BACKGROUND: In pediatric surgical practice, physicians may face malpractice claims leading to substantial compensations and even criminal liability.OBJECTIVES: To examine the legal processes and responsibilities of physicians by reviewing Supreme Court decisions related to malpractice claims involving pediatric surgeons.DESIGN AND SETTINGS: A retrospective study based on the online archive of Supreme Court decisions.PATIENTS AND METHODS: A search was conducted using keywords from the Supreme Court decision search engine. Decisions were reached regarding malpractice claims involving pediatric surgery.MAIN OUTCOMES MEASURES: The medical procedure that was the subject of the malpractice claim, the resulting damage, the expertise of the physicians, and the reasons for the Supreme Court's reversal and approval were evaluated.SAMPLE SIZE: 82 Supreme Court decisionsRESULTS: Among 82 decisions, circumcision (46%; n=38) was the most common. Appendicitis and testicular torsion followed. Total/subtotal penile amputation was present in 40% (n=15) of circumcisions. Half of the appendicitis cases resulted in death, and all testicular torsion cases resulted in organ loss. General surgeons were the most frequent physicians involved in litigation, accounting for 16% of cases (n=13), followed by pediatric surgeons and general practitioners, each accounting for 15% of cases (n=12). Supreme Courts found physicians at fault in 35% of criminal cases and 38% of civil cases. Deficiencies in expert reports were the reason for reversals in 42% of the decisions.CONCLUSION: Supreme Courts conduct comprehensive evaluations in malpractice cases, considering factors such as indication, authority, fault status, complication management, and causal link. Physicians' understanding of these issues will significantly contribute to minimizing malpractice claims.LIMITATIONS: Retrospective study

BACKGROUND: The increase in carbapenem-resistant K. pneumoniae (CR-Kp) in intensive care units (ICUs) causes treatment difficulties and increases risk in mortality.OBJECTIVES: The aim of this study was to investigate the susceptibility rates of CR-Kp isolates obtained from ICUs to ceftazidime-avibactam (CAZ-AVI) and colistin, carbapenem resistance genes, clonal relationships and clinical characteristics of the patients.DESIGN: Retrospective cohortSETTING: Single-center, University of Health Sciences, Ümraniye Training and Research HospitalMATERIALS AND METHODS: This study was conducted between June 2023 and December 2024. Isolates were identified using VITEK MS v.3.2, and antibiotic susceptibility testing was performed using the VITEK 2 Compact system. CAZ-AVI susceptibility was determined using disk diffusion, and colistin susceptibility was determined using broth microdilution to determine minimum inhibitory concentration (MIC) values. Carbapenem resistance genes were determined using multiplex real-time polymerase chain reaction (RT-PCR) and clonal relationship arbitrarily primed-polymerase chain reaction (AP-PCR).MAIN OUTCOME MEASURES: Resistance genes of CR-Kp isolates, clonal relationships, CAZ-AVI and colistin resistance, and clinical characteristics of patientsSAMPLE SIZE: Ninety-seven isolates from 76 patientsRESULTS: Among patients with CR-Kp isolates, central venous catheter use was detected in 59 cases (78%), ventilator-associated pneumonia in 44 cases (58%), and bacteremia in 39 cases (51%), respectively. It was determined that 53 of the patients (70%) died. Using the AP-PCR method, 60 different genotypes were identified among 97 isolates, and clustering was determined in 42 of the isolates (46%). It was determined that 36 (37%) of the isolates were resistant to colistin and 42 (45%) were resistant to CAZ-AVI. NDM+OXA-48, OXA-48, KPC, KPC+NDM, and NDM genes were detected in 40 (43%), 32 (35%), 10 (11%), 2 (2%), and 3 (3%) isolates, respectively. It was determined that 30 (75%) of the isolates with NDM+OXA-48 and only 4 (12%) of the isolates with OXA-48 were resistant to CAZ-AVI.CONCLUSION: In addition to OXA-48, an increase in the frequency of CR-Kp isolates containing the NDM, NDM+OXA-48, KPC+NDM, and OXA-48+KPC genes were also detected. It was also determined that resistance to colistin and CAZ-AVI is increasing. The AP-PCR method can also be used to investigate infections.LIMITATIONS: Single center, Pulsed Field Gel Electrophoresis (PFGE) could not be performed together with AP-PCR

