The Implication of Coronary Artery Calcium Testing for Cardiovascular Disease Prevention and Diabetes

Over the last two decades coronary artery calcium (CAC) scanning has emerged as a quick, safe, and inexpensive method to detect the presence of coronary atherosclerosis. Data from multiple studies has shown that compared to individuals who do not have any coronary calcifications, those with severe calcifications (i.e., CAC score >300) have a 10-fold increase in their risk of coronary heart disease events and cardiovascular disease. Conversely, those that have a CAC of 0 have a very low event rate (~0.1%/year), with data that now extends to 15 years in some studies. Thus, the most notable implication of identifying CAC in individuals who do not have known cardiovascular disease is that it allows targeting of more aggressive therapies to those who have the highest risk of having future events. Such identification of risk is especially important for individuals who are not on any therapies for coronary heart disease, or when intensification of treatment is being considered but has an uncertain role. This review will highlight some of the recent data on CAC testing, while focusing on the implications of those findings on patient management. The evolving role of CAC in patients with diabetes will also be highlighted.

Erratum: Correction of Figure. The Implication of Coronary Artery Calcium Testing for Cardiovascular Disease Prevention and Diabetes

We found an error in Fig. 5A in the review article.

Outcome of Early Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac Arrest Managed in Universiti Kebangsaan Malaysia Medical Centre

Out-of-hospital cardiac arrest (OHCA) patients require immediate cardiopulmonary resuscitation (CPR). Early initiation of CPR and defibrillation before arrival at Emergency Department (ED) increases the chance of survival from sudden cardiac arrest. The main objective of this study was to identify the factors that influenced the outcome of early cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest (OHCA) patients managed at the ED of Universiti Kebangsaan Malaysia Medical Centre (UKMMC). The second objective was to determine the incidence of CPR initiated by the public prior to ambulance arrival. The present study was a one-year cross-sectional study. The OHCA patients were identified from the ED resuscitation logbook. Patients’ medical records were used to obtain details of the resuscitation. Factors recorded included: aetiology of arrest, initiation of on-scene CPR, use of automated external defibrillators (AEDs), mode of transportation and the incidence of return of spontaneous circulation (ROSC) in the ED. Categorical data was analysed using chi-square and Fisher exact tests. Nine patients out of 98 had early CPR. Three patients achieved ROSC. Gender was significantly associated with ROSC (p-value=0.015). More patients who received early CPR achieved ROSC compared to those who received late CPR. The provision of early CPR and usage of AEDs by the public is still low. Female gender had a positive influence on ROSC. Efforts are required to increase the awareness and involvement of the public in initiating early CPR prior to the arrival of ambulance service.

Primary tuberculosis of palate

Primary tuberculosis (TB) of the hard palate is very rare. A 74-year-old man was presented with 6-month history of dysphagia along with an irregular mass in the hard and soft palate. Magnetic resonance imaging (MRI) revealed thickened and increased signal intensity within hard and soft palate. Tissue biopsy showed focal caseating granulomatous-like lesion and the histochemical staining using Ziehl–Neelsen stain for acid-fast bacilli was positive. Positive histochemical studies provided evidences that the hard palate mass was most likely due to TB. Thus, the patient was started on antituberculous therapy

Is universal sample processing methodology better than conventional techniques for detection of tuberculosis.

