Retinoblastoma: Update on Current Management

Retinoblastoma (Rb) is the most common primary intraocular malignancy in children with an incidence from 1:15,000 to 1:20,000 live births. It can present as a unilateral or bilateral involvement of the eyes. It is generally induced by biallelic mutation of the RB1 tumor suppressor gene that leads to malignant transformation of primitive retinal cells. The most common presentation is leukocoria, followed by strabismus. The initial assessment and future treatment of such tumor should be based on the laterality, the stage of the tumor, and the presenting age of the child. In general, the primary target of therapy is to preserve the child’s life. However, preserving the globe and preserving vision should be achieved whenever it’s possible. Retinoblastoma treatment has evolved from enucleating the affected globe to also involving external beam radiation therapy, cryotherapy, laser photocoagulation, thermotherapy, brachytherapy, and chemotherapy (intravitreal, intra-arterial, and systematic). This chapter is intended to discuss briefly the clinical presentation of Rb, as well as a comprehensive review about the evolution and current treatment modalities with a focus on cases with low-risk features

Polyvascular Disease in Patients Presenting with Acute Coronary Syndrome: Its Predictors and Outcomes

We evaluated prevalence and clinical outcome of polyvascular disease (PolyVD) in patients presenting with acute coronary syndrome (ACS). Data for 7689 consecutive ACS patients were collected from the 2nd Gulf Registry of Acute Coronary Events between October 2008 and June 2009. Patients were divided into 2 groups (ACS with versus without PolyVD). All-cause mortality was assessed at 1 and 12 months. Patients with PolyVD were older and more likely to have cardiovascular risk factors. On presentation, those patients were more likely to have atypical angina, high resting heart rate, high Killip class, and GRACE risk scoring. They were less likely to receive evidence-based therapies. Diabetes mellitus, renal failure, and hypertension were independent predictors for presence of PolyVD. PolyVD was associated with worse in-hospital outcomes (except for major bleedings) and all-cause mortality even after adjusting for baseline covariates. Great efforts should be directed toward primary and secondary preventive measures

Demystifying Smoker's Paradox: A Propensity Score-Weighted Analysis in Patients Hospitalized With Acute Heart Failure.

Background Smoker's paradox has been observed with several vascular disorders, yet there are limited data in patients with acute heart failure (HF). We examined the effects of smoking in patients with acute HF using data from a large multicenter registry. The objective was to determine if the design and analytic approach could explain the smoker's paradox in acute HF mortality. Methods and Results The data were sourced from the acute HF registry (Gulf CARE [Gulf Acute Heart Failure Registry]), a multicenter registry that recruited patients over 10 months admitted with a diagnosis of acute HF from 47 hospitals in 7 Middle Eastern countries. The association between smoking and mortality (in hospital) was examined using covariate adjustment, making use of mortality risk factors. A parallel analysis was performed using covariate balancing through propensity scores. Of 5005 patients hospitalized with acute HF, 1103 (22%) were current smokers. The in-hospital mortality rates were significantly lower in current smoker's before (odds ratio, 0.71; 95% CI, 0.52-0.96) and more so after (odds ratio, 0.47; 95% CI, 0.31-0.70) covariate adjustment. With the propensity score-derived covariate balance, the smoking effect became much less certain (odds ratio, 0.63; 95% CI, 0.36-1.11). Conclusions The current study illustrates the fact that the smoker's paradox is likely to be a result of residual confounding as covariate adjustment may not resolve this if there are many competing prognostic confounders. In this situation, propensity score methods for covariate balancing seem preferable. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01467973.Gulf CARE (Gulf Acute Heart Failure Registry) is an investigator- initiated study conducted under the auspices of the Gulf Heart Association and funded by Servier, Paris, France; and (for centers in Saudi Arabia), by the Saudi Heart Association (The Deanship of Scientific Research at King Saud University, Riyadh, Saudi Arabia [research group number: RG -1436- 013]). This does not alter our adherence to policies on sharing data and materials; and the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The publication of this article was funded by the Qatar National Library

Incidence of Late Onset Neonatal Sepsis in Very Low Birth Weight Infants in a Tertiary Hospital: An ongoing challenge

Objectives: Late onset neonatal septicaemia (LONS) is one of the major causes of morbidity and mortality in very low birth weight (VLBW) infants. The main objective of this study was to investigate the rate of LONS in the Neonatal Intensive Care Unit (NICU) of King Khalid University Hospital (KKUH) in Riyadh, Saudi Arabia over a three year period and compare it to international standards. Methods: To determine the incidence of LONS, a retrospective study was undertaken and premature infants with a birth weight less than 1250 g were included, giving a total of 273 infants. Their bacterial profile and the antimicrobial susceptibility of the isolates were investigated, and the changes in trends over the study period studied. Results:91.5% of included infants (217/237) had 1 or more blood cultures obtained beyond the second day of life. 41% (98/237) of included infants had at least one episode of proven sepsis. The majority (71.4%) of first episode sepsis was caused by Gram-positive organisms. Coagulase negative Staphylococcus accounted for around 80% of all Gram-positive infections. Gram-negative pathogens accounted for 24.5% of the late onset infections while fungal organisms were responsible for 4%. Conclusion: The rate of LONS was high and exceeded internationally reported rates in our tertiary care NICU. Gram-positive organisms continue to be major causative isolates. High priority should be placed on preventative steps to control nosocomial sepsis.

