Objective: For the first time, we reported experiences with an intestinal rehabilitation unit (IRU) from a country without home parenteral nutrition (HPN). Methods:We included patients with a diagnosis of intestinal failure (IF) since the establishment of our IRU from February 2018 to February 2020. We further report on our protocols for management of enterocutaneous fistulas (ECFs), short-bowel syndrome (SBS), chronic intestinal pseudo-obstruction and motility disorders.Results: Among a total of 349 patients who have been admitted, 100 patients had IF and were included . Mean (SD) age of patients was 46.3 ± 16.1 years. Most common cause of IF was ECFs (32%), SBS (24%), and SBS + fistula (22%). Most common causes of SBS were mesenteric ischemia (63.3%) and repeated surgery (22.4%). Median (interquartile range [IQR]) duration of parenteral nutrition (PN) for patients was 32 (18-60) days. The most common reconstructive surgery performed was resection and anastomosis (75.4%), followed by serial transverse enteroplasty procedure (10.5%) and closure of ostoma (7%). Patients were hospitalized for a median (IQR) of 33 (17.5-61) days. Most common complications were sepsis (45%), catheter infections (43%), and catheter thrombosis (20%), respectively. At the final follow-up, 61% stopped receiving PN, 23% became candidates for transplantation, and 16% died. Conclusion:Considering that most countries lack facilities for HPN, by establishing IRUs using specific treatment protocols and autologous gastrointestinal reconstruction techniques will provide a means to manage patients with IF, thus decreasing death rates and number of patients who require intestinal transplantations due to IF.

Background Coronavirus disease 2019 (COVID-19) still is a global emergency. According to the studies, pregnant women are of the at risk populations and any underlying disease(s) might even worsen their condition. The aim of this study is reporting a complex case of immune thrombocytopenic purpura (ITP) during pregnancy who has been diagnosed with COVID-19 as well as suspicion of HELLP syndrome. Case presentation A 24-year-old woman with a platelet count of 6000/mL and resistance to conventional therapies was referred. A day after starting 0.5 g/day of methylprednisolone for her, fever and a decrease in SpO2 presented. According to the paraclinical investigations, COVID-19 was diagnosed and the conventional COVID-19 treatments started for her (the methylprednisolone pulse stopped). Due to the increased liver enzymes and low platelet count, with suspicion of HELLP syndrome, cesarean section surgery was performed which resulted in a healthy neonate. Then, the methylprednisolone pulse was restarted for and she developed an increase in the platelet count. Conclusion It is not clear how COVID-19 and pregnancy affected the patient’s condition and the underlying disease; however, it seems the delivery and/or restarting the methylprednisolone pulses caused improvement in her condition.

Scalp arteriovenous malformations (AVMs) are abnormal vascular lesions, which can be managed effectively and safely with surgical or endovascular approaches. Here, we discuss a case of scalp AVM malformation in a 25-year-old female, in which due to the proximity of the feeder artery to right orbit, surgical excision was preferred and the AVM was excised with an uneventful post-op course.

Aim To compare the success rate of vaginal misoprostol versus intravenous (IV) oxytocin in termination of pregnancy in the second trimester intrauterine fetal death (IUFD). Methods This was an open‐label randomized controlled study for 106 women with second trimester IUFD. Patients were randomly divided into two groups: women given vaginal misoprostol (400 mcg every 6 h up to 48 h) versus those given IV oxytocin (starting with 50 units up to a maximum of 300 units). When the first‐line treatment (as mentioned above) failed, treatment methods were replaced with each other. When the second‐line treatment failed, the patients underwent dilation and evacuation. Results The first‐line treatment yielded the successful rate of 88.7% versus 73.7% for misoprostol versus oxytocin, respectively (p = 0.047). Among those with first‐line treatment failure, the second‐line treatment yielded success rate of 85.7% versus 83.3% for misoprostol versus oxytocin (p = 0.891). The mean duration of induction to delivery in women with successful response to first‐line treatment was 28.72 and 20.55 h after initially receiving misoprostol versus oxytocin, respectively (p < 0.001). While during second‐line treatment, this mean interval was not significantly different among those with misoprostol versus oxytocin (p = 0.128). No severe adverse events were observed. Conclusion Vaginal misoprostol was associated with higher termination rate than oxytocin without adverse events when used as the first‐line treatment. Both methods yielded the same success rate when used as the second‐line treatment.

Introduction: To date, in the Middle East no center has yet to establish an intestinal rehabilitation unit specializing in care for patients with intestinal failure.In this study we report our experiences with an intestinal rehabilitation unit (IRU) in a country without home parenteral nutrition (HPN). Methods: Our IRU was first set up in February 2018. All patients diagnosed with intestinal failure (IF) up to February 2020 have been included in this report. Results: In total, 349 individuals referred to our IRU for treatment. One hundred individuals were diagnosed with IF, among which 68% of patients were males. The mean (SD) age of patients was 46.3 ± 16.1 years. In our series the most prevalent causes for IF included ECF (32%), SBS (24%, which included mesenteric ischemia and repeated surgery as the most common causes of SBS), SBS+fistula (22%), post-operative prolonged ileus (7%), advanced cancer (6%) and chronic intestinal pseudo obstruction (5%), respectively. The median (IQR) amount of days patients received parenteral nutrition (PN) was 32 (18, 60) days. Regarding autologous gastrointestinal reconstruction, resection and anastomosis was performed in 75.4% of patients, serial transverse enteroplasty procedure (STEP) was done in 10.5% and closure of ostoma was done in 7% of patients. In total, six patients had isolated ITxs and three had multivisceral transplantations. Median (IQR) hospitalization time and length of ICU stay were 33 (17.5, 61) and 3 (0, 5.6) days, respectively. Based on the Clavien-Dindo classification, 29%, 26%, 18%, 9% and 2% developed complications grades 1, 2, 3A, 4 and 5, respectively. Overall, 45% of patients developed sepsis, 43% developed catheter infections, 20% catheter thrombosis and 18% developed sludge or gall stones. During the study period, 61% became off PN, 23% of them became candidates for ITx and 16% died, respectively. Conclusion: Establishing an IRU and applying reconstruction techniques, especially in countries without facilities for HPN, will aid in the management of patients with IF and will decrease the number of deaths and number of candidates for ITx.