Background: The identification of infectious cases is a crucial first step for tuberculosis control programmes worldwide. It relies exclusively on the detection of acid‑fast bacilli in sputum by smear microscopy. Therefore, there is an urgent and definite need to improve the sensitivity of smear microscopy. Objective: The USP method was compared with the two most commonly used conventional methods of smear microscopy namely; direct smear microscopy and the microscopy by modified Petroff’s method. Materials and Methods: Two samples from each patient were taken from 197 patients of presumptive tuberculosis. One smear was made for direct Ziehl‑Neelsen staining and two smears were made after processing by two concentration methods i.e., modified Petroff’s and USP solution. LJ media were inoculated for culture after processing by both concentration methods. Results: Among 197 cases 93 were culture positive by either method. Out of 93 culture‑positive sample, 78.5% were direct smear positive, 89% were 4%NaOH smear positive and 96% were USP smear‑positive samples but difference in diagnostic accuracy of USP (96%) and modified Petroff method (93%) is not statistically significant (P > 0.01). Conclusion: The present study evaluated the smear microscopy by USP method with two conventional methods, direct microscopy and microscopy by modified Petroff’s method. The study concludes that although USP method is more sensitive than conventional methods, it is not feasible to include it in diagnosis of early tuberculosis within RNTCP.

pattern of medical errors and litigation against doctors in Saudi Arabia

Adverse events are frequent in clinical practice, but only a few studies in Saudi Arabia have addressed them. The current study was designed to review the lawsuits against healthcare professionals by analyzing records of the cases dealt with by the Medico-legal Committees [MLC] in various provinces in Saudi Arabia, in order to determine the pattern of medical errors and litigations in the country. A pre-designed data sheet was used to collect data from the records of the Medical Violation Committee [MVC] and the Medical Jurisprudence Committee [MJC]. The data sheets consisted of information on details of the cases, details on where the error had occurred, and details of the errors. The review of records revealed 642 cases, most of which were from hospitals run by the Ministry of Health [MOH]. The operating room was where most of the errors [20.4%] had occurred, followed by the emergency room [18.1%]. Surgery was at the top of the specialties [25.1%]. Most of the deaths occurred in surgery and obstetrics [about 25% for each], followed by other medical specialties [17%]. About half of the lawsuit cases studied [46.5%] involved patients belonging to a relatively young age group [20-50 years]. Most of the medical error litigations involved surgeons and obstetricians especially in MOH hospitals. The process of litigations and documentation need to be improved, and access to the records for research and education need to be made easier. In addition, there is a need for more prospective field studies

Temporal Myositis with Middle Fossa Epidural Abscess as the Complications of Acute Otitis Media.

Acute otitis media is an inflammatory process involving the mucoperiosteum of the middle ear cleft. The clinical spectrum can be extended from a self-limiting benign condition to a complicated disease with intracranial involvement. Intracranial and extracranial complications of acute otitis media is still occur in the modern antibiotic era and has potentially serious consequences with high mortality rate. We report a case of acute otitis media with temporal myositis and middle fossa epidural abscess which is rarely seen as the complications from the disease.

Student perspectives on a course on medical ethics in Saudi Arabia

Medical students face ethical issues as early as the first year of medical school. Teaching bioethics is challenging because medical students and some teachers make a distinction between hard science and so-called 'soft' ones like bioethics. Courses in ethics were taught in the first and third years at the College of Medicine at King Saud University, Riyadh, Saudi Arabia, at the time this study was conducted. The objective of this study was to determine the students' perspectives of the courses and their attitudes towards teaching ethics. Apredesigned, self-administered, piloted questionnairewas administered to all students in the third year. The questions covered the curriculum, themethods of instruction and the content of the course. The response rate to 327 questionnaires distributed was 77%. Most students were satisfied with the course and its timing [84%], but more than 85% considered that the method of instruction should be changed to case-based teaching. A majority [89%] agreed that ethical issues based on Islamic fiqh [jurisprudence] should continue to be discussed, and they wished to discuss issues related to the doctor-patient relationship and professionalism. The students' preferences for the topics to be covered were: brain death [76.8%], organ transplantation [72.4%], cosmetic surgery [68.8%], abortion [66.8%], terminal care [61.6%], reproduction [59.6%], doctors' rights [56.4%], end-of-life issues [56%] and medical errors [45%].The medical students were satisfied with the course and its content but were dissatisfied with the method of instruction. This was taken into consideration in subsequent years.

