Maintenance Dose of Vitamin D: How Much Is Enough?

BACKGROUND: It is still unclear the ideal vitamin D dosage once the deficiency and insufficiency is treated. Once deficiency was corrected we prospectively treated patients with 2,000 IU of vitamin D3 to check whether this dosage is enough to keep them above the 30 ng/mL of 25-hydroxy-vitamin D (25[OH]D). METHODS: One hundred and thirty-five Saudi Arabian men and women treatment naïve for the vitamin D deficiency and insufficiency were part of this study. History and clinical examination were done to rule out any metabolic bone disease. Weight and height was taken to calculate the body mass index (BMI). Patients who were vitamin D deficient (≥30 ng/mL), a standard treatment of 50,000 IU of vitamin D3 weekly for 3 months, a blood test for the vitamin D levels at the end of 3 months, maintenance dose of 2,000 IU of vitamin D3 for 3 months and a third blood sample after 3 months. RESULTS: The data for 128 patients was available for analysis. The average age was 44.95±12.97 years with the mean BMI of 29.60±2.59 kg/m2. The baseline 25(OH)D level was 13.16±3.30 ng/mL. The increase in the level of 25(OH)D on 50,000 IU weekly was significant from 13.16±3.3 ng/mL to 36.97±4.67 ng/mL (P < 0.001) and then 2,000 IU daily for next 3 months, the level of 25(OH)D dropped top 20.38±5.42 ng/mL (P < 0.001). CONCLUSIONS: Our study indicates that the maintenance dose of 2,000 IU of vitamin D is not enough for patients to keep the 25(OH)D levels above 30 ng/mL.

Adnexal torsion in children: the role of family practice physicians and paediatricians

Objectives: Ovarian torsion [OT] is uncommon and is initially presented to paediatricians and family medicine physicians. The aim of this study is to assess the presentation, reasons for delayed diagnoses, outcomes, and recommended modalities for the early diagnosis of OT

Methods: A retrospective study was carried out in children

Results: Although the data of 15 patients were collected, only 11 medical records of patients with adnexal torsion were available for complete review. The average age of the participants in this study was 9.9 +/- 3.5 years. All patients complained of abdominal pain; whereas 8 [72.7%] patients presented with vomiting. The average duration of symptoms was 39.7 +/- 66 h. Each discipline of general practitioners and paediatricians attended four [36.3%] children. The average delay of presentation to the hospital was 52 +/- 68.78 h, and the average delay in diagnosis and final surgery after admission to the hospital was 9.1 +/- 2.7 h. Ultrasound and Doppler imaging were the only diagnostic tools used for pre-operative diagnoses

Conclusions: We believe that paediatricians and general practitioners are the first line of physicians to initially assess patients with OT, and they should have a high index of suspicion while managing patients with OT. They should perform early ultrasound and Doppler and refer patients to tertiary care centres where early intervention could save the patients' ovaries and future fertility

Uterine and tubal abnormalities in infertile Saudi Arabian women: a teaching hospital experience

Background and Objective: hysterosalpingography [HSG] is commonly used in the evaluation of the subfertile and infertile women. This study was undertaken to assimilate the findings observed during HSG in Saudi Arabian infertile patients and to find the most common pathology identified by the HSG

Patients and Methods: a retrospective analysis was conducted of subfertile and infertile patients who had undergone HSG between June 2007 and May 2012. Patients' demographic data were collected from the medical records of the King Fahd Hospital of the University, Al Khobar, Saudi Arabia. The data included age, years of marriage, menstrual history either regular or irregular, primary/secondary infertility, hormonal profile, previous infection or pelvic surgery, and diagnostic laparoscopy. Radiographic reports of HSG were collected from the IPAC system and analyzed for fimbrial findings, tubal patency, and cervical and uterine cavitary pathology. The data were entered in the database and analyzed using a t?test to compare means between the age, type of infertility, different pathologies and for all the parameters assessed. All tests were performed using Statistical Package for the Social Sciences, version 14.0, Chicago, Illinois, USA. A P < 0.05 was considered statistically significant with a confidence interval of 95%

