Graves' disease in Saudi Arabia: a ten-year hospital study.

OBJECTIVE: To determine clinical manifestation and mode of treatment of Graves' disease at King Khalid University Hospital Riyadh, Saudi Arabia. METHODS: A retrospective study of all cases of Graves' disease diagnosed at the hospital in the period between January 1995 and December 2004, who received a minimum of two years treatment were included in the study. RESULTS: A total of 194 patients were seen with female: male ratio of 2.9:1 and mean age of 32 +/- 0.9 years. Sixty nine percent of the patients had positive thyroid antibodies. Palpitations, tremors, weight loss and nervousness were the most common presenting manifestations. Forty nine percent of patients were treated with radioiodine, 38% with antithyroid drugs, and 13% underwent subtotal thyroidectomy. CONCLUSION: Clinical manifestations of Graves' disease in our patients distinctly differed from those reported in the West and Pacific Islanders with notable rarity of pretibial myxoedema and hyperpigmentation respectively. We also noted higher male to female ratio and an increasing utility of radioactive iodine therapy while use of antithyroid drugs and surgery are declining.

High prevalence of osteoporosis in Saudi men.

OBJECTIVE: To determine the prevalence of osteoporosis in healthy Saudi men. METHODS: We randomly recruited 429 Saudi men from the community. The recruited Saudi men were subjected to an interview to reveal their lifestyle parameters, calcium intake and level of activity. Bone densitometry was assessed at lumbar spine (L1-4) and the femoral neck. The dual x-ray absorptiometry (DXA) scan was carried out in the Nuclear Medicine at King Khalid University Hospital, Riyadh, Saudi Arabia from September 2002 to December 2004. The World Health Organization definition of low bone mineral density was used. RESULTS: Poor oral calcium intake and low level of daily activity were noted. The overall prevalence of osteopenia for the lumbar spine in the whole group was 35.7% while osteoporosis was present in 21.4% of the subjects. In the femoral neck, osteopenia was noted in 38% and osteoporosis in 11.4%. When either lumbar spine or femoral neck osteoporosis is used for diagnosis, the prevalence of osteoporosis rises to 23.5%. Within the whole group, osteopenia and osteoporosis were more common in individuals above the age of 50 than those below 50 years old. CONCLUSION: Low bone mineral density occurs with high frequency in Saudi men. Lumbar spine appears to be affected to a higher degree. The reason for the high prevalence of osteoporosis in Saudi men is unclear. Possible underlying causes include nutritional, life style and genetic factors.

Treatment of Graves' hyperthyroidism--prognostic factors for outcome.

OBJECTIVE: To determine whether clinical and biochemical features of Graves' disease at presentation predict response to medical and radioiodine treatment. METHODS: We carried out a retrospective 10-year study of 194 consecutive Saudi subjects with Graves' disease who were treated with antithyroid drugs, radioiodine therapy, or both, between January 1995 and December 2004 at King Khalid University Hospital, Riyadh, Saudi Arabia. RESULTS: At diagnosis, the mean age was 32 +/- 0.9 years. Only 26% of patients had successful outcome after a course of antithyroid medication. None of the clinical or biochemical factors were associated with a favorable outcome of antithyroid treatment. One dose of radioiodine [13-15 mCi (481-555 MBq)] cured hyperthyroidism in 83% of patients. Presence of ophthalmopathy at presentation was shown to be a significant contributing factor to failure to respond to a single dose of radioiodine (odds ratio, 6.4; 95% CI, 1.51-24.4; p<0.01). Failure of radioiodine treatment was also associated with higher serum free T3 concentration at presentation (p=0.003). CONCLUSION: In patients with Graves' hyperthyroidism, radioiodine treatment is associated with higher success rate than antithyroid drugs. A dose of 13-15 mCi (481-555 MBq) seems to be practical and effective, and should be considered as first line therapy. Patients with high free T3 concentration and, those with ophthalmopathy at presentation were more likely to fail radioiodine treatment. A higher dose of radioiodine may be advisable in such patients.

