Spinal calcifying pseudoneoplasm of the neuraxis (CAPNON) associated with facet joint pathologies: CAPNON diagnostic and pathogenic insights.

Calcifying pseudoneoplasm of the neuraxis (CAPNON) is a rare tumor-like fibro-osseous lesion that can develop anywhere in the neuraxis. Approximately a half of reported CAPNONs developed in the spinal region, mostly close to the facet joint (FJ). The diagnosis of spinal CAPNONs is challenging given the existence of mimics and associated pathologies including calcific degeneration of the FJ ligaments (DFJL) and synovial cysts (SCs). The pathogenesis of CAPNON remains elusive, although there have been a few hypotheses including degenerative, reactive, proliferative and immune-mediated processes. Our present study examined clinical, radiological and pathological features of 12 spinal CAPNONs in comparison to 9 DFJL foci, and diagnostic and pathogenic relationship between CAPNONs and FJ pathologies. On imaging, CAPNONs were all tumor-like and typically bigger than DFJL foci. All CAPNONs showed pathologically diagnostic features including characteristic cores, consistently identifiable core-surrounding/peripheral palisading of macrophages and other cells including multinucleated giant cells, variable infiltration of CD8+ T-cells, and multifocal immunopositivity of neurofilament light chain (NF-L). These features were absent or limited in the DFJL foci with statistically significant differences from CAPNONs, except calcifications. Spinal CAPNONs co-existed with DFJL foci in all cases; some had transitional foci with overlapping focal CAPNON and DFJL-like features. These findings, along with our previously reported relationship between CAPNONs and SCs, suggest that spinal CAPNONs may occur in association with or in transition from calcifying/calcified degenerative lesions of FJ ligaments and/or SCs when a reactive proliferative process is complemented by other pathogenic changes such as immune-mediated pathology and NF-L deposition/expression.

Clinicopathologic characteristics of Nocardia brain abscesses: Necrotic and non-necrotic foci of various stages.

Nocardia brain abscesses are rare bacterial infections associated with a high mortality rate, and their preoperative diagnosis can be difficult for various reasons including a nonspecific clinical presentation. While late-stage nocardial brain abscesses may be radiologically characteristic, early-stage lesions are nonspecific and indistinguishable from another inflammatory/infectious process and other mimics. Despite the paucity of previous histopathological descriptions, histopathological examination is critical for the identification of the pathogen, lesion stage(s), and possible coexisting pathology. In this study, we examined the clinical, radiological and histopathological features of 10 patients with brain nocardiosis. Microscopic findings were analysed in correlation with clinical and radiological features in 9 patients, which revealed that brain nocardiosis was characterized by numerous necrotic and non-necrotic foci of various stages (I-IV) along with Nocardia identification, as well as the leptomeningeal involvement in most cases, and co-infection of brain nocardiosis with toxoplasmosis in 2 patients. The imaging features were characteristic with a multilobulated/bilobed ring-enhancing appearance in 8 patients including 2 patients with multiple lobulated and non-lobulated lesions and 1 patient showing the progression from a non-lobulated to lobulated lesion. These findings suggest that nocardial brain abscesses particularly at late-stages share common characteristics. Nevertheless, given the complex pathologic features, including possible co-infection by other pathogens, nocardial brain abscesses remain a therapeutic challenge.

The Diagnostic Yield of Magnetic Resonance Cholangiopancreatography in the Setting of Acute Pancreaticobiliary Disease - A Single Center Experience.

PURPOSE: To discern whether preceding ultrasound (US) results, patient demographics and biochemical markers can be implemented as predictors of an abnormal Magnetic Resonance Cholangiopancreatography (MRCP) study in the context of acute pancreaticobiliary disease. METHODS: A retrospective study was performed assessing US results, age, gender, elevated lipase and biliary enzymes for consecutive patients who underwent an urgent MRCP following an initial US for acute pancreaticobiliary disease between January 2017-December 2018. Multivariable binary logistic regression models were constructed to assess for predictors of clinically significant MRCPs, and discrepant US/MRCP results. RESULTS: A total of 155 patients (mean age 56, 111 females) were included. Age (OR 1.03, P < 0.05), hyperlipasemia (OR 5.33, P < 0.05) and a positive US (OR 40.75, P < 0.05) were found to be independent predictors for a subsequent abnormal MRCP. Contrarily, gender and elevated biliary enzymes were not reliable predictors of an abnormal MRCP, or significant MRCP/US discrepancies. Of 66 cases (43%) of discordant US/MRCPs, half had clinically significant discrepant findings such as newly discovered choledocholithiasis and pancreaticobiliary neoplasia. Age was the sole predictor for a significant US/MRCP discrepancy, with 2% increase in the odds of a significant discrepancy per year of increase in age. CONCLUSION: An abnormal US, hyperlipasemia and increased age serve as predictors for a subsequent abnormal MRCP, as opposed to gender and biliary enzyme elevation. Age was the sole predictor of a significant US/MRCP discrepancy that provided new information which significantly impacted subsequent management. In the remaining cases, however, MRCP proved useful in reaffirming the clinical diagnosis and avoiding further investigations.