Results: data from the medical records of 117 patients with an average age of 32.59 +/- 5.48 years were analyzed. Of this total, 48 [41%] had been diagnosed as having primary infertility. In 95 [81.2%] patients, there was an abnormality in the fallopian tubes and in 27 [23%] patients, there was an abnormality in the uterus. Patients with primary infertility were significantly younger [29.7 +/- 5.6 vs. 34.58 +/- 4.75; P < 0.001], and tubal and uterine pathology was more common [P < 0.08 and 0.01]

Conclusions: our review indicates that the most common pathology found through HSG in women presenting with infertility is tubal blockage

Effect of smoking on reproductive hormones and semen parameters of infertile Saudi Arabians

The purpose of this retrospective study is to look into the effect of smoking on semen and hormonal profile of Saudi Arabians attending infertility clinics.Medical record numbers of patients who attended infertility clinics and who underwent full assessment were identified rom Quadramed system and out-patient log books between January 2010 and December 2012. The standard protocol of the patients include full history, age, number of years of marriage personal habits of smoking, alcohol consumption, primary or secondary infertility. Standard laboratory tests which were performed, included, complete blood picture, random blood sugar, testosterone, follicle stimulation hormone, luteinizing hormone, prolactin level and semen analysis; volume, count, progressive motility and morphology. The data was entered in the database and analyzed. During the study period, 279 patients attended and infertility clinic and only 258 gave the sample for analysis. The average age of patients in the smoking group was 34.23 +/- 7.66 and in the nonsmokers 34.07 +/- 7.92 years. Primary infertility was more common in smokers versus nonsmokers P < 0.001 confidence interval [CI]< -44.0705, total serum testosterone level was lower 383.8 +/- 239.5 versus 422.5 +/- 139.2 ng/dL [0.009 CI< -9.9415], serum prolactin level was higher 18.68 +/- 13.28 versus 12.85 +/- 12.34 ng/mL [0.001 CI < 8.3794]. The average volume of the semen among the smokers was 2.8 +/- 1.35 mL and in nonsmokers it was 3.08 +/- 0.76 mL [P < 0.008 CI< -0.123]. The mean progressive motility in smokers was 31.5 +/- 23.1 compared to nonsmokers 40.05 +/- 25.43% [0.002 CI< -3.2962] and total sperm count was 119.52 +/- 114.12 and 139.71 +/- 104.82 million/mL [0.07 CI < 1.4657]. This study shows that the effect of smoking is dramatic reduction in the hormonal levels and semen parameters. It is recommended that smoking men undergoing fertility treatment should stop smoking to increase their chances of having offspring

Late presentation of ovarian torsion

Ovarian Torsion [OT] is a gynecological emergency that requires quick recognition and prompt treatment to save the ovary in females of reproductive age. When the torsion occurs in the right ovary, the symptoms may be confused with the appendix. In our patient, right sided ovarian torsion was suspected as appendicitis. After 17 hours of delay, instead of removal of the ovary, de-torsion and preservation of the ovary was done despite that part of the ovary and the fallopian tube were ischemic, edematous and appeared necrotic. On follow-up, signs, symptoms and ultrasound suggested that the ovary survived. This case highlights that delayed de-torsion of adnexa has a place in the management of adnexal torsion

Assessment of low vitamin D among Saudi Arabians. Did we overshoot the runway?

