prevalence and management strategies for peripheral artery disease associated with diabetes mellitus in the Arab world

A growing body of published literature has indicated that diabetes mellitus [DM] is a global health epidemic. There is a staggering upsurge of the prevalence of DM and its associated complications across the globe. Peripheral artery disease [PAD] is a devastating long-term complication of DM. Although there is an exponential increase in the prevalence of diabetes in the Arab world, there are few reports that contain scant data that do not reflect the real magnitude of challenges to health-care agencies. Major risk factors for PAD include smoking, type 2 DM [T2DM], hypertension, hyperlipidaemia, hyperhomocysteinaemia, and advancing age. PAD is an agedependent disorder that is under-diagnosed, under-estimated, and sub-optimally treated. Diagnosing PAD is challenging in patients with DM because, despite the presence of severe tissue loss, it may remain asymptomatic because of associated neuropathy. PAD is considered to be a strong predictor of future cardiovascular events. The purpose of this review is to provide data regarding the existing prevalence of DM and diabetes-induced PAD with special focus on the Arab world. Subsequently, deep insight regarding the diagnostic modalities and management guidelines is provided. There is a dramatic rise in the prevalence of diabetes-induced PAD that leads to significant morbidity and a marked reduction in the quality of life. Early identification of individuals with risk factors can help to minimize the onset of PAD in patients with DM, thus preventing limb and life-threatening complications. This review argues for more nationally representative surveillance data in the Arab world regarding the impact of DM on PAD

Publish or perish mantra in the medical field: a systematic review of the reasons, consequences and remedies

Objectives: Generally, academic promotions, job retention, job mobility, and professional development of a medical faculty members are judged primarily by the growth in publication outputs. Universities and research institutions are more likely to recruit and promote those academics carrying voluminous resumes with larger number of published articles. This review elaborates the causes and consequences of the pressure to publish and the ways and means to cope with this paradigm

Methods: In 2015, database of Abstracts of Reviews of Effects, LISTA [EBSCO], Medline and Oxford University Library were searched for the English language full-text articles published during 2000-2015, by using MeSH terms "pressure to publish", "urge to publish", "research ethics", "plagiarism", "article retraction", "medical field". This search was further refined by selecting the articles in terms of relevancy and contents

Results: This research showed that some universities offer generous grants to researchers with a high h-index and with more publications in elite journals, which promise an enhanced prospect of citations and elevation in the scientific rankings of the funding institutions. This generates an involuntary obsession to publish with the primary intention to obtain promotions, high scientific rankings, and improved job security. This compelling pressure to publish results in widespread publication of non-significant research with a high index of plagiarism that eventually leads to an increased frequency of retractions

Conclusion: Research centers and academic institutions have an obligation to train their academics in sound scientific writing and to apprise them of the publication ethics and the grave consequences of plagiarism and research misconduct

Measuring the attitudes of healthcare faculty members towards interprofessional education in KSA

Objectives: Interprofessional Education [IPE], although well-understood in developed countries, is not uniformly perceived across developing countries. This study aimed to measure healthcare faculty attitudes towards IPE and to measure possible significant differences in demographic characteristics of faculty for their readiness to incorporate IPE in existing curricula

Methods: This simple-random sampling study was conducted by administering the Readiness for Interprofessional Learning Scale [RIPLS] to 200 randomly selected faculty members of health colleges of University of Dammam [UoD] and Taibah University [TU] KSA. The survey was conducted as a paper-based survey at UoD and online at TU

Results: The average score for all items [except one item] of the RIPLS were high [mean > 3.4]. There were signifi- cant gender differences on issues related to the role of IPE in promoting students' understanding of their own professional limitations [p < 0.05] and on the need for healthcare students to learn together [p < 0.10]. There were significant differences between faculty responses from UoD and TU with regard to their perceptions of IPE's role in fostering positive thinking about other healthcare professionals [p < 0.05] and their belief in the role of trust and respect among professions for successful outcomes [p < 0.10]. Comparisons of faculty attitudes of different age groups towards IPE showed significant differences [0.000

Conclusion: This study showed favourable attitudes of healthcare faculty from both universities towards IPE. These encouraging findings might provide an impetus for potential engagement of faculty of the Saudi health colleges in the delivery of IPE when implemented

mapping of preferred resources for surgical education: perceptions of surgical trainees at the Advanced International Minimally Invasive Surgery Academy [AIMS], Milan, Italy

Objectives: Surgical training courses provide the trainees with anatomical knowledge and manual dexterity. This study aimed to capture the learning styles and training preferences of participants attending a masterclass training centre. This data can facilitate the program directors in tailoring the course contents to enhance the learning environment

