ECMO support for late presenting arterial switch operation; case report and review of literature

Infants presenting for late arterial switch operation are at risk of myocardial depression and cardiac arrest due left ventricle deconditioning. In this report we present a female infant diagnosed to have transposition of great arteries (TGA) with intact septum who presented at 3 months of age for late arterial switch operation. Prior to surgery, the left ventricle size and mass index appeared to be satisfactory in term of muscular size and function. She underwent late arterial switch operation (ASO). Soon after surgery, the infant developed myocardial depression with hemodynamic instability and high left atrial pressure associated with left atrial dilatation. ECMO was deployed and patient stayed 10 days on ECMO until left cardiac function recovered. The infant was decannulated successfully and was subsequently discharged home with acceptable cardiac function.In conclusion, patients presenting for late arterial switch operation are at risk for left ventricular deconditioning and pulmonary hypertension. Deconditioned left ventricle may fail post repair with inability to handle systemic circulation. Among limited options for these challenging cases primary ASO with integrated ECMO support can be used to allow deconditioned left ventricle to recover its function and ability to handle systemic circulation. Keywords: Arterial switch operation, ECMO, Transposition of great arterie

Bedside ultrasonography screening for congenital renal anomalies in children with congenital heart diseases undergoing cardiac repair

Introduction: Ultrasound (US) assessment of renal anomalies in children requiring pediatric cardiac surgery is not a standard practice. This study is highlighting the role of bedside US performed by intensivist to detect occult renal anomalies associated with congenital heart disease (CHD). Methods: A cross sectional study for 100 consecutive children with CHD admitted to Pediatric Cardiac Intensive Care Unit (PCICU) in 2015. US of kidneys screening was performed by trained pediatric cardiac intensivists to ascertain the presence of both kidneys in renal fossae without gross anomalies and to investigate if early detection of occult kidney anomaly would have any impact on outcome. Results: After screening of 100 consecutive children with CHD with renal US, we identified in 94 cases (94%) normal right and left kidney in the standard sonographer shape within the renal fossae. In 6 cases further investigation revealed ectopic kidney in 3 patients (50%), solitary functional kidney in 2 patients (33%) and bilateral grade IV hydronephrosis in one patient (17%). Urinary tract infection developed peri-operatively in 66% of the cases with kidney anomalies with statistical significance compared to patients with normal renal US (P: 0.0011). No significant renal impairment was noted in these patients post-surgery. We observed no specific association between the type of renal anomaly and specific CHD. Conclusion: Routine renal US in children with CHD demonstrated prevalence of associated congenital renal anomalies in 6% of children undergoing cardiac surgery. The presence of occult renal anomalies was associated with higher UTI risk. Performing routine renal US as a standard practice in children with CHD is justifiable. Keywords: Renal ultrasound, Congenital renal anomalies, Congenital heart diseas

Acute Severe Hyponatremia following Hysteroscopic Procedure in a Young Patient: A Case Report and Review of the Literature

Background. Hysteroscopic surgery is a minimally invasive procedure used to diagnose and treat intrauterine pathologies. It requires distension of the uterine cavity for the adequate visualization of the operative field. Glycine (1.5%) is one of the most commonly used solutions because it is nonconductive and also has good optical properties. However, acute hyponatremia is a critical complication that can develop after the absorption of a sufficient amount of the irrigation medium. Case Presentation. We report a case of a 43-year-old female patient who developed acute symptomatic hyponatremia (104 mEq/L) and pulmonary edema secondary to hysteroscopic resection of leiomyoma and hastily approached with rapid sodium correction measures. Conclusion. Multiple strategies can be taken to reduce the risk of fluid absorption and subsequent hyponatremia. Moreover, attention should be paid to the treatment approach for patients with acute hyponatremia following hysteroscopic procedures; rapid correction of acute hyponatremia for such patients might be safe, although there is no consensus in the literature, and further trials are needed.+e authors thank the patient for giving her consent for publication of this case. +ey thank Dr. Amal Musleh for doing the procedure. +ey thank Dr. Mohammad Jaradat for his contribution to the treatment of the patient. +ey thank the surgical team in the Red Crescent hospital

Effectiveness and Safety of Secukinumab for Psoriasis in a Real-World Clinical Setting in the Asia-Pacific and Middle East Regions: Results from the REALIA Study

