The rapidly changing epidemiology of Staphylococcus aureus and evolution of strains with enhanced virulence is a significant issue in global healthcare. Hospital-associated methicillin-resistant S. aureus (HA-MRSA) lineages are being completely replaced by community-associated S. aureus (CA-MRSA) in many regions. Surveillance programs tracing the reservoirs and sources of infections are needed. Using molecular diagnostics, antibiograms, and patient demographics, we have examined the distributions of S. aureus in Ha’il hospitals. Out of 274 S. aureus isolates recovered from clinical specimens, 181 (66%, n = 181) were MRSA, some with HA-MRSA patterns across 26 antimicrobials with almost full resistances to all beta-lactams, while the majority were highly susceptible to all non-beta-lactams, indicating the CA-MRSA type. The rest of isolates (34%, n = 93) were methicillin-susceptible, penicillin-resistant MSSA lineages (90%). The MRSA in men was over 56% among total MRSA (n = 181) isolates and 37% of overall isolates (n = 102 of 274) compared to MSSA in total isolates (17.5%, n = 48), respectively. However, these were 28.4% (n = 78) and 12.4% (n = 34) for MRSA and MSSA infections in women, respectively. MRSA rates per age groups of 0–20, 21–50, and >50 years of age were 15% (n = 42), 17% (n = 48), and 32% (n = 89), respectively. However, MSSA in the same age groups were 13% (n = 35), 9% (n = 25), and 8% (n = 22). Interestingly, MRSA increased proportional to age, while MSSA concomitantly decreased, implying dominance of the latter ancestors early in life and then gradual replacement by MRSA. The dominance and seriousness of MRSA despite enormous efforts in place is potentially for the increased use of beta-lactams known to enhance virulence. The Intriguing prevalence of the CA-MRSA patterns in young otherwise healthy individuals replaced by MRSA later in seniors and the dominance of penicillin-resistant MSSA phenotypes imply three types of host- and age-specific evolutionary lineages. Thus, the decreasing MSSA trend by age with concomitant increase and sub-clonal differentiation into HA-MRSA in seniors and CA-MRSA in young and otherwise healthy patients strongly support the notion of subclinal emergences from a resident penicillin-resistant MSSA ancestor. Future vertical studies should focus on the surveillance of invasive CA-MRSA rates and phenotypes.

There is a plethora of data in the EEG literature on the characteristics of the most prominent component of interictal epileptiform discharges (IED), namely the negative (fast) phase. Surprisingly, however, little attention has been drawn to the after-coming slow wave (ASW), and its pathological as well as clinical significance. In this paper, we will address the significance of prominent (high amplitude) ASW, giving rise to a triphasic morphology of the IED (focal triphasic sharp waves and spikes—FTSW). We will discuss this EEG pattern with respect to its clinical, neurophysiological, and neuropathological significance. This investigation was conducted on a heterogeneous group of patients at KKH, Ha'il, KSA. Our data revealed that FTSW were rare EEG events occurring primarily in the first two decades of life. Ninety percent of the patients with FTSW had epilepsy, presenting clinically with generalized convulsive seizures, often without partial onset. The majority of these patients responded favorably to anticonvulsant monotherapy. We were surprised to find that half of the patients with FTSW had chronic and/or static CNS pathology, particularly congenital CNS anomalies. Even though more than one mechanism may be involved in the pathogenesis of FTSW, we believe a deeply seated pacemaker as the source of this EEG pattern is the most compelling theory. The presence of FTSW should alert clinicians to the possibility of an underlying chronic and/or static CNS pathology, in particular congenital CNS anomalies, underscoring the significance of neuroimaging in the work-up of this population. Moreover, it is conceivable that the prominent ASW may contribute to the interictal intellectual dysfunction of these patients, justifying aggressive anticonvulsant therapy.

A 32-year-old female, with a history of secondarily-generalized convulsive epilepsy, mental retardation, and a psychiatric illness, developed neuroleptic malignant syndrome while receiving carbamazepine and amitriptyline concurrently. We hypothesize that the addition of amitriptyline to carbamazepine caused a decrease in the serum level of carbamazepine, resulting in NMS. We conclude that combination therapy with carbamazepine and amitriptyline should be avoided in patients who are predisposed to NMS. The purpose of this paper is to warn physicians against combination therapy with carbamazepine and tricyclic antidepressants which may be conducive to neuroleptic malignant syndrome in susceptible patients.

Interictal epileptiform discharges (IEDs) with negative polarity have been extensively studied in the EEG literature. However, little attention has been drawn to IED with positive polarity [positive sharp waves (PSWs)]. In this paper, we discuss pathophysiological, neuroimaging, and clinical correlates of this pattern in a heterogeneous group of children and adults who demonstrated PSW in their scalp EEG. We prospectively reviewed the EEGs of 1,250 patients from a heterogeneous population over a period of 1 year. Thirty-one patients had PSW in their EEG. We documented EEG parameters as well as demographic, clinical, and neuroimaging data. Statistical analysis was performed to correlate the aforementioned data. The analysis showed that PSW is an epileptogenic pattern with localizing significance, occurring primarily in the younger age groups. Furthermore, there was a strong association of PSW with chronic and/or static CNS pathology, in particular, congenital CNS anomalies, often accompanied by psychomotor retardation. Patients with "multifocal'' PSW invariably exhibited severe intellectual and motor deficits associated consistently with a variety of congenital CNS insults. PSW is a rare and under-reported EEG abnormality which, similar to negative IED, signifies focal epileptogenecity. The presence of PSW should prompt neuroimaging studies to investigate an associated chronic/static CNS pathology, in particular, congenital CNS anomalies. This association is particularly strong when PSW is multifocal in which case patients present with severe intellectual and motor deficits.

