Accuracy of Classifying Lung Carcinoma Using Immunohistochemical Markers on Limited Biopsy Material: A Two-Center Study

Introduction Accurate classification of lung cancer into primary and metastatic carcinomas is critical for treatment approaches. Immunohistochemistry (IHC) has always been pivotal in unveiling the diverse cell differentiation lineages present in lung cancer by using specific biomarkers such as TTF1 and p63/p40, which closely reflect the relationship between genotype and phenotype.. Methods A retrospective cross-sectional study was conducted to evaluate 57 Tru-Cut biopsies over two years, from 2020-2022. Tumour morphology was evaluated, and IHC for TTF-1, Napsin A, CK-7, P-63, P-40, and CD-56 was performed in two steps. Results Of the lung cancer cases, 58.5% were adenocarcinoma (ADC), 24.5% were squamous cell carcinoma (SCC), 9.4% were small cell carcinoma, and 7.5% were poorly differentiated carcinoma. TTF1 stain had sensitivity and specificity of 78.9% and 50% in 33 cases of ADC, respectively, while CK7 and Napsin A had 100% sensitivity. P63 stain had 77% sensitivity and 50% specificity in 15 cases of SCC, while P-40 had 100% sensitivity. The CD56 stain was 100% sensitive in five cases of small cell carcinoma. Conclusion IHC staining on small lung biopsies allows accurate sub-classification of poorly differentiated lung cancers; however, there is still significant variability. Surgical resection specimens can be further classified due to architectural features that biopsies lack. Morphological findings would be beneficial in the development of an algorithm for sub-classifying lung carcinoma using a variety of markers.

The Association Between Medication Non-Adherence and Early and Late Readmission Rates for Patients with Acute Coronary Syndrome

Purpose

Unplanned hospital readmission forms costly, but preventable burdens on healthcare system. This study was designed to evaluate cardiovascular-related readmission rate after discharge of acute coronary syndrome (ACS) patients and its relationship with medication adherence at a university hospital, Saudi Arabia.

Methods

A total of 370 consecutive patients presenting with ACS were involved. The inclusion criteria were clinical and coronary angiography diagnostic data of ACS. Exclusion criteria included heart valve disease, myocarditis, hepatic disease, and history of acute infection during the previous two weeks. Patients were divided into index admission group (n = 291) and unplanned readmission group (n = 79). Readmission and medication adherence rates were evaluated during 1–30, 31–180, 181–365, and 366–548 days post-ACS discharge. Medication adherence was estimated with a (yes/no) questionnaire.

Results

The overall readmission rate was 21.4%; individual rates were 30.4%, 38.0%, 27.8%, and 3.8% and the overall medication adherence rate was 62.03%, while individual rates were 54.2%, 70.0%, 63.6%, and 33.3% during the four periods, respectively. There were strong correlations between medication non-adherence and readmission rates. Heart failure, ST-elevated myocardial infarction, unstable angina, cerebrovascular accident, and arrhythmia represented the top causes. Body mass index was higher in readmission group. There were significant correlations between smoking, hypertension, cerebrovascular accident, ischemic heart disease, previous stent, instent restenosis, and LDL-cholesterol as predictor factors and readmission rate.

Conclusion

The cardiovascular-related unplanned readmission rate post-ACS discharge was 21.4%, and medication non-adherence rate was 37.97%. There were strong correlations between them in the time frames from 1-month to 1.5-year post-discharge. The individual rates decreased by time, but the first month showed lower rates than the following 5 months and this indicated the role of factors other than medication non-adherence in readmission. The rates are generally consistent with the international levels but utilizing technology can further improve medication adherence and reduce readmission rates.

A Giant Hepatic Hemangioma Presenting With Bilateral Pulmonary Embolism: A Case Report

Hepatic hemangiomas are the most common benign tumors found in the liver. Herein, we present a case of a giant hepatic hemangioma (>4 cm) complicated by bilateral pulmonary embolism originating from the inferior vena cava thrombus with clinical and radiological features of portal hypertension. A 52-year-old woman presented to the emergency department of our institution with a history of blackouts. She underwent an extensive workup for potential causes of syncope, and a massive bilateral pulmonary embolism was detected. On examination, the patient was conscious, and her vital signs were within normal ranges. Abdominal examination revealed massive ascites and irregular nodular hepatomegaly without splenomegaly. Laboratory test results revealed normal liver function. The patient had elevated D-dimer levels. The serum-ascites albumin gradient was not elevated. Tumor marker levels were all within the normal range, and autoimmune profile results and test results for thrombophilia markers were negative. Abdominopelvic CT demonstrated hepatomegaly and a giant fungating chronic hepatic hemangioma occupying the right lobe along with an infrarenal inferior vena cava thrombus. The patient was discharged and prescribed a therapeutic dose of enoxaparin and diuretics. As the patient was not a candidate for resection due to the large hemangioma size and invasion of the liver tissue, she was referred to another center for a liver transplant. Hepatic hemangiomas are benign lesions and are usually managed conservatively since surgical intervention is controversial and is reserved for symptomatic or complicated cases. With an anatomically challenging lesion, enucleation/resection could not be achieved, and liver transplantation was the best achievable option.

