Demographic, Clinical, Radiological, and Surgical Outcome of Patients with Intestinal Tuberculosis: A Single-Center Retrospective Study

Saif Ghabisha,1 Faisal Ahmed,2 Abdullatif Mothanna Almohtadi,3,4 Khairalah Abdulkarem Alghazali,4,5 Mohamed Badheeb,6 Saleh Al-Wageeh1 1Department of General Surgery, School of Medicine, Ibb University, Ibb, Yemen; 2Department of Urology, School of Medicine, Ibb University, Ibb, Yemen; 3Department of Radiology, School of Medicine, Ibb University, Ibb, Yemen; 4Department of Radiology, Ibb Scan Center, Ibb, Yemen; 5Department of Medical Immunology and Microbiology, School of Medicine, Jiblah University for Medical and Health Sciences, Ibb, Yemen; 6Internal Medicine, Yale New-Haven Health/Bridgeport Hospital, Bridgeport, CT, USACorrespondence: Faisal Ahmed, Department of Urology, School of Medicine, Ibb University, Ibb, Yemen, Tel/Fax +9674428950, Email [email protected] Mohamed Badheeb, Internal Medicine, Yale New-Haven Health/Bridgeport Hospital, Bridgeport, CT, USA, Email [email protected]: Intestinal tuberculosis (iTB) represents a potentially underrecognized clinical entity with limited clinical and radiological differentiating features. This study aims to assess the patterns of iTB clinical and radiological findings, along with the treatment approaches and the overall outcome.Methods: This retrospective cross-sectional study included patients with histopathologically confirmed iTB who presented with acute abdomen and were surgically managed between September 2005 and October 2023. Clinical and sociodemographic variables, imaging features, surgical treatments, and overall outcomes were retrospectively analyzed.Results: 96 patients with iTB were included, with a mean age of 36.1 ± 11.5 years and a relatively proportionate gender distribution. Abdominal pain was the most common presenting symptom (45.8%). The radiological features varied by the modality. Plain imaging showed non-specific findings, while ultrasonography showed loculated ascites (25%), and lymphadenopathy (22%). In computed tomography scans, multi-segmental symmetric intestinal thickening (53.1%) was the most prevalent finding. The most commonly performed surgical procedure was adhesiolysis (29.2%), with the ileocecal junction being the most commonly involved structure (39.6%). Histopathological examination of all the tissue biopsies revealed epithelioid granulomas. Postoperative complications occurred in 19 patients (19.8%), with surgical site infection being the most common complication (10.4%).Conclusion: Intestinal obstruction is an underrecognized manifestation of tuberculosis, particularly in endemic regions. The non-specific clinical presentation, coupled with the limited utility of laboratory and radiological tests, often leads to delayed recognition and treatment. Maintaining a high index of suspicion is essential, especially in younger patients, inhabitants of endemic areas, or those with laboratory findings indicative of chronic inflammation. Prompt recognition is crucial to ensure the timely initiation of anti-tuberculosis therapy and to optimize patient outcomes through appropriate follow-up.Keywords: Abdominal tuberculosis, bowel obstruction, acute abdomen, exploratory laparotomy, Yeme

Assessing the Predictive Accuracy of the S.T.O.N.E. Score for Stone-Free Rates in Semirigid Pneumatic Ureteral Lithotripsy: Implications for Validation