Role of prophylactic surgical ligation of patent ductus arteriosus in extremely low birth weight infants: Systematic review and implications for clinical practice

OBJECTIVES: To investigate the effectiveness and safety of prophylactic surgical ligation of patent ductus arteriosus (PDA) on mortality and morbidity of preterm infants weighing less than 1000 g at birth. MATERIALS AND METHODS: The study conducted a systematic search of available database from 1996-2008. Retrieved articles were assessed for eligibility and data was abstracted independently by two reviewers. Decisions to include studies for review and the methodological quality of included studies were asssessed in duplicate based on predetermined criteria. No language restrictions were applied. RESULTS: Only one eligible study that enrolled 84 extremely low birth weight infants was identified. Prophylactic surgical ligation of PDA resulted in a statistically significant reduction of severe stage II or III necrotizing enterocolitis, [RR 0.25, 95% CI (0.08, 0.83), P value 0.02, number needed to treat 5]. The study, however, found no statistically significant difference in mortality, intraventricular hemorrhage, bronchopulmonary dysplasia, and retinopathy of prematurity. CONCLUSIONS: Current evidence does not support the use of prophylactic surgical ligation of PDA in the management of the preterm infants

Probiotics for infantile colic: a systematic review

Background: Infantile colic is a common paediatric condition which causes significant parental distress. Increased intestinal coliform colonization in addition to alteration in Lactobacillus abundance and distribution may play an important role in its pathogenesis. The objectives of this systematic review are to evaluate the efficacy of probiotic supplementation in the reduction of crying time and successful treatment of infantile colic. Methods: Literature searches were conducted of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials. Only randomized controlled trials enrolling term, healthy infants with colic were included. A meta-analysis of included trials was performed utilizing the Cochrane Collaboration methodology. Results: Three trials that enrolled 220 breastfed infants met inclusion criteria, of which 209 infants were available for analysis. Two of the studies were assessed as good quality. Lactobacillus reuteri (strains-American Type Culture Collection Strain 55730 and DSM 17 938) was the only species utilized in the therapeutic intervention. Two of the trials were industry funded. Probiotic supplementation compared to simethicone or placebo significantly and progressively shortened crying times to 7 days reaching a plateau at three weeks post initiation of therapy [mean difference −56.03 minutes; 95% CI (−59.92, -52.15)]. Similarly, probiotics compared to placebo significantly increased the treatment success of infantile colic with a relative risk (RR) of 0.06; 95% CI (0.01, 0.25) and a number needed to treat of 2. Conclusions: Although L. reuteri may be effective as a treatment strategy for crying in exclusively breastfed infants with colic, the evidence supporting probiotic use for the treatment of infant colic or crying in formula-fed infants remains unresolved. Results from larger rigorously designed studies will help draw more definitive conclusions. Keywords: Infantile colic, Probiotics, Systematic review, Lactobacillus reuter

16. Contrast induced nephropathy, a single Saudi tertiary center experience

Contrast-induced nephropathy (CIN) is a leading cause of hospital-acquired acute kidney injury. Limited data exists about CIN in Saudi Arabia. We sought to explore the incidence, and characteristics of CIN victims in a Saudi tertiary care center. Methods: Patients who underwent cardiac catheterization (CC) or renal denervation between January 1st, 2012 and June 30th, 2013 were screened. CIN was defined as ⩾25% increase in Creatinine, occurring within 24–7  h after contrast exposure. Baseline characteristics, and incidence of CIN were described. Results: 437 patients were eligible for this analysis. Of those 434 underwent CC and 3 renal denervation. The mean age of the study cohort was 56.9 (±11.8). 56.6% were Saudi nationals, and 78.2% were males. Diabetes, hypertension, and pre-existing chronic kidney disease were found in 52.5%, 59.12%, and 5.35%, respectively. 73.7% were hydrated prior to the procedure, and 42.9% were hydrated following the procedure. Overall incidence of contrast-induced nephropathy was 31.3%. 56.5% developed CIN within 48 h after the index procedure; while 35.6% developed it after 96 h. All patients developing CIN recovered without dialysis. Baseline estimated GFR, and HTN were the only independent predictors for CIN. Conclusion: Our study is the first study in Saudi Arabia reporting the incidence of CIN. CIN incidence is relatively high though the overall short-term prognosis is favorable