To compare the performance of 3 commonly used 25-hydroxyvitamin D [25-OHD] assays among a sample of the Saudi population. This cross-sectional study was carried out between January 2011 and December 2012 at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia. After informed consent, blood samples for measurement of 25-OHD level was extracted from 200 adults. The vitamin D level of each individual were determined using chemiluminescence immunoassay [CLIA], radio-immuno assay [RIA], and liquid chromatography-tandem mass spectrometry [LC-MS/MS] assay. Assays were also compared through commonly used cut-points for classification of vitamin D deficiency. Bias between assays was evaluated using Bland-Altman plots. The average age of patients was 45.7 +/- 16.1 years. A significant difference between the assays was found. The mean 25-OHD levels were highest for the LC-MS/MS [21.65 ng/mL, 95% CI 19.74-23.56], intermediate for RIA [16.607 ng/mL, 95% CI 14.87-18.32], and lowest for CLIA method [13.864 ng/mL, 95% CI 12.109-15.618]. Using 30 ng/mL as a cutoff value, only 6% was found to have normal levels of 25-OHD using CLIA, 9% using RIA, and 22% using LC-MS/MS. Levels of 25-OHD and the prevalence of vitamin D deficiency are dependent on the assay used. The reported high prevalence of hypovitaminosis D among the Saudi population can be partially explained by the use of assays that underestimate vitamin D levels

Hormonal, metabolic and clinical profile of Saudi women with polycystic ovary syndrome

Objective: To establish the hormonal, metabolic and clinical profile for Saudi women with polycystic ovary syndrome [PCOS]

Design: This is a prospective, cross-sectional study conducted at the University Hospital. All women were seen at the gynecology clinic. One hundred women aged between 18 and 45 years were included in the study; 50 women with polycystic ovary disease [PCOS] comprised the study group and 50 women without PCOS comprised the control group. The hormonal, metabolic and clinical profiles were assessed for both groups

Results: There are significantly higher levels of luteinizing hormone, prolactin, free testosterone dehydroepianosterone sulfate, 17 alpha-hydroxy progesterone and fasting insulin in the study group. There were no differences in the levels of total testosterone, estradiol and cortisone levels between both groups. The levels of follicular stimulating hormone and sex hormone binding globulin were significantly lower in the study group. There were no differences in the blood sugar level, cholesterol, triglycerides and low- and high-density lipoproteins. The womens' ages, body mass index, blood pressure, uterine dimensions and endometrial thickness were similar in both groups. The size of both ovaries was significantly greater in the study group. There were more follicles in the ovaries of the study group

Conclusion: Hormonal profile of Saudi women with PCOS was similar with what is already published in the medical literature. But, despite the fact that Saudi women with and without PCOS are overweight, they do not suffer from raised blood pressure and metabolic syndrome; this may be due to the fact that women included in this study were relatively young and the sample size might be too small to draw effective conclusions

An epidemiological analysis of the incidence of osteoporosis and osteoporosis-related fractures among the Saudi Arabian population

Osteoporosis is common in Saudi Arabia and the burden of management in an aging population will increase in coming decades. There is still no national policy nor consensus on screening for this silent disease. The objective of this analysis was to determine from the published data the prevalence of osteopenia and osteoporosis in Saudi Arabians, the prevalence of secondary osteoporosis, and the prevalence of osteoporosis-related fractures [ORF]. We also sought to determine the best age to begin and best modality for screening. Data Sources were MEDLINE [1966 to May 2011], EMBASE [1991 to May 2011], the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews [1952 to May 2011], and the Science Citation Index [1966 to May 2011], published data from the Saudi Medical Journal [1985-2011] and Annals of Saudi Medicine [1985-2011]. We selected English-language articles with at least 100 Saudi individuals. Two authors independently reviewed articles and abstracted data. The authors identified 36 potentially relevant articles, of which 24 met the inclusion criteria. Of 5160 healthy women 50 to 79 years of age [mean, SD: 56.8 [2.7]], 36.6% [6.6%] were osteopenic and 34.0% [8.5%] were osteoporotic. In three studies on males [n=822], the prevalence of osteopenia was 46.3% and osteoporosis 30.7%. Males had a significantly higher frequency of osteopenia in comparison to females [P= < .001 95% CI < -0.0333], The mean age of the patients with secondary osteoporosis was 37.4 [13.5, 18-57] years, with the osteoporosis in 46.4% and osteopenia in 34.1%. In 5 studies of ORF, the incidence of vertebral fractures was between 20%-24%.The currently available literature on Saudi Arabian population suggests that the ideal age for screening for low bone mass among the Saudi population should be earlier [55 years] than the >=65 years in Western countries. Both quatitative ultrasound and dual-energy x-ray absorptiometry could be used for screening. The relatively small number of studies on Saudi Arabians and the different machines used for diagnosis limited the authors ability make conclusions with surety.

