Qatar Medical Journal - Volume 2020, Issue 3

Background: Enteral feeding has various advantages over parenteral feeding in critically ill patients. Acutely ill patients are at risk of developing enteral feeding intolerance. Prokinetic medications improve gastrointestinal mobility and enteral feed migration and absorption. Among the available prokinetic agents, erythromycin is the most potent. Erythromycin is used in different dosages and durations with variable efficacy. Intravenous erythromycin has an early and high rate of tachyphylaxis; hence, enteral route is preferred. Recently, the combination of prokinetic medications has been increasingly used because they accelerate the prokinetic action and decrease the adverse effects.

Aim: This study aimed to determine the optimal effective prokinetic dose and duration of administering enteral erythromycin in combination with metoclopramide in critically ill patients.

Patients and methods: This study has a prospective observation design. After obtaining permission from the medical research center of the institution, all patients in the surgical and trauma intensive care unit having enteral feed intolerance and those who were already on metoclopramide for 24 hour (h) were enrolled in the study. Patients’ demographic data, diagnosis, surgical intervention, disease severity scores, erythromycin dose, duration of administration, any adverse effects, factors affecting erythromycin response, and outcome were recorded. All patients received 125 mg syrup erythromycin twice daily through a nasogastric tube (NGT). The NGT was clamped for 2 h, and half amount of previous enteral feeds was resumed. If the patient did not tolerate the feeds, the erythromycin dose was increased every 24 h in the increment of 250, 500, and 1000 mg (Figure 1). Statistical significance was considered at P <  0.05. A total of 313 patients were enrolled in the study. Majority of the patients were male, and the mean age was 45 years.

Results: Majority (48.2%) of the patients (96) with feed intolerance were post laparotomy. Ninety percent (284) of the patients responded to prokinetic erythromycin therapy, and 54% received lower dose (125 mg twice daily). In addition, 14% had diarrhea, and none of these patients tested positive for Clostridium difficile toxin or multidrug resistance bacteria. The mean duration of erythromycin therapy was 4.98 days. The most effective prokinetic dose of erythromycin was 125 mg twice daily (P = 0.001). Erythromycin was significantly effective in patients with multiple organ dysfunction and shock (P = 0.001). Patients with high disease severity index and multiple organ dysfunction had significantly higher mortality (p < 0.05). Patients not responding to erythromycin therapy also had a significant higher mortality (p = 0.001).

Conclusion: Post-laparotomy patients had high enteral feed intolerance. Enteral erythromycin in combination with metoclopramide was effective in low dose and was required for short duration. Patients who did not tolerate feeds despite increasing dose of erythromycin had higher mortality.

Background: Necrotizing fasciitis (NF) is a rare but aggressive infection that affects the superficial fascia and progressively destroys the tissue between the skin and underlying muscles. It is a surgical emergency with significant morbidity and mortality. This study aimed to explore the temporal and seasonal trends in NF infection in Qatar. Methods: A total of 327 patients diagnosed with NF, aged ≥ 18 years, and admitted to the Hamad General Hospital, Qatar, in 2002–2013 were retrospectively reviewed. The hospitalization and mortality rates in the general population in Qatar and the case fatality rate (CFR) were calculated for each year. The patients were grouped into summer, autumn, winter, and spring admissions based on their admission dates. Seasonality was studied by comparing the characteristics, bacteriological status, and outcomes of the patients admitted in different seasons. Results: The hospitalization rate of NF in Qatar was 2.9 per 100,000 population; in the study duration, this rate decreased from 2.8 to 1.6 per 100,000 population in 2002 and 2013, respectively. The mortality rate among NF cases increased from 1.9 to 3.6 per million population, and the CFR increased from 6.7 to 23 per 100 admissions in the same duration. No temporal trends in the hospitalization and mortality rates or CFR were evident in the study duration. Polybacterial infections were higher in autumn than in other seasons. Monobacterial Gram-positive infections were higher in spring than in other seasons, and monobacterial Gram-negative infections were higher in summer than in other seasons (p = 0.02). However, seasonality was not evident after further analysis in terms of species, severity, complications, length of hospital stays, and CFR in patients with NF. Conclusion: No clear trend or seasonality was observed in terms of outcomes; however, seasonality in NF-causing bacteria was evident, as polybacterial infections were significantly higher in autumn than in other seasons, whereas monobacterial infections were more frequent in spring and summer than in other seasons. However, the severity of infections, length of hospital stay, and mortality did not significantly vary. Further microbiological studies are needed to obtain confirmatory data regarding the temporal and seasonal trends of NF.