Moyamoya syndrome as a risk factor for stroke in Saudi children. Novel and usual associations.

OBJECTIVE: To report on moyamoya syndrome (MMS) as a risk factor for stroke in a prospective and retrospective cohort of Saudi children. The usual and novel associations of MMS in this cohort will also be described. METHODS: Children with stroke were evaluated at the Division of Pediatric Neurology at King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia during the periods July 1992 to February 2001 (retrospective study) and February 2001 to March 2003 (prospective study). Investigations for suspected cases included hemostatic assays, biochemical, and serological tests. Neuroimaging included CT, MRI, magnetic resonance angiography (MRA), single photon computerized tomography (SPECT) brain scan and conventional cerebral angiography. RESULTS: Moyamoya syndrome was the underlying risk factor for stroke in 6 (5.8%) of the 104 children (aged one month to 12 years). They were 4 females and 2 males. Their first cerebral ischemic event occurred at a mean age of 45 months (median = 44 months, range 17-66 months). In all 6 cases, MMS was associated with an underlying hematologic abnormality or other diseases. Protein C deficiency was identified in one girl and protein S deficiency in another. Two patients had respectively, sickle cell disease (SCD) and sickle cell-beta-thalassemia (S beta-thalassemia), which had been associated in the latter with membranous ventricular septal defect. Adams-Oliver syndrome (AOS, OMIM 100300) was associated with MMS in an 18-month-old girl. A 4-year-old boy had wrinkly skin syndrome (WSS, OMIM 278250) phenotype. The association of MMS and protein C deficiency was first reported in this cohort of patients, whereas the association of the syndrome with WWS and AOS has not, hitherto, been described. The 3 patients who had MMS associated with protein C deficiency, SCD, and AOS underwent successful revascularization surgery in the form of encephaloduroarteriosynangiosis. CONCLUSIONS: Moyamoya syndrome constitutes an important risk factor of stroke in Saudi children. Comprehensive clinical evaluation and investigations, including screening for thrombophilia and neuroimaging studies, are required for the primary diagnosis of the disease and for unraveling other diseases associated with MMS. This will help in managing these patients and in guiding genetic counseling for their families.

Comparison of bone mineral density with dual energy x-ray absorptiometry, quantitative ultrasound and single energy x-ray absorptiometry.

OBJECTIVE: We conducted this prospective study to establish the correlation between dual energy x-ray absorptiometry (DXA), quantitative ultrasound (QUS) and single energy x-ray absorptiometry (SXA) and to establish the role of QUS and SXA as a screening tool for osteoporosis. METHODS: We carried out measurements of bone mineral density (BMD) of lumbar spine and femoral neck using DXA, QUS of heel using ultrasound densitometer, and BMD of forearm using SXA. We performed all the measurements at the Nuclear Medicine Division of King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia between 2002 and 2004. We obtained the measurements of 437 female adult patients, aged 20-87 years. RESULTS: We expressed all the values as mean +/- SD. The BMD (g/cm2) of lumbar spine was 1 +/- 0.18, and femoral neck was 0.88 +/- 0.17. The broad band ultrasound attenuation (BUA) of the heel was 74.9 +/- 39.1 dB/MHz, the speed of sound (SOS) was 1542.5 +/- 81.4 m/s, and the estimated BMD was 0.52 +/- 0.15 (g/cm2). The BMD of forearm showed a value of 0.44 +/- 0.10 g/cm2. The best correlation was between absolute values of BMD of lumbar spine and femoral neck (r=0.71, p=0.000). The correlation between BMD of lumbar spine, QUS heel and forearm BMD was significant, but low to moderate (r=0.43-0.64, p=0.000). A strong correlation existed between the various parameters of heel, namely, BUA, SOS and estimated BMD (r=0.85-0.96, p=0.000). We used the World Health Organization (WHO) criterion of T-score to diagnose the patients with osteoporosis or osteopenia with each modality. We diagnosed a maximum number of patients to have osteoporosis with BMD estimation of lumbar spine (31%), followed by femoral neck (14%), forearm (11%), and heel (6%). CONCLUSION: The correlation between all modalities was significant, but varied from high to low. It was high between lumbar spine and femoral neck, moderate between lumbar spine and forearm and low between lumbar spine and QUS of heel. When we used the same WHO criterion of T-score (more than -2.5 SD below normal), QUS detected significantly less numbers with osteoporosis. We conclude that with the present cut-off of T-score, the QUS may not be used as a screening tool. It may need some modification of T-score. However, we need larger multi-center studies with a larger number of patients for further validation.