Reactive Arthritis After COVID-19: A Case Report

A 43-year-old healthy male was diagnosed with symptomatic COVID-19. Soon after recovery, he experienced severe back pain, bilateral red eye, and a new penile lesion. He was diagnosed with reactive arthritis, given he presented with arthritis, conjunctivitis, and balanitis.

The patient was treated with nonsteroidal anti-inflammatory drugs (NSAIDs), a short course of systemic steroids, and a local steroid cream on the penile lesion, followed by a local antifungal cream for two months. The patient responded well to the treatment and returned to his usual life activities.

Preferences of the Saudi Population in Breaking Bad Medical News: A Regional Study

Objective

To explore the preference among the Saudi population regarding breaking bad news (BBN) for the participant cases and their relatives and to determine the associated sociodemographic factors.

Method

A cross-sectional study was conducted among patients and companions attending inpatient and outpatient clinics of a tertiary care hospital in Western Saudi Arabia from 15 Jan to 30 May 2015. A six-item scale was designed to assess preference regarding diagnosis disclosure in three hypothetical conditions including chronic disease, incurable disease, and cancer if the participant or a close relative is concerned, separately. A BBN preference score (BBN-PS) was computed (range=0-6), with a higher score indicating a greater preference to disclose the diagnosis. Eventual motivations for diagnosis disclosure or withholding were explored.

Result

Five hundred participants were included; 56.0% were females and 55.0% were aged between 18 and 25 years. Preference to be informed with one’s diagnosis varied between 81.8% for incurable disease and 94.2% for chronic disease with complications. Preference to inform a relative with their diagnosis ranged between 69.0% for incurable disease and 86.8% for chronic disease with complications. Preference for diagnosis withholding was lower among participants of the younger age category (38.2% vs 51.2% or higher, p=0.002), with higher education (42.4% vs 60.8%, p=0.001), and working or studying in the medical field (39.7% vs 51.9%, p=0.006), compared to their counterparts, respectively. The most common motivations toward diagnosis disclosure preference were to enable the concerned person participate in their therapeutic decision (36.4%) and cope with the disease (27.4%); while preference toward diagnosis withholding was most commonly motivated by apprehensions regarding the psychological and social impact of the diagnosis (61.6%).

Conclusion

A non-negligible proportion of individuals prefer concealing a diagnosis of cancer or incurable disease to a relative, with an inter-generational disparity showing a shift to diagnosis disclosure in the young generations. There is an unmet need for evidence-based protocols for BBN based on a comprehensive assessment of patients’ expectations and needs, considering their cultural and religious values as well as the specific sociodemographic and clinical factors.

Blood Levels of Glutamine and Nitrotyrosine in Patients with Chronic Viral Hepatitis

Purpose

Oxidative stress is involved in pathogenesis of chronic viral hepatitis. Glutamine is an antioxidant, but there is a controversy about its risk-benefits. Nitrotyrosine is an oxidative stress marker. This observational cross-sectional study was designed to compare blood levels of glutamine and nitrotyrosine in treated versus untreated chronic viral hepatitis patients.

Patients and Methods

Five groups (n = 250) were included: hepatitis B untreated (HBV), hepatitis C untreated (HCV), HBV treated (HBVT), and HCV treated (HCVT) groups plus a normal control group. Liver function tests and blood levels of glutamine, nitrotyrosine, viral loads, and HBsAg were measured.

Results

Blood levels of glutamine and nitrotyrosine in all patient groups significantly increased compared with normal controls with non-significant differences in-between. Both tests showed significant large correlations with HBV-DNA or HCV-RNA test positivity, high accuracies, and cutoff scores with high sensitivities and specificities. The viral loads and HBsAg levels were significantly lower in treated versus untreated groups. However, they poorly correlated with levels of glutamine and nitrotyrosine in all patient groups.