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has become the preferred minimally invasive approach for thoracic surgical procedures, with potential advantages over traditional thoracotomy. Perioperative and long-term outcomes between uni-port (U-VATS) versus multi-port (M-VATS) techniques remains under investigation.OBJECTIVES: To compare U-VATS and M-VATS in terms of operative outcomes, complications, and oncological parameters.DESIGN: Retrospective cohort studySETTING: Single tertiary referral center, King Saud University Medical City (KSUMC), Riyadh, Saudi ArabiaPATIENTS AND METHODS: Adult patients aged 18–75 years who underwent VATS lung resection between January 2015 and September 2024 were included. Pediatric patients and those undergoing open techniques were excluded. Collected data included sociodemographic, preoperative, intraoperative, and postoperative variables. Statistical analysis used t-test, Mann-Whitney U, Chi-square, and multivariate logistic regression.MAIN OUTCOME MEASURES: Operative time, blood loss, lymph node dissection, postoperative complications, hospital stay, mortality, and recurrence.SAMPLE SIZE: 194 patients (103 U-VATS, 91 M-VATS)RESULTS: Baseline characteristics were similar between groups. U-VATS was associated with longer operative time, [mean (SD) 210.0 (110.4) vs. 154.2 (69.9) min, P<.001] and greater blood loss [416.7 (392.2) vs. 150.0 (76.4) ml, P=.034]. Malignant lymph node involvement was higher in U-VATS (39.8% vs. 19.8%, P=.021), with more lymph node stations sampled. Anatomical resections were more common in U-VATS (31.1% vs. 13.2%, P=.005). Complication rates were low, with pneumonia (4.4%) as the most frequent in M-VATS and prolonged air leak (2.9%) in U-VATS. Thirty-day mortality was comparable (17.5% vs. 15.4%). Multivariate analysis showed M-VATS was associated with dissecting more lymph nodes (odds ratio, OR: 1.223; 95% confidence interval, CI: 1.019–1.468; P=.030), while anatomical resections were more likely with U-VATS (OR: 0.40; 95% CI: 0.180–0.740; P=.006).CONCLUSIONS: Both U-VATS and M-VATS are safe for lung resections. U-VATS is more commonly used for anatomical resections and allows broader lymph node station sampling, supporting its expanding role in thoracic surgery.LIMITATIONS: Single-center retrospective design, relatively small sample, and incomplete lymph node documentation.

BACKGROUND: Apixaban is a direct-acting oral anticoagulant indicated for stroke and systemic embolism prevention in atrial fibrillation (AF) and for the treatment of venous thromboembolism (VTE). It is absorbed throughout the small intestine, with possible contribution from the distal ileum and ascending colon. The effect of ileostomy creation, which excludes the colon from the gastrointestinal tract, on apixaban plasma concentrations remains unclear.OBJECTIVES: To evaluate the impact of ileostomy creation on apixaban plasma concentrations.DESIGN: Retrospective case seriesSETTING: A single tertiary care center in Saudi ArabiaPATIENTS AND METHODS: Patients receiving apixaban who had peak apixaban plasma concentrations measured following ileostomy creation between January 2021 and June 2025 were included. Patients were followed for at least three months and up to 12 months, or until ileostomy closure, discontinuation of apixaban, or death, whichever occurred first.MAIN OUTCOME MEASURES: Peak apixaban plasma concentrations, proportion of patients within the expected 5th-95th percentile range reported in Phase II and Phase III trials, the distribution of apixaban plasma concentrations below or above the median of the expected range, and clinical bleeding or thrombotic events.SAMPLE SIZE: Ten patientsRESULTS: Apixaban was prescribed for VTE in six patients and AF in four. Eight patients (80%) had peak apixaban concentrations within the expected 5th-95th percentile range of apixaban concentrations; one patient was below the 5th percentile, and one was above the 95th percentile. Six patients had apixaban plasma peak concentrations below the median of the expected 5th-95th percentile range. Two patients experienced rectal bleeding, and no thrombotic events were observed.CONCLUSIONS: In patients with an ileostomy, apixaban peak concentrations generally fall within the expected 5th-95th percentile range, though frequently below the median. Ileostomy may slightly affect apixaban absorption, but does not appear to result in underexposure. Standard apixaban dosing seems appropriate.LIMITATIONS: Small sample size, lack of control, and retrospective design.