Ectopic pregnancy. prevalence and risk factors in women attending a tertiary care hospital in Saudi Arabia

To find the prevalence, risk factors, and pattern of management of ectopic pregnancy [EP]. This retrospective study was conducted between January 2000 and December 2010 in all patients admitted to King Fahd Hospital of University, Al-Khobar, Kingdom of Saudi Arabia. Patients with suspected history of EP were collected. We collected the following data: age, parity, history of present pregnancy, any infertility treatment, diagnostic methods, and findings. The prevalence of EP was 1.13%. The average age was 30.42 +/- 6.9 years. One hundred and eight [41.7%] women had previous pregnancies compared to 151 [58.3%] [p=0.0002, 95% CI of difference: greater than or equal to -0.0811 compared to primigravida. Eighty-four women had spontaneous pregnancy post EP. Thirty-one were 28.9 +/- 6.9 and 53 women were of 39.59 +/- 5.9 years [p<0.001; 95% CI of difference greater than or equal to -11.8735]. Abdominal pain [n=251] and vaginal bleeding [n=240] was the most common presenting symptom. This 10-year analysis showed that incidence of EP in our region is within the range as reported in the literature. Those who are undergoing in vitro fertilization [IVF], ovulation induction [OI], previous EPs are significantly more prone to acquire EP second time around. Age was an important risk factor for developing EP in women who had borne children

Influence of vitamin D levels on bone mineral density and osteoporosis

The effects of vitamin D on bone mass remain to be understood. This study was conducted with the objective of evaluating the influence of 25-hydroxyvitamin D [25OHD] levels on bone mineral density [BMD] among Saudi nationals. Cross-sectional study carried out at university hospital from 1 February 2008 to 31 May 2008. Healthy Saudi men and women in the peak bone mass [PBM] age group and those aged >50 years were recruited from the outpatient department of King Fahd University Hospital, Al Khobar, Saudi Arabia, between February 1, 2008, and May 31, 2008. Patient age and sex were documented, and body mass index was calculated. Hematological, biochemical, and serum 25OHD tests were performed. BMD was determined by dual-energy x-ray absorptiometry of the upper femur and lumbar spine. Patients were divided into three groups, based on their 25OHD level. Data from 400 patients were analyzed. Among individuals with a normal 25OHD level, 50% of women and 7% of men in the PBM age group and 26.4% of women and 49.2% of men aged >50 years had low bone mass. In patients with 25OHD insufficiency, 84.2% of women and 88.9% of men in the PBM age group and 83.3% of women and 80% of men aged >50 years had low bone mass. Results for patients with 25OHD deficiency revealed that none of the men and women in the PBM age group or >50 years old had normal BMD. Significant positive correlations between 25OHD level and BMD and significant negative correlations with parathyroid hormone were shown in most of the groups. This study showed that the vitamin D level significantly influences BMD reading among Saudi individuals. Evaluation and treatment of hypovitaminosis D should be considered during management of low bone mass

Are We Missing Osteoporosis-Related Vertebral Fractures in Men?

STUDY DESIGN: Retrospective study. PURPOSE: To assess the prevalence of osteoporosis related spinal fractures among Saudi Arabian males. OVERVIEW OF LITERATURE: Vertebral fractures are the most common complication of osteoporosis and is the first sign in both sexes and only 25 to 30% of radiographically observed vertebral deformities are recognized. METHODS: We analyzed the chest radiographs of consecutive Saudi Arabian men > or = 50 years and who visited the emergency room of King Fahd University Hospital, Al Khobar, Saudi Arabia for a period of 12 months between November 1, 2007 and October 31, 2008. The site and type of fractures were classified as per the semi-quantitative technique. The other data retrieved from the medical records of patients included medications and clinical investigations for osteoporosis. RESULTS: Nine hundred seventy chest radiographs were performed during the study period and 876 radiographs could be analyzed. One hundred fifteen patients (13.1%) had 157 fractures. The mean age was 67.85 +/- 10.1 years. There was more than one fracture in 21 patients (18.2%). The majority of fractures (n = 102, 64.9%) were observed in thoracic spine. Seventy-one (45.2%) fractures were classified as mild, 54 (34.4%) were moderate and 32 (20.4%) were severe. For 26 (22.6%) patients, the report of the radiologist highlighted the fracture. CONCLUSIONS: Saudi Arabian males with osteoporosis continue to be missed despite the high prevalence osteoporosis leading to vertebral fractures. We believe it is important for physicians to identify vertebral fractures early and treat then appropriately before an extremity fracture occurs with high mortality.