Faisal Ahmed,1 Khaled Al-Kohlany,2 Khalil Al-Naggar,1 Ibrahim Alnadhari,3,4 Abdulfattah Yahya Altam,5 Mohamed Badheeb6 1Department of Urology, School of Medicine, Ibb University, Ibb, Yemen; 2Department of Urology, College of Medicine, Sana’a University, Sana’a, Yemen; 3Al Wakra Hospital, Hamad Medical Corporation, Al Wakra, Qatar; 4Department of Surgery, School of Medicine, Qatar University, Doha, Qatar; 5Department of General Surgery, School of Medicine, 21 September University, Sana’a, Yemen; 6Department of Internal Medicine, Yale New-Haven Health/Bridgeport Hospital, Bridgeport, CT, USACorrespondence: Faisal Ahmed, Department of Urology, School of Medicine, Ibb University, Ibb, Yemen, Email [email protected]: The lack of reliable predictive tools for outcomes following ureteral lithotripsy (ULT) presents significant challenges in clinical decision-making. This study evaluates the efficacy of the S.T.O.N.E. score—an assessment incorporating Size, Topography, Obstruction, Number, and Hounsfield units (HU)—in predicting the likelihood of achieving a stone-free rate (SFR) in patients undergoing semirigid pneumatic ULT.Methods: This retrospective analysis involved 266 patients with ureteral stones who underwent ULT at IBB University Hospitals from April 2021 to September 2023. The S.T.O.N.E. score was derived from preoperative CT scans, and a nomogram was created to predict SFR failure. Discrimination and calibration were assessed using the area under the receiver operating characteristic curve (AUC) and calibration curve, while decision curve analysis (DCA) evaluated clinical utility.Results: The cohort’s mean age was 47.7 ± 15 years, with a predominance of males (72.2%). The mean S.T.O.N.E. score was 7.8 ± 1.8. The overall SFR of 85.3% and residual stones were detected in 39 patients (14.7%). Multivariate analysis identified higher HU (AOR: 1.01; 95% CI: 1.00– 1.01; P < 0.001), proximal stone location (AOR: 15.13; 95% CI: 1.52– 51.13; P = 0.020), moderate (AOR: 34.23; 95% CI: 8.28– 141.45; P < 0.001) and severe hydronephrosis (AOR: 33.75; 95% CI: 4.55– 250.36; P = 0.0006), and larger stone size (AOR: 1.51; 95% CI: 1.30– 1.75; P < 0.0001) as significant predictors of SFR failure. The S.T.O.N.E. score effectively predicts SFR failure, with an optimal threshold of > 8 achieving 85.0% accuracy. The model demonstrated 72.0% sensitivity, 81.0% specificity, and strong calibration. DCA indicated clinical utility, differentiating between low- and high-risk patients based on their S.T.O.N.E. scores.Conclusion: The S.T.O.N.E. score is a valuable tool for predicting post-ULT SFR, aiding preoperative decision-making and potentially improving surgical outcomes by identifying high-risk patients. Further validation in diverse populations is needed to confirm its clinical utility.Plain Language Summary: Ureteral lithotripsy (ULT) is a procedure used to treat ureteral stones; however, predicting the success of this treatment remains challenging for urologists. This study evaluates the S.T.O.N.E. score, a tool designed to estimate a patient’s likelihood of achieving stone-free status following ULT by considering factors such as stone size and location. Researchers analyzed data from 266 patients who underwent ULT at IBB University Hospitals between April 2021 and September 2023. The findings indicate that the S.T.O.N.E. score effectively predicts the presence of residual stones post-treatment. These results suggest that the score may assist urologists in making more informed decisions prior to surgery, particularly for patients at elevated risk. However, further research is necessary to validate its applicability across diverse patient populations.Keywords: lithotripsy, nomograms, S.T.O.N.E. score, ureter, ureteroscopy, urolithiasis, stone free rat

Evaluating the Diagnostic Accuracy of the Alvarado Score and Abdominal Ultrasound for Acute Appendicitis: A Retrospective Single-Center Study