Background: Healthcare workers managing Coronavirus 19 (COVID-19) patients are at increased risk of poor mental wellbeing. The available literature on the psychological impact in the Arabian Gulf region is limited, and a more in-depth analysis of factors affecting frontline healthcare workers’ mental wellbeing is warranted. The aim of this study was to evaluate and explore healthcare workers’ wellbeing working in quarantine centers in Qatar.

Methods: This study was a cross-sectional, web-based survey conducted on healthcare workers managing patients in designated quarantine centers. Healthcare workers associated with 51 COVID-19 quarantine centers were eligible to participate in this survey from April 19 to May 3, 2020. The primary outcome of interest was mental wellbeing as measured by the Warwick-Edinburgh Mental Well-Being Scale (WEMWBS).

Results: A total of 127 of 169 contacted staff members completed the survey, with a participation rate of 75%. Approximately 17.4% of participants had well-being scores of less than 45, indicating suboptimal wellbeing and a high risk of psychological distress and depression. The multivariable logistic regression analysis showed that nurses are associated with increased risk (more than the fivefold higher risk of having WEMWBS score < 45) of adverse mental wellbeing (adjusted OR 5.65; 95% CI 0.57, 56.4; p = 0.140).

Conclusion: The psychological impact of working in quarantine centers on healthcare workers was less than what has been reported globally. Nurses are the most vulnerable group. It is essential that health services monitor the psychological impact on its workforce and puts appropriate mitigation strategies in place.

Aim: The aim of this study was to evaluate the progression of tricuspid regurgitation (TR) in patients with pacemaker leads across the tricuspid valve and assess the clinical effect on right ventricular (RV) function.

Methods: Patients who had undergone permanent pacemaker implantation at our institution over an 8-year period were identified. Those who had an echo (for any indication) pre- and postdevice implantation were included in this study, and their data assessed. Clinical information was obtained from their medical records. A total of 65 patients (mean age 70 ± 13 years, 31 (48%) males, and 34 (52%) females) were enrolled in the study.

Results: The median interval of echo after implantation was 12 (12 to 24) months. Before implantation, 29 patients had TR, which increased to 51 (78%) during follow up, indicating that 22 patients developed new TR. Of those with preexisting TR, the grade of TR had worsened by at least one grade in 17 patients. RV function as measured by tricuspid annular plane systolic excursion (TAPSE) had decreased from 1.87 ± 0.44 to 1.68 ± 0.42 (p = 0.002). Eighteen patients had developed signs of right heart failure (either breathlessness with raised jugular venous pressure or pedal edema or both), of which 13 had only new pedal edema.

Conclusion: There is a definite progression of TR in patients with a pacing lead across the tricuspid valve (TV) associated with an increase in the incidence of right heart failure. Patients with a pacing lead across the TV should be followed closely for signs of right heart failure.

This is a case of benign mucinous cystadenoma of the spleen in Benghazi, Libya. It is the first reported in Libya and most probably the fourth in Africa. Primary mucinous cystadenoma of the spleen is an extremely unique benign cystic lesion. Only a very few number of cases have been reported. These cysts are assumed to arise from invagination of the splenic capsular epithelium or from the ectopic pancreatic tissue. We report a rare case of primary mucinous cystadenoma of the spleen without evidence of pancreatic tissue in the specimen. Despite being a rare condition, mucinous cystadenoma of the spleen should remain in the differential diagnosis of any splenic cysts.