Spontaneous extrusion of migrated fish bone in the neck after 48 hours of ingestion.

Foreign body in the neck usually will present with acute symptom of odynophagia or dysphagia. Migration of these foreign bodies to the adjacent structures or to the external skin may occur as late complication especially if the initial workup missed to detect their presence. Mostly the migrated foreign bodies were the fish bone as it has sharp ends. Depending on the tract that it made, serious complications may occur. We present a case of migrating fish bone in the neck with spontaneous extrusion without any complication. The foreign body was ingested not more than 48 hours before the extrusion.

Factors affecting the progression of diabetic nephropathy and its complications: a single-center experience in Saudi Arabia

One out of five Saudi diabetics develops end-stage renal disease [ESRD]. Factors associated with progressive loss of renal function have not been extensively studied and reported in our community. We sought to evaluate the pattern and progression in glomerular filtration rate [GFR] and investigate the potential risk factors associated with progression to diabetic nephropathy [DN] among Saudi patients. Hospital-based retrospective analysis of type 2 diabetic patients seen between January 1989 and January 2004 at Security Forces Hospital and King Saud University in Riyadh, Saudi Arabia. DN was defined as persistent proteinuria assessed by urine dipstick [at least twice for at least two consecutive years and/or serum creatinine >130 micromol/L; and/or GFR <60 mL/min/1.73m[2]. Of 1952 files reviewed, 621 [31.8%] met the criteria for DN, and 294 [47%] were males. The mean [SD] age of the patients at baseline was 66.9 [11.4] years, and mean duration of diabetes was 15.4 [7.5] years. GFR deteriorated from a baseline value of 78.3 [30.3] mL/min/1.73m[2] to 45.1 [24.1] mL/min/1.73m[2] at the last visit, with a mean rate of decline in GFR of 3.3 mL/min/year. Progression of nephropathy was observed in 455 [73.3%] patients, with 250 [40.3%] patients doubling their first-hospital-visit serum creatinine level in a mean of 10.0 [6.0] years. At the end of the study, 1 6.5% of the cohort developed ESRD and were dialyzed. GFR >90 mL/min/1.73m[2] at the first hospital visit; duration of diabetes >10 years; persistent proteinuria; systolic blood pressure >130 mm Hg; and presence of retinopathy were significant markers associated with progression of nephropathy. Diabetic nephropathy tends to be progressive among Saudis, with GFR deteriorating at a rate of 3.3 mL/year and with a doubling of serum creatinine level in 40.3% of patients in 9.9 years

antibiotic prophylaxis in knee arthroscopy mandatory?

To determine the need of prophylactic antibiotics in knee arthroscopic procedures. Three thousand patients, who presented to our sport medicine clinic in The Royal Rehabilitation Center at King Hussein Medical Center between January 2002 and February 2004, were assessed. Patients who refused to be enrolled in the study, those who would need complex procedures as anterior cruciate ligament reconstruction or accompanied arthrotomy and those with predisposing factors to infection as diabetes mellitus, immune deficiency disorders and steroid therapy were excluded from the study. Patients were divided into two groups; patients in group A were given one gram 1[st] generation cephalosporins at the induction of anesthesia and patients in group B were kept without antibiotic prophylaxis. All surgeries were conducted under general anesthesia with tourniquet. The patients were followed at 1, 3, 7 days and 3, 6 months for signs of infection. Statistical analysis was performed using the student t- test. One hundred eighty patients were included in the study and divided into two groups with equal numbers. There were no significant differences between the two groups in terms of age, pathology detected in knees, surgical procedures performed and operative time. No infection was detected in both groups during follow up. No complications of antibiotic use were encountered. Our results are preliminary to an ongoing study but we can conclude that using antibiotic prophylaxis, as a routine, in operative knee arthroscopy is not mandatory. Antibiotic usage may increase cost and may lead to antibiotic complications. Antibiotic prophylaxis may have a role in complex knee arthroscopic procedures as anterior cruciate ligament reconstruction

