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Thamer A Almangour,1 Leen Ghonem,2 Ahmad Aljabri,2 Alya Alruwaili,3 Mohammed Al Musawa,4 Nader Damfu,5 Mesfer S Almalki,6 Majda Alattas,4 Hossam Abed,4 Doaa Naeem,5 Nawaf Almalki,5 Abdullah A Alhifany7 1Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, 11451, Saudi Arabia; 2Clinical Pharmacy Services, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia; 3Infectious Diseases Services, King Fahad Medical City, Riyadh, Saudi Arabia; 4Pharmaceutical Care Division, King Faisal Specialist Hospital & Research Centre, Jeddah, Saudi Arabia; 5Pharmaceutical Care Department, King Abdul Aziz Medical City, Jeddah, Saudi Arabia; 6Pharmaceutical Services, Security Forces Hospital, Makkah, Saudi Arabia; 7Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi ArabiaCorrespondence: Thamer A Almangour, Email talmangour@ksu.edu.sa.comBackground: The aim of this study was to compare the safety and effectiveness of ceftazidime-avibactam (CAZ-AVI) to colistin-based regimen in the treatment of infections caused by carbapenem-resistant Enterobacterales (CRE).Methods: This was a retrospective, multicenter, observational cohort study of inpatients who received either CAZ-AVI or intravenous colistin for treatment of infections due to CRE. The study was conducted in 5 tertiary care hospitals in Saudi Arabia. Main study outcomes included in-hospital mortality, clinical cure at end of treatment, and acute kidney injury (AKI). Univariate analysis and multivariate logistic regression model were conducted to assess the independent impact of CAZ-AVI on the clinical outcome.Results: A total of 230 patients were included in this study: 149 patients received CAZ-AVI and 81 patients received colistin-based regimen. Clinical cure (71% vs 52%; P = 0.004; OR, 2.29; 95% CI, 1.31– 4.01) was significantly more common in patients who received CAZ-AVI. After adjusting the difference between the two groups, treatment with CAZ-AVI is independently associated with clinical cure (adjusted OR, 2.75; 95% CI, 1.28– 5.91). In-hospital mortality (35% vs 44%; P = 0.156; OR, 0.67; 95% CI, 0.39– 1.16) was lower in patients who received CAZ-AVI but the difference was not significant. AKI (15% vs 33%; P = 0.002; OR, 0.37; 95% CI, 0.19– 0.69) was significantly less common in patients who received CAZ-AVI.Conclusion: CAZ-AVI is associated with higher rate of clinical cure and lower rate of AKI compared to colistin. Our findings support the preferential use of CAZ-AVI over colistin-based regimen for treating these infections.Keywords: ceftazidime-avibactam, colistin, colistimethate sodium, carbapenem-resistant Enterobacterales

Heyde syndrome is the association between gastrointestinal (GI) bleeding from intestinal angiodysplasia (IA) and aortic stenosis (AS). Although the course of disease progression that links AS and GI bleeding has not been determined, overlaps among AS, intestinal dysplasia, and acquired von Willebrand's syndrome is thought to result in GI bleeding. Proper repair of the aortic valve can result in significant improvement of GI bleeding and its recurrence. Herein, we are reporting this rare case, in which a patient with moderate AS on echocardiogram presents with recurrent GI bleeding from multiple IA in the setting of elevated factor VIII levels, to propose a theory that angiodysplasia could potentially develop due to intermittent, recurrent low-grade obstruction of submucosal veins at the level of the muscularis propria secondary to venous thrombosis related to elevated factor VIII levels.

Esophagogastroduodenoscopy (EGD) is one of the forefronts of minimally invasive modalities with excellent safety records and tremendous capability but despite its accolades and functions, there are still very rare complications including air embolism. It is a life-threatening condition that could lead to a significant increase in morbidity and mortality. However, there are limited data for incidence of air embolism in association with gastrointestinal endoscopy. Diagnosis of air embolism after or during gastrointestinal endoscopy might be a difficult task due to overlapping presentations with anesthesia effects on the cardiopulmonary and the neurological systems, as a result, there should be increased awareness allowing clinicians to quickly rule out air embolism in patient with altered mental status or cardiopulmonary changes after or during gastrointestinal endoscopy. Herein, we report a unique case of cerebral air embolism after EGD in a 79-year-old female patient. In addition, we also performed a systematic review of cases based on PRISMA guideline, with the aim to investigate the demographics and clinical outcomes associated with this complication. This systematic review of cases hopes to increase the awareness about this rare entity. J Med Cases. 2021;12(3):119-125 doi: https://doi.org/10.14740/jmc3639