INTRODUCTION: Secukinumab has demonstrated sustained long-term efficacy with a favourable safety profile in various manifestations of psoriatic disease. We investigated effectiveness and safety of secukinumab, other biologics and conventional systemic therapies in patients with chronic plaque psoriasis in a real-world setting. METHODS: REALIA was a non-interventional, multicentre, prospective, parallel group study. Eligible patients were ≥ 18 years old with chronic plaque psoriasis commencing a new treatment with a biologic agent or conventional systemic therapies. RESULTS: At baseline, 541 patients were divided into three cohorts based on treatment initiated: conventional systemics (173), secukinumab (184) and other biologics (184). A significantly higher proportion of patients achieved almost clear to clear skin based on physician's judgement in secukinumab versus conventional systemics at month 3 (64.7% versus 22.8%, P < 0.001) and month 6 (61.8% versus 20.8%, P < 0.001). At month 12, clear to almost clear skin was achieved by 52.1% of the patients in secukinumab versus 35.8% in conventional systemics (P = 0.066). The proportion of patients achieving Psoriasis Area Severity Index (PASI) 90 on conventional systemics, secukinumab and other biologics was 18.8%, 59.7% and 40.0% at month 3 and 35.3%, 60.8% and 50.0% at month 12, respectively. Secukinumab patients showed significantly higher change in PASI total score from baseline versus conventional systemics at month 3 {least squares [LS] mean [standard error (SE)]: -14.49 [0.648] versus -8.48 [1.149], P < 0.001} and numerically higher [LS mean (SE): -13.60 (0.475) versus -10.84 (1.733), P = 0.122] at month 12. The proportion of patients with Dermatology Life Quality Index 0/1 score on conventional systemics, secukinumab and other biologics was 22.6%, 65.0% and 41.6% at month 3 and 32.0%, 63.5% and 41.3% at month 12, respectively. Safety profile was comparable across cohorts. CONCLUSIONS: Secukinumab is effective and well tolerated in patients with chronic plaque psoriasis in a real-world setting in an Asia-Pacific and Middle East population, and these results are in agreement with clinical outcomes of secukinumab reported in randomised clinical trials. TRIAL REGISTRATION NUMBER: 170803-001645

Management of Atopic Dermatitis in Adults in Saudi Arabia: Consensus Recommendations from the Dermatological Expert Group

Abdullah Alakeel,1 Afaf Al Sheikh,2,3 Ali A Alraddadi,4– 6 Khalid Mohammed Alattas,7 Maha Aldayel,8 Mohammed Abdulaziz Alajlan,9 Mohammed Al-Haddab,1 Mohammad Almohideb,3,10 Mohamed Fatani,11 Issam R Hamadah,12 Ruaa Alharithy,13,14 Yousef Binamer,15,16 Kim Papp,17 Ahmed Elaraby18 1Department of Dermatology, College of Medicine, King Saud University, Riyadh, Saudi Arabia; 2Division of Dermatology, Department of Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia; 3Department of Dermatology, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; 4Department of Dermatology, Ministry of National Guard-Health Affairs, Jeddah, Saudi Arabia; 5King Abdullah International Research Center, Jeddah, Saudi Arabia; 6King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; 7King Fahad Central Hospital, Jazan, Saudi Arabia; 8Dammam Medical Complex, Dammam, Saudi Arabia; 9Dermatology Section MSD, King Fahad Medical City, Riyadh, Saudi Arabia; 10King Abdulaziz Medical City, Riyadh, Saudi Arabia; 11Hera General Hospital, Makkah, Saudi Arabia; 12King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; 13Security Forces Hospital, Riyadh, Saudi Arabia; 14Princess Nourah University, Riyadh, Saudi Arabia; 15Department of Dermatology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; 16Department of Dermatology, Alfaisal University, Riyadh, Saudi Arabia; 17Probity Medical Research Inc. and K. Papp Clinical Research Inc., Waterloo, ON, Canada; 18Bachelor of pharmacy, Cairo University, Giza, EgyptCorrespondence: Issam R Hamadah, Email [email protected]; [email protected]: Atopic dermatitis (AD) is a long-term, pruritic, recurrent, systemic, inflammatory skin disorder. In the Middle East region, the burden of AD is understudied, and there is a dearth of AD guideline documents for practitioners.Methods: An expert panel meeting, encompassing 12 dermatologists from the Kingdom of Saudi Arabia (KSA), was congregated to develop evidence- and experience-based consensus recommendations for AD management, especially in adults in KSA. They completed a questionnaire with seven clinical statements, and a consensus was defined when the responses of ≥ 75% of participants coincided.Results: The expert recommendations were as follows: American Association of Dermatology guidelines are to be followed for defining AD; Eczema Area and Severity Index or SCORing atopic dermatitis index may be used to quantify the disease severity; Dermatology Life Quality Index may be used to determine the impact of AD on patients’ quality of life; Atopic Dermatitis Control Tool may be used to assess long-term disease control in AD patients; and the European guidelines are to be followed for the management of AD. In AD patients who are inadequately controlled with topical or systemic therapies, the preferred systemic agent for use either alone or in combination with topical treatments is dupilumab, cyclosporine, methotrexate, phototherapy, or other available systemic treatments that may include mycophenolate mofetil or oral corticosteroids.Conclusion: These expert recommendations assist physicians by providing a reference framework for optimal care of adult AD patients.Keywords: atopic dermatitis, Dermatology Life Quality Index, Eczema Area and Severity Index, SCORing atopic dermatiti