Pharmacologic prophylaxis and treatment of venous thromboembolism after knee arthroplasty

The objective of this study was to evaluate the efficacy of unfractionated heparin, warfarin and low molecular weight heparins [LMWH] used for the prevention of venous thromboembolism in arthroplastic surgery of the knee joint. In this prospective study from August 2002 to November 2004, 60 patients were included and divided into three groups with equal numbers, with each group receiving different treatment protocol. Postoperatively, the occurrence of symptomatic deep vein thrombosis [DVT] or pulmonary embolism [PE] was recorded during the first 30 days after surgery and at a routine follow-up visit. A significantly lower prevalence of DVT and PE was found in patients using warfarin and LMWH as prophylaxis in comparison with patients using unfractionated heparin. Warfarin and low molecular weight heparins are more beneficial and effective than unfractionated heparin for DVT and PE prophylaxis in arthroplastic knee surgeries

Embryonic stem cells cultured in biodegradable scaffold repair infarcted myocardium in mice / 生理学报

Our previous findings demonstrated that directly injecting embryonic stem cells (ESCs) into ischemic region of the heart improved cardiac function in animals with experimental myocardial infarction (MI). Tissue engineering with stem cells may provide tissue creation and repair. This study was designed to investigate the effectiveness of grafting of ESC-seeded biodegradable patch on infarcted heart. MI in mice was induced by ligation of the left coronary artery. Mouse ESCs were seeded on polyglycolic-acid (PGA) material patches. Three days after culture, an ESC-seeded patch was transplanted on the surface of ischemic and peri-ischemic myocardium. Eight weeks after MI operation and patch transplantation, hemodynamics and cardiac function were evaluated in four (sham-operated, MI, MI + cell-free patch, and MI + ESC-patch) groups of mice. The blood pressure and left ventricular function were significantly reduced in the MI animals. Compared with MI alone and MI + cell-free patch groups, the animals received MI + ESC-seeded patches significantly improved blood pressure and ventricular function. The survival rate of the MI mice grafted with MI + ESC-seeded patches was markedly higher than that in MI alone or MI + cell-free patch animals. GFP-positive tissue was detected in infarcted area with grafting of ESC-seeded patch, which suggests the survivors of ESCs and possible myocardial regeneration. Our data demonstrate that grafting of ESC-seeded bioabsorbable patch can repair infarcted myocardium and improve cardiac function in MI mice. This novel approach of combining stem cells and biodegradable materials may provide a therapeutic modality for repairing injured heart.

Agenesis of gall bladder, A case report

Congenital absence of gall bladder is a rare anomaly, we report a case of agenesis of gall bladder in a 62-year-old female patient who presented with obstructive jaundice misdiagnosed as a gall bladder and common bile duct stones on a pre-operative ultrasound and computerized tomography. The diagnosis of absent gall bladder was confirmed during laparotomy by per-operative cholangiogram. The relative embryological development, diagnostic pitfalls, intra operative management, and therapeutic strategies are discussed