BACKGROUND: Liver size can indicate the presence of liver diseases such as cirrhosis, hepatitis, and malignancy. Accurate assessment of liver span is essential for the early identification of liver pathologies.OBJECTIVES: The objective of this study is to establish a reference value for the average liver size of the Saudi population using abdominal computed tomography (CT) scans. A secondary objective of the study is to explore the correlations of demographic factors and comorbidities with liver size.DESIGN: A retrospective cross-sectional studySETTING: Tertiary healthcare center in Riyadh, Saudi ArabiaPATIENTS AND METHODS: A retrospective cross-sectional analysis of liver span, liver width, and spleen span was performed. The maximum oblique craniocaudal (MaxCC) length and transverse width of the liver and maximum length of the spleen were obtained in coronal view. The demographic characteristics and comorbidities of patients were collected.MAIN OUTCOME MEASURES: Liver span, width, and spleen span of the study population. In addition to demographic characteristics and comorbidities that were correlates of larger liver size.SAMPLE SIZE: 2500 adult patients who underwent CT scans for conditions unrelated to liver disease.RESULTS: The mean (SD) liver span of the study population was 17.6 cm (2.4), while mean liver width was 18.9 cm (2.8). Multivariate analysis showed that a larger liver span was significantly correlated with increased age, height, a diagnosis of diabetes, as well as fatty liver and a larger BMI score.CONCLUSIONS: Measurement of the liver span using the MaxCC length and liver width is a simple method for routine clinical screening. The values established are useful in screening for liver disease that causes hepatomegaly and should therefore be used more frequently in a clinical setting in CT imaging.LIMITATIONS: Retrospective single-center design and reliance on CT-based diagnosis of fatty liver, which may not detect subclinical steatohepatitis.

BACKGROUND: Fiberoptic bronchoscopy is a crucial diagnostic tool in the evaluation of lung cancer, particularly in tumors with endobronchial involvement. While forceps biopsy, bronchial brushing, and bronchial washing are commonly used, the diagnostic value and optimal timing of bronchial washing remain debatable.OBJECTIVES: To evaluate the effect of pre- and post-biopsy bronchial washing on cytological diagnostic yield in patients with visible endobronchial lesions.DESIGN: Prospective diagnostic studySETTINGS: Single tertiary university hospitalMATERIALS AND METHODS: Between April 2018 and April 2021, 55 patients with bronchoscopically visible endobronchial lesions underwent flexible bronchoscopy. Patients with invisible or submucosal tumors were excluded. Bronchial washings were obtained before and after 4–6 forceps biopsies. Cytological analyses were conducted blindly on all specimens. Statistical analysis included Chi-square and McNemar tests, with P<.05 considered significant.MAIN OUTCOME MEASURES: Cytological diagnostic positivity rates in pre- and post-biopsy bronchial washings.SAMPLE SIZE: Fifty-five patientsRESULTS: Forceps biopsy alone achieved a diagnostic yield of 95%, which increased to 96% when combined with bronchial washing. Post-biopsy washing demonstrated a significantly higher cytological positivity rate (47%) than pre-biopsy washing (22%) (P=.002). No complications were observed.CONCLUSIONS: Bronchial washing after forceps biopsy significantly improves cytological diagnostic yield in endobronchial lung lesions. Its simplicity, low cost, and additional diagnostic yield support its routine use in bronchoscopic evaluation.LIMITATIONS: Single-center design and relatively small sample size; other cytologic methods such as brushing orendobronchial ultrasound (EBUS) were not evaluated.