Conclusion

Blood levels of glutamine and nitrotyrosine significantly increased in treated and untreated chronic viral hepatitis B and C patients compared with normal controls. Both tests showed high accuracies and cutoff scores with high sensitivities and specificities. However, they did not differ significantly in treated versus untreated patients. To our knowledge, this is the first data showing elevation of glutamine and nitrotyrosine in treated and untreated chronic viral hepatitis. A prospective longitudinal study with repeated measurements of glutamine and nitrotyrosine is recommended to verify if they can predict response to treatment. Study of other oxidative stress markers is also advised to clarify if the elevated nitrotyrosine could be an oxidative stress marker in these patients, and whether the increased glutamine could act as an antioxidant or as a predictive agent for deleterious consequences.

Effect of sequential eradication therapy on serum osteoprotegerin levels in patients with Helicobacter pylori infection and co-existing inflammatory bowel disease

Objective

To investigate the effect of sequential Helicobacter pylori eradication therapy on serum osteoprotegerin levels in patients with H. pylori infection and co-existing inflammatory bowel disease (IBD).

Methods

Three groups of patients were involved in this observational cross-sectional study: IBD (n = 83), H. pylori infection (HP, n = 68), and H. pylori infection with co-existing IBD (HP + IBD, n = 52). These groups were compared with a normal control group (NC, n = 50). Serum osteoprotegerin, serum bone alkaline phosphatase (BALP), and fecal calprotectin (FC) levels were measured.

Results

Serum osteoprotegerin levels were significantly correlated with the simple endoscopic score for Crohn’s disease and Mayo score for ulcerative colitis. The receiver operating characteristic analysis of osteoprotegerin revealed high values for the area under the curve, sensitivity, and specificity. Discriminant analysis illustrated that osteoprotegerin levels significantly differentiated patients with IBD from healthy controls. Osteoprotegerin and FC levels distinguished the IBD and HP + IBD groups from the NC and HP groups.

Conclusions

Sequential eradication therapy did not affect serum osteoprotegerin levels in patients with H. pylori infection and co-existing IBD. Serum osteoprotegerin elevation might be a marker for IBD development in patients with past or current H. pylori infection.

The Effect of Male Physicians' Outfits on the General Population's Perception in Saudi Arabia

Overview

Successful medical care depends on the trust developed between a physician and his patient. Professionally dressed doctors are likely to achieve a higher level of trust from their patients than those with a non-professional appearance.For many years, the physician’s famous white coat has been the standard professional wear around the world.

Few studies in Saudi Arabia have been conducted to analyze what kind of physician outfits patients prefer and whether the choice of attire affects the patient’s level of trust. These studies were either done in a single health institute, or in few primary healthcare clinics in one city.

This study aims to analyze whether the type of clothing worn by a physician improves the level of trust between a patient and a doctor. Participants were asked about different styles of clothing, including Western business attire, traditional Saudi outfits, and surgical scrubs, and whether wearing the white coat was preferred. Moreover, we sought to establish if differences in age, gender, nationality, or educational background affected the responses.

Methods

This cross-sectional study was carried out in August and September 2018. Participants living in Saudi Arabia anonymously filled out an electronic questionnaire, distributed by social media, which measured the effect of male physicians’ outfits on the general population's perception in Saudi Arabia. Participants were shown photographs of possible dress styles for physicians. Data were collected on the participants’ demographics, their most and least preferred doctor’s outfits, and the effect of the physician’s attire on their level of trust.

Results

A total of 8231 participants were included in the survey: 53% males, 87.9% with university-level education or higher, and 93.5% of Saudi nationality; 76.1% of the participants responded “yes” saying that the outfit would have an effect on how a patient might receive medical advice and follow the doctor’s recommendations. The most preferred outfits chosen by the participants were surgical scrubs with a white coat (39.3%), followed by a Western shirt and tie with a white coat (30.3%). The least preferred outfit was the full (traditional) Saudi outfit with a white coat (25.4%), followed by a Western business suit without a white coat (23.2%). The choices of most and least preferred attire were found to be impacted by different demographic factors, such as age, gender, and nationality, but not the educational background.

Conclusion

Physicians practicing in Saudi Arabia should note that their attire will earn the patient’s trust and encourage compliance with advice or treatment. The most preferred outfits were surgical scrubs with a white coat and a Western shirt and tie worn with a white coat, whereas the least preferred ones were the traditional Saudi thobe, with and without shemagh or ghutra, and the Western business suit without a white coat.