Saleh Al-wageeh,1 Qasem Abdulkarem Alyhari,1 Faisal Ahmed,2 Abdulfattah Altam,3 Gubran Alshehari,4 Mohamed Badheeb5 1Department of General Surgery, School of Medicine, Ibb University, Ibb, Yemen; 2Department of Urology, School of Medicine, Ibb University, Ibb, Yemen; 3Department of General Surgery, School of Medicine, 21 September University, Sana’a, Yemen; 4Student Research Committee, School of Medicine, Ibb University, Ibb, Yemen; 5Department of Internal Medicine, Yale New-Haven Health/Bridgeport Hospital, Bridgeport, CT, USACorrespondence: Faisal Ahmed, Department of Urology, School of Medicine, Ibb University of Medical Sciences, Ibb, Yemen, Email [email protected] Mohamed Badheeb, Internal Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT, USA, Email [email protected]: Acute appendicitis is a complex diagnosis that often requires both clinical and radiological evaluation. Significant variations in diagnostic approaches are evident among clinicians and healthcare institutions. While certain guidelines advocate for risk stratification based on clinical characteristics, others emphasize the importance of pre-operative imaging. This study seeks to explore the accuracy of the Alvarado Score and abdominal ultrasound (AUS) in diagnosing acute appendicitis.Methods: Suspected cases of appendicitis admitted to Al-Thora Hospital in Ibb, Yemen, from Jan 2021 to July 2022 were evaluated. The demographics, clinical, and laboratory data were collected and analyzed. This study assessed Alvarado scores (calculated based on clinical evaluation and laboratory data) and pre-operative AUS findings, correlating them with post-operative and histopathology findings. The Alvarado scores and AUS sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were assessed using the ROC curve.Results: Out of 1021 cases of acute abdomen, 171 patients were suspected of appendicitis. Using AUS along with the Alvarado score, appendicitis was presumed in 137 patients who underwent appendectomy. 130 (94.9%) patients had positive intraoperative and histopathology findings while 7 (5.1%) had negative findings. The Alvarado Score had a sensitivity and specificity of 94.62% and 87.80% at cutoffs of 6, respectively [Area under the curve (AUC): 0.985; 95% confidence interval (CI), 0.954 to 0.998; p < 0.0001]. Abdominal US showed a sensitivity of 98.46% and specificity of 82.93% (AUC:0.907; 95% CI, 0.853 to 0.946; p < 0.0001).Conclusion: Alvarado’s score and AUS exhibited high sensitivity and specificity in diagnosing acute appendicitis. The substantial accuracy and efficacy of both the Alvarado score and AUS support their utilization as primary investigative tools in resource-limited settings. This approach can help avoid unnecessary appendectomies and minimize the financial burden on patients.Plain Language Summary: Acute appendicitis poses a diagnostic challenge, with a high rate of false-positive cases identified post-operatively. Computed tomography has been recommended by several surgical societies; however, it is limited by unaffordability and unavailability. Herein, we utilized the Alvarado score along with abdominal ultrasound as an alternative accurate, and cost-effective diagnostic approach. In this study, the negative appendectomy rate was 5.1%. The sensitivity of abdominal ultrasound in detecting appendicitis was 98.5%, with a specificity of 82.9%. The positive predictive value, negative predictive value, and accuracy were determined to be 94.8%, 94.4%, and 94.7%, respectively. The mean Alvarado score was 6.9± 2.4, with a sensitivity and specificity of 97.81% and 97.06% at cutoffs of 6, respectively. The area under the curve values of the ROC curve for Alvarado’s and abdominal ultrasound were 0.985 (95% CI, 0.954 to 0.998) and (AUC:0.907; 95% CI, 0.853 to 0.946), which was statistically significant (p < 0.0001).Keywords: Acute appendicitis, Alvarado’s score, sensitivity, specificity, ultrasoun

Cancer Pattern among Adults in Najran, Saudi Arabia - 2014-2019

Background: Najran is one of the thirteen regions in Saudi Arabia, located in the southwest of the country with a recently established oncology center and cancer registry. This paper describes for the first time the incidence of cancer in this region which has a unique geographic and demographic attribute. Methodology: This is a retrospective descriptive study that included all adult (diagnosis age &gt;14 years) cancer patients captured by Najran regional cancer registry in the period of 2014 to 2019. Available data, including demographics, diagnosis, site of the tumor, and histopathology were analyzed. Pediatric malignancies were excluded. During the studied period, a regional registry was established and linked to the central Saudi Cancer Registry. All confirmed cancer cases in Najran were captured in this registry. Results: The Total number of records was 1600 diagnosed over a 6-year period (range, 200-330 per year). More females were reported (54.6%) than males (45.4%). The median age was 52 years (SD, ±19). The three most common cancers were breast (14.2 %), thyroid (11.8%), and Colorectal (8.4%). Among the females, breast (25.3%) was the most common cancer followed by thyroid (16.7%), and colorectal (7%); while in males, colorectal cancers (10.2%), hepatocellular carcinoma (6.7%), and leukemia (6.6) were the most common. Conclusions: Breast cancer in females and colorectal cancer in males were the most frequent types of solid malignancies in Najran, Saudi Arabia. Our study shows that the pattern of cancers bears some similarities with the national and Gulf data with some differences that warrant further exploration.</jats:p

Iatrogenic Ureteral and Colonic Injuries During Emergency Cesarean Section: A Lesson Learned from a Surgical Catastrophe &ndash; A Case Report