Methods: Between 2010 and 2013, a questionnaire was administered to all participants at the end of each course at the Advanced International Minimally Invasive Surgery Academy [AIMS] in Milan, Italy. The instrument explored the feedback of participants regarding their surgical experiences, learning needs and desired surgical educational resources in minimally invasive surgery

Results: Of 636 respondents, 606 [95%] performed some laparoscopic procedures at their workplaces. Of the respondents, 467 [73%] preferred 'direct experience in the operating room', 424 [66%] preferred 'tutoring with skilled colleague', and 275 [43%] wanted 'hands-on training on animals in their own countries'. Female respondents favoured national congresses as educational resources more than males, with mean ranks of 207.22 vs. 176.51, respectively [p 0.022]. The respondents serving hospitals preferred international congresses [mean rank 189.21] more than the respondents serving universities [mean rank 181.72] and private clinics [mean rank 127.45]

Conclusion: This study shows that surgical trainees prefer hands-on training in operating rooms, tutoring by skilled colleagues and short fellowships to learn and enhance their surgical skills. Surgical educators can focus on these preferred surgical educational resources to enhance students' acquisition of surgical skills

Small group teaching improves students' acquisition of knowledge and skills

To evaluate the effectiveness of small group teaching [SGT] in improving the undergraduate medical students' knowledge and skills. This study took place at the College of Medicine, Taibah University, Madina, Kingdom of Saudi Arabia between September 2011 and September 2012. Small group teaching was applied by the surgery department. In this prospective study, fifth year students were divided into groups of 8 students, and teaching strategies of SGT were applied. The marks in the clinical examinations of long case and objective structured clinical examination [OSCE] of the students with a traditional teaching cohort of 2010-2011 were compared to a SGT cohort of 2011- 2012. Data were analyzed by comparing the means, standard error, and standard deviation. One hundred and sixty-four students were incorporated, 82 students for each year [41 males and 41 females] in each group. The analysis showed a statistical significant difference in marks obtained by male and female students of both cohorts [p=0.000]. In the 2011-2012 group, male students' mean score was 43.1 +/- 2.99 which was higher than the 2010-2011 male students' [mean +/- SD: 38.7 +/- 2.81; p=0.000]. Similarly, the 2011-2012 female students attained a higher mean score than those in the 2010-2011 [39.8 +/- 4.0 and 35.6 +/- 3.88] [p=0.000]. Small group teaching is a valuable strategy in enhancing students' performance in the clinical settings. Small group teaching can be applied to other clinical disciplines of the medical curriculum for production of safe and clinically competent graduates

Clinicopathological pattern of malignant parotid gland tumors in Saudi Arabia

To report our experience of varied presentations and diverse histopathological spectrum of parotid gland malignancies. This retrospective analysis incorporated patients with histological evidence of malignant parotid tumors at King Khalid University Hospital, Riyadh, Saudi Arabia over a 20-year period from 1984 through 2004. The medical records of these patients were analyzed for their demographic characteristics, clinical features, operations performed, and pathological diversity. Thirty-two patients comprised this study group. There is a male preponderance over females with a ratio of 2.2:1 22 men and 10 women and mean age of 51.8 range 28-81 years. A painless lump was the most frequent clinical manifestation observed in 23 71.8% patients followed by facial nerve dysfunction in 14 43.7% patients. Parotidectomy was performed in 22 68.7% patients: 16 superficial and 6 total. A partial facial nerve sacrifice was undertaken in 14 43.7%, and total nerve sacrifice in 9 28.1% patients. Four 12.5% patients presented with cervical lymph node metastases necessitating radical neck dissection. Nine 28.1% patients had mucoepidermoid carcinoma, 8 25% adenoid cystic carcinoma, 6 18.7% adenocarcinoma, not otherwise specified, and 2 6.2% were reported to have carcinoma in pleomorphic adenoma. Twenty 62.5% specimens revealed high-grade aggressive lesions, and out of these, 19 59.3% patients presented with stage III/IV disease. Malignant parotid tumors are exceedingly rare, occurring at a relatively earlier age group with male preponderance, and invariably declare at a late clinical stage in our community. Histopathological features hallmark a locally advanced disease with an aggressive behavior

Higher prevalence in young population and rightward shift of colorectal carcinoma

To report the pattern, subsite distribution and histological features of colorectal cancer in a University Hospital in Riyadh. The study was carried out in King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia, where the medical records of patients diagnosed to have colorectal carcinoma were retrieved spanning a 5-year period from 1999 through 2004. The demographic data, primary location and extent of the lesion, and various pathologic characteristics were analyzed. Fifty-seven patients with colorectal carcinoma were included; 45 men and 12 women, age range 21-76 years [mean 44 years]. Thirty-six [63%] subjects were found to be younger than 40 years, whereas 33 [57.8%] cases had right sided and 24 [42.2%] left sided colon cancers. Eighteen [31.5%] patients presented with early [I, II] and 39 [68.5%] with late [III, IV] stage. Dukes B and C were reported in 53 [92.9%] patients and out of those, 30 cases presented with right sided colonic carcinoma. There is a profound rightward shift of colorectal carcinoma compounded with a rising incidence of advanced lesions in younger age group

