUND: Urinary bladder dysfunction in the form of acontractile/hypocontractile bladder is very common after spinal cord injury and it may lead to recurrent urinary tract infection (UTI), stones formation, and deteriorating renal function. Conventionally, these patients evacuate their bladders by life-long clean intermittent catheterization (CIC) or an indwelling catheter (IC). For these patients, another option is to use innervated skeletal muscle wrap around the bladder to augment detrusor function and voluntary evacuation of bladder. METHODS: We selected 5 patients with acontractile/hypocontractile bladder following spinal cord trauma. These patients were assessed by urodynamic study for post void residual volume (PVRV), detrusor pressure (Pdet), urine flow rate (Vmax), and bladder contractility index (BCI). All five patients underwent Rectus Abdominis Detrusor Myoplasty (RADM). RESULTS: Complete spontaneous voiding was achieved in all patients. Rectus abdominis detrusor myoplasty (RADM) elicits a statistically significant reduction in PVRV and statistically significant increase in urine flow rate, bladder contractility and detrusor pressure after 6 months. Recurrent UTIs ceased in all patients. There were no immediate or late complications. CONCLUSION: RADM appears to be a promising option in a patient with acontractile/hypocontractile bladder to restore the bladder function. It avoids CIC in all patients leading to improvement in quality of life in select group of patients.

Hypercapnic respiratory failure during pregnancy due to polymyositis-related respiratory muscle weakness: a case report.

BACKGROUND: Polymyositis is a rare medical disorder complicating pregnancy. Ventilatory muscle weakness leading to respiratory failure is an uncommon manifestation of this autoimmune disease. We report a case of life-threatening hypercapnic respiratory failure due to polymyositis-related respiratory muscle weakness in a pregnant woman. CASE PRESENTATION: A 31-year-old, African woman in her second trimester of pregnancy presented to the emergency department with fever, shortness of breath and muscle weakness. Initial investigations excluded pulmonary infection, thromboembolism, and cardiac dysfunction as the underlying cause of her symptoms. She developed deterioration in her level of consciousness due to carbon dioxide narcosis requiring invasive mechanical ventilation. Further workup revealed markedly elevated serum creatine kinase, abnormal electromyography and edema of her thigh muscles on magnetic resonance imaging. Diagnosis of polymyositis was confirmed by muscle biopsy. After receiving pulse steroid, intravenous immunoglobulins, and maintenance immunosuppressive therapy, our patient's respiratory muscle function improved and she was weaned off mechanical ventilation. Despite good maternal recovery from critical illness, the fetus developed intrauterine growth retardation and distress necessitating emergency cesarian section. CONCLUSIONS: New-onset polymyositis during pregnancy presenting with respiratory failure is rare. Early diagnosis and prompt initiation of therapy is necessary to improve fetal and maternal outcomes.

Somatic survival and organ donation among brain-dead patients in the state of Qatar.

BACKGROUND: The Qatari law, as in many other countries, uses brain death as the main criteria for organ donation and cessation of medical support. By contrast, most of the public in Qatar do not agree with the limitation or withdrawal of medical care until the time of cardiac death. The current study aims to examine the duration of somatic survival after brain death, organ donation rate in brain-dead patients as well as review the underlying etiologies and level of support provided in the state of Qatar. METHODS: This is a retrospective study of all patients diagnosed with brain death over a 10-year period conducted at the largest tertiary center in Qatar (Hamad General Hospital). RESULTS: Among the 53 patients who were diagnosed with brain death during the study period, the median and mean somatic survivals of brain-dead patients in the current study were 3 and 4.5 days respectively. The most common etiology was intracranial hemorrhage (45.3 %) followed by ischemic stroke (17 %). Ischemic stroke patients had a median survival of 11 days. Organ donation was accepted by only two families (6.6 %) of the 30 brain dead patients deemed suitable for organ donation. CONCLUSION: The average somatic survival of brain-dead patients is less than one week irrespective of supportive measures provided. Organ donation rate was extremely low among brain-dead patients in Qatar. Improved public education may lead to significant improvement in resource utilization as well as organ transplant donors and should be a major target area of future health care policies.

Epidemiology and Outcome of Ventilator-Associated Pneumonia in a Heterogeneous ICU Population in Qatar.

