Saint Agnes Medical Center

Background: Parenteral nutrition (PN) is a life-sustaining therapy essential for patients who are unable to meet their nutritional needs enterally. However, individualized PN formulations impose substantial economic burdens on healthcare systems. This study aims to quantify the cost of individualized PN bags across different patient populations and identify key cost drivers to inform cost-effective clinical practice and policy development. Methods: A retrospective cohort study was conducted at King Fahad Medical City, Riyadh, Saudi Arabia, analyzing 900 unique patient-specific PN orders between February 2023 and August 2023. Patients were stratified into three groups: adults (≥18 years), pediatrics (1 month to 17 years), and neonates (<1 month), with 300 unique patients per group. The cost assessment included macronutrients, micronutrients, consumables, equipment, and personnel time, all measured using a standardized work sampling methodology. Descriptive statistics characterized demographic and clinical profiles. One-way ANOVA was used to compare costs across groups, and multivariate linear regression identified significant cost predictors, with log-transformation applied to address the skewness in the cost data. Results: Mean cost per PN bag varied significantly among patient groups (ANOVA, p < 0.001): adults 517.1 ± 274 SAR, pediatrics 383.2 ± 86.75 SAR, and neonates 243.14 ± 98 SAR. We found that PN volume, lipid dose, and the number of additives were the primary modifiable drivers of PN cost. Multivariate regression analysis identified PN volume (β = 0.182, p < 0.001), lipid dose (β = 0.145, p = 0.002), and number of additives (β = 0.098, p = 0.028) as significant predictors of cost, explaining 91.2% of the cost variance (R2 = 0.912). Consumables contributed 18-22% of total costs across groups. Pediatric patients demonstrated markedly longer therapy duration (median 98 days, IQR 65-142) compared to adults (median 18 days, IQR 8-35) and neonates (median 24 days, IQR 12-42). Conclusions: This study provides the first stratified, real-world cost benchmarks for individualized PN in a Saudi tertiary-care setting and quantifies actionable cost drivers. Actionable implications include standardizing stable-patient procedures, implementing pharmacist-led appropriateness screening, and earlier transition to enteral nutrition to reduce costs while maintaining quality of care. Future research should evaluate the cost-effectiveness of standardized versus individualized formulations and investigate the relationship between cost variations and clinical outcomes.

The purpose of this systematic review was to evaluate the association between the timing of solid food introduction during infancy and the risk of childhood obesity. The review specifically examined whether early introduction (before four months of age) is linked with increased risk of overweight or obesity in childhood. We conducted a systematic search of five major databases (PubMed/MEDLINE, Embase, Web of Science, Cochrane Library, and Google Scholar) from inception to January 15, 2025. Eligible studies included observational cohort, cross-sectional, quasi-experimental, and case-control studies that assessed the relationship between the timing of solid food introduction and childhood obesity outcomes. Two independent reviewers screened articles, extracted data, and assessed study quality using appropriate tools (ROBINS-I tool (Risk Of Bias In Non-randomized Studies of Interventions), AXIS, or the Newcastle-Ottawa Scale (NOS). Due to heterogeneity in study design, population, and outcome definitions, a narrative synthesis was conducted instead of meta-analysis. Seventeen studies met the inclusion criteria out of 1,402 screened records. Most studies found that the introduction of solid foods before four months of age was associated with increased risk of childhood obesity or higher BMI z-scores. This association was more prominent in formula-fed infants. However, variation in study design, exposure classification, and measurement outcomes limited comparability. Risk of bias across studies ranged from moderate to serious, primarily due to confounding and reliance on parental recall. Early introduction of solid foods (before four months) appears to be associated with increased childhood obesity risk, particularly in the absence of breastfeeding. Nevertheless, due to variability and methodological limitations across studies, findings should be interpreted with caution. Further high-quality prospective studies using standardized outcome measures are warranted. The review protocol is registered in PROSPERO (CRD42025640375).

The development of a staple line or anastomotic leak after sleeve gastrectomy (SG) or gastric bypass (RYGB) continues to be one of the most feared complications after bariatric surgery. Such leaks do not only affect the immediate management but are also associated with a significant increase in morbidity and mortality. Using the data from the MBSAQIP database, we carried out a multivariate analysis and identified the most common risk factors for a leak after a primary bariatric surgery. Using the odds ratio (OR) of those factors, a risk index was developed, and a subsequent analysis was performed upon the index itself to determine the risk of a leak according to the number of points. Data from 193,847 patients was analyzed, 140,605 had a SG (72.5%), and 53,242 had a RYGB (27.5%). A leak was present in 190 patients (0.1%) after SG and in 113 (0.2%) after RYGB. Statistically significant risk factors included: albumin < 3g/dL (OR 3.196), previous foregut surgery (OR 2.827), preoperative therapeutic anticoagulation (OR 1.874), smoking (OR 1.776), hypertension (OR 1.404), sleep apnea (OR 1.322), and bypass surgery (OR 1.487). The risk of leak according to the number of points: 1 (OR 1.469), 2 (OR 2.066), 3 (OR 3.655), 4 (OR 3.609), 5 (OR 3.772), 6 (OR 4.075), 7 (OR 22.278). As expected, the incremental number of factors increases exponentially the risk of a leak. Hypoalbuminemia, smoking, therapeutic anticoagulation and history of foregut surgery are the mostsignificant risk factors. This score allows us to estimate more precisely the risk of a leak.