there a relationship between body mass index and serum vitamin D levels?

To evaluate the relationship between vitamin D level and body mass index [BMI] among Saudi Arabian citizens. Four hundred healthy individuals aged >/= 25 years [200 males and 200 females] were included in this cross-sectional study. Subjects were recruited in the period between 1st February 2008 and 31st May 2008 from the medical staff and employees of King Fahd Hospital of the University, Al-Khobar, Kingdom of Saudi Arabia, and from patients attending the endocrinology, orthopedic, and infertility clinics at the same hospital. Clinical evaluation was carried out, and BMI was calculated. Serum 25 hydroxy vitamin D [25OHD], in addition to serum parathyroid hormone levels and calcium chemistry were measured for all subjects. The mean age was 46.5 +/- 14.6 years for males, and 42.6 +/- 15.9 years for females [p=0.01]. Mean BMI was similar in both genders, and the difference in the level of serum 25OHD just reached statistical significance [p=0.04]. Male subjects with vitamin D deficiency were found to be older [p=0.03], and with higher BMI [p=0.01] compared to males with normal 25OHD. Although female subjects with hypovitaminosis D were also older than subjects with normal vitamin D level [p=0.01], BMI was significantly lower in females with vitamin D deficiency [p=0.001]. Obese males are at higher risk of having low 25OHD levels, while obesity in females appears to be protective against vitamin D deficiency in the population studied. We believe that obese male and thin female patients should be appropriately investigated, and treated for vitamin D deficiency

Osteoporosis prophylaxis in patients receiving chronic glucocorticoid therapy

Glucocorticoid-induced osteoporosis [GIOP] is the most common form of secondary osteoporosis, yet few patients receive proper measures to prevent its development. We retrospectively searched prescription records to determine if patients receiving oral prednisolone were receiving prophylaxis or treatment for osteopenia and osteoporosis. Patients who were prescribed > 7.5 milligrams of prednisolone for 6 months or longer during a 6 month period were identified through the prescription monitoring system. Demographic and clinical data were extracted from the patient records, and dual energy x-ray absorptiometry [DEXA] scans were retrieved, when available. Use of oral calcium, vitamin D and anti-resorptives was recorded. One hundred males and 65 females were receiving oral prednisolone for a mean [SD] duration of 40.4 [29.9] months in males and 41.2 [36.4] months in females. Twenty-one females [12.7%] and 5 [3%] males had bone mineral density measured by DEXA. Of those, 10 [47.6%] females and 3 [50%] males were osteoporotic and 11[52.4%] females and 2 [40%] males were osteopenic. Calcium and vitamin D were prescribed to the majority of patients [60% to 80%], but none were prescribed antiresorptive/anabolic therapy. Patients in this study were neither investigated properly nor treated according to the minimum recommendations for the management of GIOP. Physician awareness about the prevention and treatment of GIOP should be a priority for the local health care system