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There exists a paucity of data in the EEG literature on characteristics of "atypical" interictal epileptiform discharges (IEDs), including sharp slow waves (SSWs). This article aims to address the clinical, neurophysiological, and neuropathological significance of SSW The EEGs of 920 patients at a tertiary-care facility were prospectively reviewed over a period of one year. Thirty-six patients had SSWs in their EEG. Of these, 6 patients were excluded because of inadequate clinical data. The clinical and neuroimaging data of the remaining 30 patients were then retrospectively collected and reviewed, and the findings were correlated. The data revealed that SSWs were rare and age-related EEG events occurring primarily in the first two decades of life. All patients with SSWs had documented epilepsy, presenting clinically with partial or generalized epilepsy. It is notable that one-third of the patients with SSWs had chronic or static central nervous system (CNS) pathology, particularly congenital CNS anomalies. Though more than one mechanism may be involved in the pathogenesis of SSWs, this research indicates that the most compelling theory is a deeply seated cortical generator giving rise to this EEG pattern. The presence of SSWs should alert clinicians to the presence of partial or generalized epilepsy or an underlying chronic or static CNS pathology, in particular congenital CNS anomalies, underscoring the significance of brain magnetic resonance imaging in the work-up of this population.

Context:Adrenocortical cancer (ACC) is rare but frequently fatal malignancy. Tumor extension into the inferior vena cava signifies an advanced stage (stage III) of the disease and is frequently associated with high risk of recurrence and short-term survival.Objective:To present the surgical and medical management of an unusual case of ACC with IVC invasion up to the right atrium. He has the longest reported tumor-free survival of such a situation. We also reviewed and summarized the literature of similar cases.Patient:We present a 15-year old boy who presented with an 11 cm ACC extending into the IVC up to the right atrium and causing the Budd Chiari syndrome. He had complete surgical excision under cardiopulmonary bypass of a large ACC followed by Mitotane adjunctive therapy for 5 years. He is alive and free of any clinical or radiological signs of recurrence 98 months after surgery. This is the longest tumor-free survival reported in the literature of similar cases.Conclusion:Significant invasion of the IVC up to the right atrium by ACC should not preclude surgery with the intent of complete resection. Cardiopulmonary bypass significantly aids this surgical procedure and Mitotane therapy should be instituted postoperatively. Long-term free-survival is possible in such a situation.Lessons:our patient and the literature review strongly suggest that complete surgical extirpation is the primary choice for patients with ACC invading the IVC, including those reaching the right atrium.

Sanjad-Sakati syndrome (SSS) was first described in the middle-east in children of consanguineous parents 1. it is a rare autosomal recessive disorder known also as middle-east syndrome or Richadson-Kirk syndrome or hypoparathyroidism-retardation-dysmorphism (HRd) syndrome 2. Children afflicted with this condition are born with intrauterine growth retardation, and present with hypocalcemic tetany or seizures due to hypoparathyroidism at an early stage in their lives 3. in this paper we report , for the first time, the presence of partial agenesis of corpus callosum in SSS. CASE REPORT A 13-year old Saudi male, a known case of SSS, came to the emergency room of King Khalid Hospital on Aug 11, 2011 with a chief complaint of persistent vomiting and fever of a two day duration. He had a history of oesophageal and urinary reflux, decreased appetite, and asthma. Birth history revealed that he was born at King Khalid Hospital 13 years earlier by spontaneous vaginal delivery. He had a low birth weight (1.5kg) and had repeated convulsions shortly after delivery that prompted his admission to the intensive care unit where he was treated with calcium which was later switched to alfa calcidol, given on a regular basis. His weight increased to 2.51kg in two months. developmental milestones were delayed in that he was unable to sit until three years-of-age, walk until six years-of-age, and talk until ten years-of-age. Family history revealed that parents were cousins. the patient has two siblings, a sister and a brother both of whom are in good health. General physical examination showed the patient to be shortstatured with facial dysmorphic features including a long narrow face, deep-set eyes, beaked nose, depressed nasal bridge, micrognathia, thin lips, low set and large floppy ears, small hands and feet. He also appeared dehydrated, restless and dyspneic. His weight was 9.8kg, height 80cm, and head circumference 40cm. the patient had hypotonia, poor motor coordination, delayed developmental milestones, feeding difficulties caused by gastric reflux, impairment of chewing, and impaired swallowing, along with a low perception of pain. this symptom complex was consistent with (SSS). the history was significant in that he was described as being aloof with a preference for socialization with adults rather than children. A brain magnetic resonance image (mRi) showed absence of the splenium and part of the isthmus (Figure) with no abnormalities of anterior pituitary, the ventricular system, or the