BACKGROUND: Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare and severe autoimmune disease characterized by pauci-immune necrotizing vasculitis.OBJECTIVES: The study aims to explore the frequency, clinical characteristics, and management of AAV patients in two tertiary centers in the United Arab Emirates (UAE) over 17 years.DESIGN: A retrospective observational case seriesSETTING: Two tertiary centers in the UAEMETHODS: Patients diagnosed with granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), or eosinophilic granulomatosis with polyangiitis (EGPA) from 2008 to 2024 were included. Demographic, clinical, laboratory, histopathological information, treatment, complications, relapses, and mortality were collected. ANCA testing for anti–proteinase 3 (PR3) and anti–myeloperoxidase (MPO) antibodies was performed using enzyme-linked immunosorbent assays. Descriptive statistical analysis was performed to summarize the data.MAIN OUTCOME MEASURES: Subtype distribution, organ involvement, ANCA positivity, relapse, and mortality rates.SAMPLE SIZE: Twenty-six patientsRESULTS: We identified 26 AAV patients with a median age of 52.5 years. The majority were females (58%, n=15), and half were locals. The most common AAV subtype was microscopic polyangiitis (50%, n=13), followed by granulomatosis with polyangiitis (38%, n=10) and eosinophilic granulomatosis with polyangiitis (12%, n=3). ANCAs tested positive in nearly all of these cases. The most common clinical manifestations of AAV were constitutional symptoms with renal and pulmonary involvement. The induction therapy included corticosteroids, rituximab, cyclophosphamide, mycophenolate mofetil, and plasma exchange. The most prescribed maintenance medications were corticosteroids and azathioprine. The overall relapse rate was 31%, and the overall mortality rate was 19% (n=5).CONCLUSION: In our cohort, MPA was the most common subtype, being predominantly associated with P-ANCA/MPO-ANCA positivity. Notably, few studies from the Gulf region have addressed this topic. It's unclear whether this finding reflects low occurrence or potential underdiagnosis and, thus, points to unmet needs and a significant gap in the understanding of AAV. Multicenter studies are needed to validate these results and improve AAV management in Middle Eastern populations.LIMITATIONS: Retrospective design with small number of participants

BACKGROUND: The comparative effectiveness of intercostal tube drainage (ITD) and less invasive methods in initial pneumothorax management remains uncertain.OBJECTIVES: To compare ITD with other invasive approaches in adults.DESIGN: A systematic review and meta-analysis based on PRISMA guidelines, covering twelve studies from nine countries (Iran, UK, Netherlands, USA, Belgium, Kuwait, Norway, Pakistan, Switzerland) published between 1994 and 2021.MATERIALS AND METHODS: A comprehensive search was conducted in PubMed, and Google Scholar. The study encompassed randomized controlled trials (RCTs), prospective and retrospective analyses with adults presenting pneumothorax. Quality assessment was conducted using the Cochrane risk-of-bias (RoB 2) tool for randomized trials and the MINORS tool for non-randomized studies.MAIN OUTCOME MEASURES: Immediate success rates, hospital stay durations, complication rates, and recurrence rates at 12 months.SAMPLE SIZE: A total of 1204 patients were included across 12 studies, ten RCTs (n=932), one prospective (n=60) and one retrospective study (n=212).RESULTS: Meta-analysis showed no statistically significant differences between the ITD and the less invasive techniques in the immediate success rate (OR: 0.88, 95% CI: 0.47-1.65, P=.69). Also, no difference was noticed in the 1-week success rate (OR: 1.01, 95% CI: 0.6-1.5, P=.96) and recurrence (OR: 1.20, 95% CI: 0.80-1.80, P=.38).RISK OF BIAS: The RoB was low in 82% of studies assessed by RoB 2 and the study evaluated by MINORS demonstrated a moderate RoB.HETEROGENEITY: A high statistical heterogeneity was observed (I2=77%).CONCLUSIONS: ITD and other invasive approaches demonstrated comparable effectiveness, with no significant differences in immediate success, 1-week success, or recurrence rates.LIMITATIONS: The studies varied widely in design, patient groups, and quality. There were also signs of publication bias and a limited number of high-quality RCTs.PROSPERO REGISTRATION NUMBER: CRD42024517888.