Reappraisal of the management of cholelithiasis in diabetics

Recently, dramatic advances in research have elucidated the prognosis of gallstone disease and have permitted a more selective choice of persons for treatment based on symptom status and projected prognosis. Ultrasound- detected-incidental gallstones are infrequently clinically significant, but this finding has prompted the surgeons to have a liberal attitude towards the operative indications for cholelithiasis particularly after the advent of laparoscopy. At the same time, the management of gallstones in the diabetics still remains controversial. Early retrospective studies reported an alarmingly high incidence of gallstones in diabetics as compared with the general population and in view of profound morbidity and mortality rates observed in the diabetics, prophylactic cholecystectomy was generally recommended. However, recent evidence-based studies challenged this approach and concluded that prophylactic cholecystectomy is not justified in diabetic patients with asymptomatic gallstones. It is inferred that, as in the general population, asymptomatic cholelithiasis in diabetics should be managed expectantly and preemptive surgery should not be routinely performed. However, early laparoscopic cholecystectomy is preferred in cases of symptomatic cholelithiasis

Validity of leukocyte count to predict the severity of acute appendicitis

To ascertain whether white blood cell [WBC] count with differential analysis may predict severity of disease in acute appendicitis. We conducted this retrospective study on appendectomy patients from 1996 to 2001, at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia. We reviewed patient's age, gender, duration of symptoms, temperature on admission, WBC count including differential and the histological diagnosis of the appendicular specimen. We further analyzed the data of those patients found to have acute, gangrenous and perforated appendicitis to determine the correlation between a high WBC count and a more advanced form of appendicitis. Out of an aggregate of 232 patients, 162 were males and 70 females with a mean age of 23.7 years [range, 12-70 years]. Mean duration of symptoms was 1.9 +/- 1.1 days, mean temperature 37.8 +/- 1.4 degree celcius, with reported elevated WBC count in 167 [71.9%] and normal in 65 [28.1%] cases. Mean WBC counts in acute were 14.5 +/- 7.3 x 109/L, gangrenous 17.1 +/- 3.9 x 109/L and perforated appendicitis 17.9 +/- 2.1 x 109/L. This reflected a persistently higher WBC count in the complex [gangrenous, perforated] appendicitis compared with acute appendicitis [p less than 0.05]. The differential analysis showed neutrophilia in 123 [53%] and lymphopenia in 112 [48%] cases and out of these, 116 [94%] with neutrophilia and 107 [95%] with lymphopenia were reported to have appendicitis. A high WBC with differential count is a reliable indicator of the severity of appendicitis and signifies a more advanced stage

Carcinoid tumors of the appendix. Our experience in a University Hospital

To present our experience of carcinoid tumors of the appendix managed at a university teaching hospital. Complex symptomatology, varied biochemical affections and different surgical therapeutic modalities are discussed. The medical records of all the patients who underwent consecutive appendectomies at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia from 1994 to 1999 were retrospectively analyzed. The data of patients identified to have histological evidence of carcinoid tumors of the appendix were further reviewed for the demographic details, indications for surgery, surgical procedure, tumor localization in the appendix and size; concomitant appendicitis and further surgical procedures were considered. During the study period, 1547 appendectomies were performed and, out of these, 9 [0.6%] cases were reported to have carcinoid tumors of the appendix. There were 4 male and 5 female patients, age range 17-51 years [median 29.8 years]. Seven subjects had a clinical evidence of appendicitis while 2 presented with chronic abdominal pain. There were 6 open and 3 laparoscopic appendectomies. Six carcinoid tumors were encountered at the appendiceal apex, 2 at the midportion, and one at the base with a mean diameter of 9.5 mm [range, 4-19 mm]. One patient had histologically confirmed residual tumor, which necessitated a right hemicolectomy 3 weeks later. All patients remained disease-free during a mean follow up of 7 years [range, 4-10 years]. Carcinoid tumors of the appendix are extremely rare and invariably remain asymptomatic. Simple appendectomy offers adequate relief while the need for further extensive surgery depends on tumor characteristics and dissemination. Despite an excellent prognosis, all reported patients should be followed up with urinary 5-hydroxyindoleacetic acid and abdominal ultrasonography