Abstract Introduction: Shrinking lung syndrome (SLS) is a rare complication of systemic autoimmune disease – most notably in patients with systemic lupus erythematosus (SLE) [1]. Reduced lung volumes and a restrictive deficit on lung function testing are typical. It is a diagnosis of exclusion. The etiology remains unknown. We describe a case series of SLS associated with connective tissue diseases (CTD) Case Presentation: Key patient demographics and Clinical characteristics are illustrated in Table 1. Case 1: A 63-year-old female with rheumatoid arthritis (RA), and systemic lupus erythematosus (SLE) was evaluated for dyspnea. She had episodic chest pressure with associated chronic dry cough. Pulmonary function tests (PFTs) showed severe restrictive lung disease and very severe diffusion impairment. Chest x-ray showed chronic bibasilar linear atelectasis. CT Chest confirmed bibasilar atelectasis, and bronchiectasis in the mid to lower lungs with no signs of pulmonary fibrosis. Case 2: A 36-year-old female with chronic mixed connective tissue disease (MCTD) for 17 years was evaluated for chronic dyspnea. PFTs over time revealed progressive restrictive lung disease patterns. HRCT of the chest showed apical minimal scarring bilaterally, and patchy paroxysmal bronchiectasis, and no signs of ILD. Case 3: A 46-year-old female with chronic SLE, Sjogren syndrome, RA for 13 years was evaluated for chronic dyspnea, cough, and bendopnea. PFTs showed a severe chronic restrictive lung disease. HRCT chest showed mild bibasilar atelectasis, no ILD, and small lung volumes. She demonstrated a dramatic reduction in lung function over the last 2 years. Conclusion: Shrinking lung syndrome is a rare manifestation of an autoimmune disease that causes Restrictive Lung disease without Interstitial Lung Disease. Very few cases are reported in the literature. SLS is a “Clinical” diagnosis of exclusion in patients with progressive shortness of breath and decreasing lung volumes. The mainstay of diagnosis remains chest imaging with repeated pulmonary function tests. Awareness may impact early recognition which may pave the way for longitudinal studies and Registries which may help understand pathobiology and prognosis of this rare complication.

Melanoma is a malignant disorder of the skin that originates from melanocytes. It is the most aggressive of the skin malignancies. This case study presents a unique case of a 52-year-old male gardener with melanoma on the plantar side of his foot, which progressed to a large ulcer. Delayed care, attributed to insurance mistakes and language barriers, allowed for advancing the patient's condition, highlighting the detrimental impact of healthcare barriers on patient outcomes. The case emphasizes the urgent need for simplified and efficient healthcare processes and access to timely intervention. Addressing systemic disparities and implementing culturally competent care practices are necessary to provide equitable access to healthcare, reduce disease progression, and improve patient outcomes.

Barrett's esophagus (BE) remains a significant precursor to esophageal adenocarcinoma, requiring accurate and efficient diagnosis and management. The increasing application of machine learning (ML) technologies presents a transformative opportunity for diagnosing and treating BE. This systematic review evaluates the effectiveness and accuracy of machine learning technologies in BE diagnosis and management by conducting a comprehensive search across PubMed, Scopus, and Web of Science databases up to the year 2023. The studies were organized into five categories: computer-aided systems, natural language processing and text-based systems, deep learning on histology and biopsy images, real-time and video analysis, and miscellaneous studies. Results indicate high sensitivity and specificity across machine learning applications. Specifically, computer-aided systems showed sensitivities ranging from 84% to 100% and specificities from 64% to 90.7%. Natural language processing and text-based systems achieved an accuracy as high as 98.7%. Deep learning techniques applied to histology and biopsy images displayed sensitivities up to greater than 90% and a specificity of 100%. Furthermore, real-time and video analysis technologies demonstrated high performance with assessment speeds of up to 48 frames per second (fps) and a mean average precision of 75.3%. Overall, the reviewed literature underscores the growing capability and efficiency of machine learning technologies in diagnosing and managing Barrett's esophagus, often outperforming traditional diagnostic methods. These findings highlight the promising future role of machine learning in enhancing clinical practice and improving patient care for Barrett's esophagus.

Point-of-care ultrasound (POCUS) is increasingly being adopted in the field of internal medicine, leading to the development of POCUS curricula in undergraduate and postgraduate medical education programs. Prominent internal medicine societies and organizations worldwide recognize the expanding utilization of POCUS by internal medicine physicians, emphasizing the need for practitioners to be aware of both its benefits and limitations. Despite the growing enthusiasm for POCUS, clinicians, particularly those with limited clinical experience, must be cautious regarding its inherent limitations and the potential impact on their clinical practice. This review aims to outline the limitations and potential drawbacks of POCUS for medical students, residents, and internists who wish to stay abreast of the escalating use of POCUS in internal medicine and have a desire, or have already commenced, to incorporate POCUS into their practice. Additionally, it provides recommendations for enhancing POCUS proficiency to mitigate these limitations.

Hepatopulmonary syndrome (HPS) is a rare complication of liver disease characterized by intrapulmonary vascular dilatations leading to arterial hypoxemia. We present the case of a 59-year-old female with a past medical history of bilateral breast cancer status post mastectomy who presented with progressive dyspnea on exertion and fatigue. A comprehensive diagnostic workup was conducted to exclude other cardiac, pulmonary, and systemic etiologies. She was diagnosed with autoimmune hepatitis along with chronic hepatitis C. Echocardiography revealed characteristic findings of intrapulmonary shunting characteristic of HPS. The patient showed improvement in pulmonary symptoms and oxygenation status following the initiation of steroid therapy. Although corticosteroids are not the definitive treatment for HPS, they were considered a supportive measure in this case. However, it is important to note that liver transplantation remains the definitive treatment for HPS. This case underscores the importance of echocardiography and the potential role of supportive measures, like corticosteroids, in managing HPS-related symptoms, particularly in patients with autoimmune hepatitis, as a bridging therapy while awaiting liver transplantation.