Faisal Ahmed,1 Saleh Al-Wageeh,2 Mohamed Badheeb,3 Abdulfattah Altam,4 Afaf Alsharif5 1Department of Urology, School of Medicine, Ibb University of Medical Sciences, Ibb, Yemen; 2Department of General Surgery, School of Medicine, Ibb University of Medical Sciences, Ibb, Yemen; 3Department of Internal Medicine, Faculty of Medicine, Hadhramout University, Hadhramout, Yemen; 4Department of General Surgery, School of Medicine, 21 September University, Sana’a, Yemen; 5Department of Gynecology, School of Medicine, Jeblah University for Medical and Health Sciences, Ibb, YemenCorrespondence: Faisal Ahmed, Department of Urology, School of Medicine, Ibb University of Medical Sciences, Ibb, Yemen, Tel/Fax +967 4428950, Email [email protected]: Iatrogenic concomitant ureteral and colonic injury in emergency cesarean section (C-section) is an exceedingly rare, yet, catastrophic complication and has not been reported to our knowledge.Case Report: A 30-year-old woman presented with decreased urination for 2 days after a C-section. Ultrasonography showed severe left hydronephrosis and moderate abdominal free fluid. A ureteroscopy revealed a total occlusion of the left ureter, and subsequently, a ureteroneocystostomy was performed. Two days later, the patient was complicated with abdominal distension that necessitated re-exploration. The exploration revealed colonic injury (rectosigmoid), peritonitis, endometritis, and ureteral anastomosis disruption. A colostomy, repair of colonic injury, hysterectomy, and ureterocutaneous diversion were performed. The patient’s hospital stay was complicated, with stomal retraction requiring operative revision and wound dehiscence, which was treated conservatively. After 6 months, the colostomy was closed, and the ureter was anastomosed via the Boari-flap procedure.Conclusion: Injuries to the urinary and gastrointestinal tracts are serious complications of a cesarean section; concurrent involvement is exceedingly rare; however, delayed recognition and intervention can worsen the prognosis.Keywords: case report, cesarean section, colon injury, iatrogenic, ureteral injur

External Fixation as a Primary and Definitive Treatment for Complex Tibial Diaphyseal Fractures: An Underutilized and Efficacious Approach

Ahmed Albushtra,1 Abdulsalam Hadi Mohsen,2 Khaled Ali Alnozaili,3 Faisal Ahmed,4 Younes Mohsen Ali Abdu Aljobahi,1 Fawaz Mohammed,1 Mohamed Badheeb5 1Department of Orthopedic, School of Medicine, Ibb University, Ibb, Yemen; 2Department of Orthopedic, School of Medicine, Aden University, Aden, Yemen; 3Department of Orthopedic, School of Medicine, 21 September University, Sana’a, Yemen; 4Department of Urology, School of Medicine, Ibb University, Ibb, Yemen; 5Department of Internal Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT, USACorrespondence: Faisal Ahmed, Department of Urology, School of Medicine, Ibb University, Ibb, Yemen, Tel/Fax +967 4428950, Email [email protected]: External fixation is one of the most often utilized treatment options for complicated tibial diaphyseal fractures (TDF). The purpose of this study was to assess the efficacy of unilateral external fixators as primary and definitive therapy for complex TDF in a resource-limited setting.Materials and Methods: A retrospective study between June 2016 and March 2021 included 110 subjects with TDF who were treated with an external fixator as definitive fixation in hospitals affiliated with Ibb University. The patient’s demographic characteristics, complications, and outcomes were gathered and analyzed. Factors associated with pin site infection were also investigated.Results: The mean age was 42.1 ± 10.1 years, with 92.7% being male. Rural residents accounted for 22.7%. Smoking and diabetes mellitus were present in 27.3% and 30.0%, respectively. General complications occurred in 12.0%, with pulmonary embolism being the most common at 4.5%. Orthopedic complications included pin-track infections in 27.3% (30) and osteomyelitis in 1.8% (2). Pin site infections required medical treatment in 21 cases and external fixator changes in five. Two cases each needed several debridements for osteomyelitis and soft tissue. Full union occurred in 79.1% (87) over 23.1 ± 3.2 weeks and final alignment in 97.3% (107) over 34.8 ± 4.8 weeks. Malunions occurred in 1.8% (2), and one case had hypertrophic nonunion. Factors like rural residency, smoking, diabetes, open fractures, worst fracture grade (Gustilo and Anderson type C), and general complications occurrence significantly correlated with pin site infection (all p-values < 0.05).Conclusion: A unilateral external fixator as a primary and definitive treatment is a viable, simple, and effective option for TDF with a high success rate even in a resource-limited setting. In this study, residents in rural areas, smoking, diabetes, open fracture, worst fracture grade, and general complication occurrence were associated with pin site infection occurrence.Keywords: external fixation, definitive treatment, tibial fractures, pin tract infectio