Objective. The purpose of this study is to collect data on epidemiology, microbiology, and outcome of VAP in our ICUs for reevaluation of the therapeutic strategies. Methods. This retrospective study involved all adult patients, 15 years of age or older, diagnosed with VAP in multidisciplinary ICUs at Hamad General Hospital between January 2010 and December 2012. Results. A total of 106 patients were enrolled. The mean incidence of VAP was 5.0 per 1000 ventilator-days. It was predominant among younger age group (<60 years), male patients (80.2%), and trauma ICU admissions (49.0%). The most common comorbidity was hypertension (34%) and polytrauma (36.8%) was the most frequent admission diagnosis. 30-day mortality was 23.6% and it was significantly higher in ≥60 years age group, female gender, patients with diabetes mellitus, hypertension, chronic respiratory disease, ≥1 comorbidity, and poor functional status, smokers, medical and surgical ICU admissions, and patients with previous stay in medical/surgical wards, inappropriate empirical therapy, and admission diagnosis of respiratory failure. Gram-negative bacilli were the most frequent respiratory specimen isolates, Pseudomonas spp. being the most common. Majority of our Acinetobacter isolates were multidrug resistant. Conclusion. The incidence of VAP in our ICUs was low. Higher mortality rates were observed in certain subgroup of patients. Resistance to commonly used antimicrobials is likely to require reevaluation of the therapeutic strategies at our institution.

Extra corporeal membrane oxygenation to facilitate lung protective ventilation and prevent ventilator-induced lung injury in severe Pneumocystis pneumonia with pneumomediastinum: a case report and short literature review.

BACKGROUND: Pulmonary infections caused by Pneumocystis jirovecii in immunocompromised host can be associated with cysts, pneumatoceles and air leaks that can progress to pneumomediastinum and pneumothoraxes. In such cases, it can be challenging to maintain adequate gas exchange by conventional mechanical ventilation and at the same time prevent further ventilator-induced lung injury. We report a young HIV positive male with poorly compliant lungs and pneumomediastinum secondary to severe Pneumocystis infection, rescued with veno-venous extra corporeal membrane oxygenation (V-V ECMO). CASE PRESENTATION: A 26 year old male with no significant past medical history was admitted with fever, cough and shortness of breath. He initially required non-invasive ventilation for respiratory failure. However, his respiratory function progressively deteriorated due to increasing pulmonary infiltrates and development of pneumomediastinum, eventually requiring endotracheal intubation and invasive ventilation. Despite attempts at optimizing gas exchange by ventilatory maneuvers, patients' pulmonary parameters worsened necessitating rescue ECMO therapy. The introduction of V-V ECMO facilitated the use of ultra-protective lung ventilation and prevented progression of pneumomediastinum, maintaining optimal gas exchange. It allowed time for the antibiotics to show effect and pulmonary parenchyma to heal. Further diagnostic workup revealed Pneumocystis jirovecii as the causative organism for pneumonia and serology confirmed Human Immunodeficiency Virus infection. Patient was successfully treated with appropriate antimicrobials and de-cannulated after six days of ECMO support. CONCLUSION: ECMO was an effective salvage therapy in HIV positive patient with an otherwise fatal respiratory failure due to Pneumocystis pneumonia and air leak syndrome.

Does extracorporeal shock wave lithotripsy cause hearing impairment? Evaluation by transient evoked otoacoustic emissions.

OBJECTIVE: To evaluate if multiple sessions of extracorporeal shock wave lithotripsy (ESWL) have any effect on the transient evoked otoacoustic emissions (TEOAEs). STUDY DESIGN: Prospective study. SETTING: Academic tertiary medical centre. METHODS: Thirty patients undergoing multiple sessions of ESWL for urinary stone disease were assessed using TEOAEs before and after ESWL. RESULTS: It was found that ESWL does not cause any significant changes in TEOAEs. CONCLUSIONS: ESWL is a safe procedure and does not cause any changes in TEOAEs.

Carcinosarcoma of urinary bladder mimicking vesical calculus: a case report.

We report a 50 year old male who presented with a short history of gross hematuria. An ultrasonogram detected a mass arising from the right lateral wall of the urinary bladder. Computed tomography of the abdomen revealed that the mass was a calcified lesion mimicking a bladder stone. Cystoscopy confirmed the presence of the calcified lesion and biopsy revealed a rare biphasic tumor of the urinary bladder comprising of osteosarcoma and a papillary urothelial neoplasm of low malignant potential. The rarity of this tumor and its associated exuberant calcification make this case an interesting one.