BACKGROUND: Hypoparathyroidism (HPT) is a significant potential complication following thyroidectomy. Identifying predictors can aid in risk stratification, management, and potentially prevention.OBJECTIVE: To determine clinical and biochemical predictors of permanent HPT in post-thyroidectomy patients.DESIGN: Single-center, retrospective cohort studySETTINGS: Tertiary care center in Saudi ArabiaPATIENTS AND METHODS: We conducted a retrospective analysis of 1085 patients who underwent total thyroidectomy from 2015 to 2022. Patients who developed postoperative HPT were categorized into transient and permanent HPT groups. Demographic, surgical, and biochemical variables were analyzed. Multivariable logistic regression was used to identify independent predictors of permanent HPT, using transient HPT as the reference.MAIN OUTCOME MEASURES: Identification of independent predictors associated with permanent HPT.SAMPLE SIZE: 1085 patients, 264 with postoperative HPTRESULTS: We had 264 patients (24.3%) who developed postoperative HPT: 207 (19.1%) had transient and 57 (5.2%) had permanent HPT. Independent predictors of permanent HPT included thyroid cancer (Odds ratio, OR 2.08, 95% Confidence Interval, CI 1.03–4.17), autoimmune thyroid disease (OR 2.01, 95% CI 1.00–4.08), increased thyroid weight (OR 1.52 per 1 SD increase, 95% CI 1.08–2.14), and longer hospital stay (≥7 days) (OR 3.53, 95% CI 1.87–6.68). Preoperative vitamin D deficiency was identified as the only modifiable risk factor (OR 2.25, 95% CI 1.17–4.32). A postoperative parathyroid hormone (PTH) level ≤1.52 pmol/L within 24 hours was strongly associated with the risk of permanent HPT.CONCLUSION: Permanent HPT is significantly associated with preoperative vitamin D deficiency, thyroid malignancy, autoimmune thyroid disease, and greater thyroid weight. A postoperative PTH level ≤1.52 pmol/L is a reliable early biochemical predictor. Risk-based stratification may support individualized patient management and follow-up planning.LIMITATIONS: This was a single-center, retrospective study, limiting generalizability, in addition to the heterogeneity in surgeon experience and the time of PTH measurements post-operatively.

BACKGROUND: Follicular cell-derived thyroid carcinomas (FCTC) are common, with stable mortality rates but significant recurrence risks. Extrathyroidal extension (ETE) affects recurrence risk and staging. The 8th edition of the AJCC/TNM classification excludes microscopic ETE from upstaging but considers gross ETE a significant factor in older patients.OBJECTIVE: This study examines clinical outcomes and disease-free survival (DFS) in FCTC patients with and without ETE, evaluating the modifying effects of age and tumor size on incomplete response risk.DESIGN: A single-center retrospective chart review was conducted at King Abdulaziz University Hospital, Jeddah, Saudi ArabiaSETTING: King Abdulaziz University HospitalPATIENTS AND METHODS: Patients aged ≥13 years diagnosed from January 2017 to December 2021 with long-term follow-up (≥18 months) were included. Medullary and anaplastic thyroid cancers were excluded. Data on demographics, tumor characteristics, risk stratification, and clinical outcomes were collected. Response to therapy was categorized per the 2015 ATA guidelines. Chi-square and Multivariable analysis assessed interactions between age, tumor size, and ETE in predicting incomplete response. Kaplan-Meier curves visualized survival differences.MAIN OUTCOME MEASURES: Identifying the interactions between age and tumor size with ETE to predict the risk of incomplete response to therapy among patients with FCTC.SAMPLE SIZE: 255 patients. The median follow-up duration was 4 years.RESULTS: Patients with ETE were present in (n=38) 15.7% (8% microscopic, 7% gross). Older patients (≥55 years) with ETE had 26.47-fold higher odds of incomplete response than younger patients. Tumor size independently predicted incomplete response, but its interaction with ETE was not significant. Patients with ETE had a significantly higher incomplete response rate (58% vs. 17%, P=.0001).CONCLUSION: Older patients with ETE face a markedly higher risk of incomplete response. Tumor size is an independent risk factor in those patients. Management should be stratified by age, advocating more aggressive management for older patients with ETE.LIMITATIONS: Retrospective, and single-center design.