Plasma fibrinogen and its correlates in adult Saudi population

To determine plasma fibrinogen and its correlates in the adult Saudi population and to investigate hyperfibrinogenemia as a possible risk factor for cardiovascular diseases [CVD]. A cross-sectional survey was designed and carried out through multi-stage stratified cluster random sampling of every third house in 6 heterogeneously populated districts of Riyadh, Kingdom of Saudi Arabia, during the period 1999 to 2002. Demographic and clinical data of 2263 adult Saudi subjects, consisting of 1934 [85.5%] men and 329 [14.5%] women, was collected through a standard questionnaire. Body mass index [BMI], blood pressure [BP] and history of smoking were recorded. Plasma fibrinogen, total serum cholesterol, triglycerides, high density lipoproteins [HDL] and blood sugar were determined in fasting blood samples. The majority [84.6%] of the subjects were between 20-50 years of age. The mean plasma fibrinogen was 336 +/- 115 mg/dl, and was increasing with age both in men and women. The mean +/- SD fibrinogen in women [357 +/- 118 mg/dl] was significantly higher [p value of 0.03] than men [332 +/- 114 mg/dl]. Hyperfibrinogenemia [>400 mg/dl] was indicated in 554 [24.6%] of the total subjects. Among hyperfibrinogenemic Saudi adults, the prevalence of hypercholesterolemia was 14.3%, hypertriglyceridemia 24%, obesity 26.3%, systolic/diastolic hypertension 11.5% and 11% and hyperglycemia 26% [in women only]. A reciprocal relation was observed between HDL and plasm fibrinogen. Significant positive correlation was seen between fibrinogen and BMI, systolic and diastolic BP and total cholesterol. There was no significant difference in the distribution of plasma fibrinogen between smokers and non-smokers [p value of 0.864]. The difference in the magnitude of metabolic as well as modifiable CVD risk factors between smokers and non-smokers was not significant, except serum triglyceride which was significantly higher in smokers than non-smokers [p value of 0.020]. A significant positive correlation was observed between hyperfibrinogenemia and obesity, systolic/diastolic hypertension and hypercholesterolemia. Our results thus support the earlier reports that hyperfibrinogenemia is a potential CVD risk factor. Unlike other reports, we could not find any correlation between smoking and plasma fibrinogen in our studied subjects. The value of hyperfibrinogenemia as a definite risk factor for CVD has to be quantified in future case-control studies comparing its significance between CVD subjects and normal controls

Circumcision: a safe and adequate technique

Circumcision is a routine procedure in our community for all males for a religious purpose. The majority are done in the neonatal period. For the first time in Saudi literature we established in our hospital a criteria for adequate circumcision and recommended guidelines to achieve these criteria which proved to be effective in performing satisfactory circumcision. We modified the technique to achieve further ease in adjusting the appropriate preputal level of cut without fear in injuring the glans penis, which we found to be of concern to the junior practitioner, particularly in babies in the lower range of normal penile length. This modification was applied to the circumcision of 1188 male infants circumcised over a period of four years aiming at a safe, adequate, and easily applicable procedure even for junior staff to do with basic available instruments

Cloacal exstrophy: experience at King Abdulaziz University Hospital, Jeddah, Saudi Arabia

Cloacal exstrophy is one of the complex anomalies which challenge the pediatric surgeons infrequently. At King Abdulaziz University Hospital, Jeddah, we had the experience of managing four cases. The reconstruction was achieved in stages and involved gastrointestinal, urological, genital. and musculoskeletal systems. All the managed cases were raised as their original genotype. A fifth case died before any surgical intervention, due to a major cardiac congenital anomaly. The aim of the present study is to report such rare anomalies and to present our experience in their management

Prevalence of nutrition deficiency disorders among children in an Iraqi village in 1994

The method of clinical ascertainment is used in community survey done in an Iraqi village near Mosul. Al-Ghubah cross-sectional population survey is conducted in September 1994 among under five years children. The aim is to determine the nature and prevalence of nutrition deficiency disorders four years after the imposition of the inequitable blockade on the Iraqi people. A high prevalence of undernutrition in the village is indicated by two findings. The first is a prevalence rate of clinically overt Protein-Energy Malnutrition of 1.5% and a prevalence rate of clinically manifested nutrition deficiency disorders combined together of 6% suggesting a much higher prevalence of subclinical mild to moderate forms of undernutrition. The second finding of the survey which confirms the first, is the very high incidence of infectious diseases among the children. The monthly incidence of: diarrheal diseases is 31%; of Acute Respiratory Infection is 20%; and of intestinal parasitic infections is 6%. Six out of every ten children have a new spell of these infections every month. These rates are at least twice that are reported from surveys done before 1990 in the same geographical area