Influence of androgens on bone mass in young women with sickle cell anemia

To evaluate the relationship between the gender hormonal levels and bone mineral density in premenopausal women suffering with sickle cell disease. A cross-sectional study including consecutive female adult patients with sickle cell anemia attending the outpatient hematology/orthopaedic clinics, or admitted to King Fahd University Hospital, Al-Khobar, Saudi Arabia, between August 2006 and June 2007. Patient's age was documented, and body mass index was calculated. Blood was drawn for complete blood picture, biochemistry, and hormonal profile including total estradiol E2 and total testosterone Te. Bone mineral density BMD was measured for all patients using dual energy x-ray absorptiometry scan at the hip and lumbar spine. We analyzed the data of 51 patients with an average age of 26 +/- 3.1 years. Patients were divided into 2 groups group A and group B. Group A had normal BMD and group B with low BMD. Thirty-one [60.8%] were in group A and 20 [39.2%] were in group B. The E2 level was not statistically different between the 2 groups, while Te level was significantly lower in women with low BMD 38 +/- 11.8 versus 22.3 +/- 11.7 ng/dl, p<0.001. Our study indicates that in premenopausal female patients with sickle cell anemia, testosterone may play a role in the preservation of bone mass

25-Hydroxyvitamin D levels among healthy Saudi Arabian women

To assess the serum level of 25 hydroxyvitamin D 25OHD among healthy Saudi Arabian women living in the eastern province. A cross-sectional randomized study was conducted between February 1st 2008 and May 31st 2008 at the King Fahd University Hospital, Al-Khobar, Kingdom of Saudi Arabia in 200 Saudi women between 25-35 years group 1 and women of >/= 50 years group 2. Clinical examination, laboratory tests, a complete blood picture, serum calcium, phosphorous, alkaline phosphatase, parathormone, and the serum levels of 25OHD levels were carried out. Data on lifestyle, dietary, and demographic questionnaires were collected. Vitamin D was defined as deficient with serum level < 50 nmol/L, insufficient between 52-72 nmol/L, and normal as 75nmol/L. In group 1, 70% of women had normal 25OHD, and in women of group 2, 45% had normal levels of 25OHD. Alkaline phosphatase and parathormone levels were significantly higher in women with low vitamin D levels. Sun exposure and consumption of dairy products were minimal. Vitamin D deficiency among healthy young Saudi women of 25-35 years was 30% and 55% in women of >/= 50 years. This study indicates that hypovitaminosis D is common in young and postmenopausal women. Efforts are require to augment and encouraged women for adequate exposure to sunlight and increased intake of fortified vitamin D products to maintain skeletal health

outcome pf pregnancy in elderly primigravidas

To investigate the effect of advancing age of 35 years and more [elderly primigravida] on the outcome of pregnancy in nulliparous women and to compare the type of complications observed in this group of women to those in the age of 20-34 years. This was a retrospective analysis of 2517 primigravidas delivered at King Fahd Hospital of the University, Al-Khobar, Kingdom of Saudi Arabia between 1996-2000. All were consecutive patients. The data were collected from the records of the labor room and the medical records were screened for maternal age, antenatal complications, gestational age, birth-weight of the neonate, sex of the neonate and the Apgar score. Three-hundred and sixty-two nulliparous were below the age of 19 years; hence, excluded from the study group. Between age of 20-34 years [Group A] there were 1950 patients with the mean age of 24.79 years [range 20-34] and in women over the age of 35 years [Group B] there were 205 patients with the mean age of 38.72 years [range 35-48 years]. Group B had significantly less number of normal deliveries 59.9 compared to group A 81% with p value of <0.001. Diabetes mellitus was common in group B as compared to group A and was statistically significant at p value <0.001. The gestational age in group B was 36.06 weeks and in group A it was 38.84 weeks [p value was markedly significant at <0.001]. Women in group B had more deliveries by cesarean section [CS] 23.8% as in group A 12.6%, a significant p value <0.001. The Apgar score at 1 and 5 minutes was significant at p value <0.001 and <0.004. The birth-weight in group B was less compared to group A, p value of <0.002. Childbearing in elderly primigravidas does have higher rates of complications due to diseases such as diabetes mellitus and preeclamptic toxemia. They are liable to have more deliveries by CS than by other methods, in spite of lower gestational age and birth weight. The overall outcome however does not appear grim, as was once believed. This study suggests that women in the age group of >35 years should be informed of their pregnancy expectations and outcomes