Extremity vascular trauma in Pakistan

To report demographic data, etiological spectrum, the varied presentation, certain vascular techniques and their outcome in patients with peripheral vascular trauma. This study included the patients who presented to the emergency room of Jinnah Hospital and Allama Iqbal Medical College Complex, Lahore, Pakistan with acute peripheral vascular injuries from May 1998 to April 2002. The Mangled Extremity Severity Score [MESS] was calculated for each individual to determine the magnitude of injury. A trauma database was devised to analyze each patient's characteristics, time since the injury, etiology of trauma, clinical presentation, associated injuries, surgical procedures performed and the result. Fifty-seven individuals were managed. The male to female ratio was 49:8 with an age range of 6-69 years [mean 29.1]. The time since injury ranged 3-19 hours [mean 9.3]. Thirty-one [54.3%] cases sustained vascular trauma by firearm, 10 [17.5%] by blunt trauma, 7 [12.2%] stabs, 6 [10.5%] machinery work and 3 [5.2%] by crush injury. Arterial bleeding from the wound was the most frequent presentation found in 18 [31.5%] patients followed by absent distal pulses recorded in 13 [22.8%] subjects. Fifty-one [89.5%] patients presented with arterial, 6 [10.5%] venous and 9 [15.7%] of these had concomitant arterial and venous injuries. Complete vascular transaction was the most common operative finding noted in 26 [45.6%] cases followed by partial tear in 23 [40.3%] subjects. Fifteen [29.4%] common femoral, 10 [19.6%] brachial, 9 [17.6%] superficial femoral, 7 [13.7%] axillary, 5 [9.8%] popliteal and 4 [7.8%] radial arteries were traumatized. The interposition vein graft was used in 21 [41.1%] cases while primary vascular repair was carried out in 19 [37.2%] patients. Forty-five [78.9%] subjects had a functional limb after vascular reconstruction. Wound infection was recorded in 7 [12.2%] individuals. Six [10.5%] amputations were carried out, all with an average MESS of 7.8 +/- 1. 3 [p<0.05]. Three patients died within 10 hours of injury due to torrential hemorrhage. Prompt surgical intervention, frequent use of saphenous vein graft and a low threshold for fasciotomy contributes to a successful outcome in patients with extremity vascular trauma

Malignant duodenocolic fistula Various therapeutic surgical modalities

Malignant duodenocolic fistulas are the most rare and evolutive complication of colonic cancer due to their rapid nutritional disturbances and difficult surgical management. This case report details a 23-year-old female who presented with diarrhea, anorexia, weight loss, anemia and abdominal pain. A series of examinations showed a transverse colon carcinoma with a malignant duodenocolic fistula and direct infiltration of the right lobe of the liver. The patient underwent extended right hemicolectomy with wide local excision of the duodenum and segmental hepatic resection. Postoperative recovery was uneventful. The analysis of other similar cases from the literature treated with this procedure or less frequently, with right hemicolectomy and pancreaticoduodenectomy, allows us to discuss the indications and results of radical surgery. Whenever feasible, resection offers the best treatment as lesser techniques such as bypass and exclusion result only in minimal palliation. The benefit of exploration should almost always be offered, even in such secondary fistulas, as a better quality of life and long term survival are realistic goals and prognostically justifiable

Cholesterolosis: incidence, correlation with serum cholesterol level and the role of laparoscopic cholecystectomy

To report the incidence of cholesterolosis in the surgically removed gallbladders, its association with serum cholesterol level and to review the role of laparoscopic cholecystectomy in the treatment. This retrospective study included all patients who had consecutive cholecystectomies for various gallbladder disorders, performed by 2 consultants during a 5-year period from January 1997 through to December 2002, in the College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia. The clinical records of those found to have cholesterolosis on histopathological examination were reviewed, and the data were analyzed for their age, sex, fasting serum cholesterol level and the final outcome of cholecystectomy. The study group was comprised of 549 patients and out of which, 74 [13.4%] had cholesterolosis of the gallbladder. There were 59 [79.9%] female and 15 [20.1%] male patients. Age ranged from 18-64-years with a mean of 35.7-years. Sixty-three [85.1%] cases were reported to have abnormally high fasting serum cholesterol levels [>=5.5 mmol/L], whereas 11 [14.9%] had normal serum cholesterol level. Cholesterolosis with coexistent gallstones was documented in 47 [63.3%] patients while 27 [36.5%] subjects showed acalculous cholesterolosis. Laparoscopic cholecystectomy was performed in 71 [95.9%] individuals, whereas 3 patients ended up with open cholecystectomy [conversion rate of 4.2%]. There were no postoperative complications. Cholesterolosis of the gallbladder is a distinct pathologic entity and carries a positive correlation with high serum cholesterol level. Laparoscopic cholecystectomy is effective, safe and a feasible treatment modality for cholesterolosis