Spontaneous coronary artery dissection (SCAD) is a grave medical condition that is defined as a separation of the coronary artery wall layer. This presentation is rare in males and can be triggered by cardio-circulatory stress, such as exercise and emotional stress. Sexual intercourse is considered potent cardiovascular stress that can be strenuous and cause rapid and significant changes in the heart rate and blood pressure which can predispose SCAD. Herein, we are reporting a very rare case of a 41-year-old male gentleman who presented with SCAD after vigorous sexual intercourse. We are reporting this case to encourage physicians to educate their patients on the topic.

Thyrotoxicosis manifests when excess levels of thyroid hormone act on different tissues throughout the body. Excess hormone levels can be related to endogenous production or exogenous ingestion and can present differently in patients. It has been theorized that high levels of thyroxine can irritate the neuroanatomical hiccup center leading to persistent hiccups. Although extremely rare, physicians should be aware of this entity to allow for proper diagnosis and management. Here, we discuss a rare case of thyrotoxicosis after an epidural steroid injection presenting with intractable hiccups.

Hypothermia defined as a core body temperature less than 35°C causes hundreds of deaths annually in the United States. It can occur in a variety of clinical settings, including environmental exposure, shock, infection, metabolic disorders, alcohol, or drug toxicity, and malnutrition. This condition can affect many different organ systems and may lead to serious complications including cardiac arrhythmia. Hypothermia is extremely rare in people living with HIV but can be seen in severely malnourished patients or those who are not receiving antiretroviral therapy (ART). It is a life-threatening situation that should be treated aggressively. To the best of our knowledge, there are only a few cases that have been reported for people living with HIV presenting with hypothermia and sinus bradycardia. Herein, we are reporting a very rare case of people living with AIDS who presented with hypothermia complicated by sinus bradycardia. In addition, we also performed a systematic review of cases based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline, to investigate the clinical characteristics and outcomes associated with this rare complication. This systematic review of cases hopefully can increase the awareness of this rare entity and help improve its outcome.

Objective The aim of the study is to evaluate the clinical and radiographic outcomes for patients undergoing posterior lumbar interbody fusion in the treatment of lumbar spine infection. Patients and methods This retrospective study included 16 patients (10 men and six women); their mean age was 55.0±8.61 years, presented with lumbar infection treated surgically through posterior approach after failure of conservative treatment. Registration Number:- Ortho-surg._4Med.Research_PED.Def._0000004. All patients underwent clinical assessment, laboratory investigations included erythrocyte sedimentation rate in the first hour, white blood cell and C-reactive protein and radiological evaluation included conventional radiographs, computed tomographic scan, and MRI. Pain and disability scores were collected preoperatively and postoperatively including back and bilateral leg pain visual analog scale (VAS) scores. In 10 patients, the lesion was located in a single level, whereas in six patients two levels were affected. The surgical maneuver included posterior instrumentation, disc space debridement, and grafting. The mean follow-up period was 31.50±4.23 months. All patients agreed to be included in this study. Results There were no instances of intraoperative complications or delayed complications requiring subsequent interventions. Patients demonstrated statistically significant reductions in the back and leg pain VAS. The average intraoperative time consumed for the whole surgery was 156 min; the average blood loss for this procedure was 812 ml. The mean postoperative hospital stay was 4.6 days. All patients showed improved VAS. Fifteen patients out of 16 have solid fusion with a fusion rate of 93.75±2.5%. The average postoperative kyphosis decreased from 15 to 8. Conclusion This study demonstrated that single-stage debridement and instrumentation using the posterior approach (posterior lumbar interbody fusion) appears to be a safe approach in treating lumbar spine infections with no infection recurrence. Pain, neurological deficits, and spinal deformity are likely to improve after surgery.