Delirium and correlates of delirium among newly admitted elderly patients: a cross-sectional study in a Saudi general hospital.

BACKGROUND: Delirium is a common, often undiagnosed disorder in elderly patients, but no studies have been conducted in Saudi Arabia. OBJECTIVES: To determine the prevalence of delirium among elderly patients on admission and to identify associated factors. DESIGN: A cross-sectional study. SETTING: Tertiary care hospital, Saudi Arabia. PATIENTS AND METHODS: Elderly patients were evaluated for delirium within 24 hours of admission using the Confusion Assessment Method (CAM). The medical records were also reviewed to identify associated factors and whether the diagnosis of delirium was documented by the admitting physician. MAIN OUTCOME MEASURES: Prevalence of delirium. RESULTS: Of 147 patients aged 60 or over screened for delirium within 24 hours of admission, 32 (21.8%) patients were identified with delirium. Seven (21.9%) of the 32 patients with delirium had documentation of their diagnosis in the patient chart by the attending physician. Univariate logistic regression identified greater age (OR=2.70, 95%-CI: 1.21-6.02), higher unemployment rate (OR=3.30, 95%-CI: 1.43-7.61), more often had 3-5 co-morbidities (OR=2.69, 95%-CI: 1.14-6.33), and more cognitive impairment (OR=38.90, 95%-CI: 8.78-172.34) as risk factors for delirium on admission. Multivariate logistic regression analysis identified greater age (OR=2.53, 95%-CI: 1.08-5.88), higher unemployment rate (OR=3.73, 95%-CI: 1.52-9.13) and 3-5 co-morbidities (OR=3.31, 95%-CI: 1.30-8.46) as risk factors for delirium. CONCLUSIONS: Delirium was common and frequently not recognized in elderly patients admitted to the hospital. Administration of the CAM was very helpful in identifying delirium at admission. LIMITATIONS: The main limitation of our study was the relatively small number of patients which might have limited the power to detect some associations.

Uterine Artery Embolization for Retained Products of Conception with Marked Vascularity: A Safe and Efficient First-Line Treatment.

OBJECTIVE: To report our clinical practice regarding a case series of retained products of conception (RPOC) with marked vascularity (MV) managed with selective uterine artery embolization (UAE) as first-line treatment. METHODS: This was a monocentric, retrospective study of 31 consecutive cases of RPOC with MV diagnosed by Doppler ultrasound in the context of postpartum/postabortal bleeding. The primary outcome was the absence of rebleeding following embolization. RESULTS: RPOC with MV occurred after abortion in 27 out of 31 patients (87%). The time elapsed between delivery/abortion and UAE ranged from 1 to 210 days (mean 55.7 ± 45 days). Primary clinical success was achieved in 23 women (74.2%) following a single embolization. In total, 27 out of 31 women (87%) had been exclusively managed by UAE with conservative success. Although procedural success was achieved in this number, six women had a further procedure to evacuate RPOC despite procedural success. Large uterine arteriovenous (AV) shunts associated with RPOC were observed in five cases (16.1%), among which two were successfully treated after a single UAE and one after two UAEs, while hysterectomy was performed in the last two cases despite two and three UAE procedures respectively. RPOC was histologically proven in ten cases (32.2%) including four out of five cases of uterine AV shunt. CONCLUSION: RPOC with MV can present with large uterine AV shunt, particularly in case of late management. Uterine artery embolization is an effective and safe first-line treatment, and should be evaluated for this indication in larger prospective trials.

Perspectives of interns and residents toward do-not-resuscitate policies in Saudi Arabia.

OBJECTIVE: Do-not-resuscitate (DNR) orders in Saudi Arabia were first regulated by a fatwa on a national level in 1988, one that excludes the patient and their families from decision making. Although the core of this policy is taken up by all hospitals in Saudi Arabia, there is no homogeneity in implementation. Here, we appraise what interns and residents know of these policies and their attitudes toward DNR. METHODS: Interns and residents in four major hospitals in Jeddah, King Abdulaziz University Hospital, National Guard Hospital, King Fahad General Hospital, and King Fahad Armed Forces Hospital, were given a questionnaire in English with four blocks of questions. RESULTS: A total of 140 questionnaires were included in our study. From these questionnaires, we conclude a lack of familiarity with DNR's policies and the fatwa and also a lack of understanding when it comes to treating DNR-labeled patients. The majority opinion was to include the patient in the decision-making process who is excluded according to the fatwa. Participants considered patients' dignity, religious concerns, and legal concerns to be important in considering resuscitation. CONCLUSION: We conclude a need to emphasize the issue of DNR and treatment of DNR patients in medical ethics classes in Saudi Arabia and put more effort to enact national DNR laws that include the patient in the decision-making process.