Prevalence of osteoporosis among postmenopausal females with diabetes mellitus.

OBJECTIVE: To assess the prevalence of osteopenia and osteoporosis among Saudi postmenopausal women with non-insulin dependent type 2 diabetes mellitus (T2DM). METHODS: The study was carried out at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia from February 2000 to September 2002. Bone mineral density (BMD) of the lumbar spine and femoral neck using dual x-ray absorptiometry (DXA; Lunar Wisconsin), were performed in 104 postmenopausal Saudi women with T2DM, and 101 postmenopausal non-diabetic women (control). Bone mineral density was measured in gm/cm2 and both T-score and Z-score were measured but only T-score was used for analysis based on World Health Organization criteria. Bone profile, 25(OH) Vitamin D, 1,25(OH)2 Vitamin D, parathyroid hormone and urine deoxypyridinoline (DPD) were measured in most patients and controls. Body fat measurement around the biceps muscles using Futrex (body composition analyzer) were performed in patients and controls. Years postmenopausal, duration of diabetes mellitus, parity, exercise, sun exposure and milk consumption were also recorded. RESULTS: In the diabetic group, the mean spine BMD was 0.928 gm/cm2 (T-score = -2.28 SD) and for femoral neck the mean BMD was 0.817 gm/cm2 (T-score = -1.21 SD). In control group, the mean spine BMD was 1.036 gm/cm2 (T-score = -1.2) and mean femoral neck BMD was 0.914 gm/cm2 (T-score = -0.608). In the diabetic group, there was 16 (16.64%) patients with normal BMD of the spine, 42 patients (43.68%) with osteopenia (mean T-score = -1.8 SD) and 45 (46.8%) with osteoporosis (mean T-score = -3.3 SD). CONCLUSION: Osteoporosis is more common among Type 2 postmenopausal females in this ethnic group. Since both groups are postmenopausal, having equal percentage of Vitamin D deficiency, multi-parity, non exposure to sun, lack of exercise and negligible milk intake, one can conclude that the low BMD can be attributed to DM in the absence of other causes of osteoporosis.

Bone mineral density and bone scintigraphy in adult Saudi female patients with osteomalacia.

OBJECTIVE: This prospective study was conducted to demonstrate the role of bone mineral density (BMD) and bone scan in the management of adult Saudi female patients with established diagnosis of osteomalacia. METHODS: Bone scan using Tc99m methylene diphosphonate (MDP) and BMD of the lumbar spine and femoral neck using dual x-ray absorptiometry (DXA) were performed at the time of diagnosis 6 months and one year after therapy in 96 Saudi female patients attending the metabolic bone disease clinic at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia, between January 1997 through to June 1999, aged between 20 and 73-years (mean 42 years). Alkaline phosphatase, calcium and inorganic phosphorus were measured for all patients before and after treatment. 25 Hydroxy Vitamin D was only measured with the first BMD measurements. RESULTS: The bone profile showed typical biochemical abnormalities of osteomalacia. The bone scan showed feature of "superscan" in all patients and "pseudofractures" in 43 patients. Bone mineral density measurements were compared with that of normal Saudi subjects matched for age and sex. The BMD was significantly low at diagnosis and showed significant improvement after therapy. The improvement of bone density in response to therapy was more evident in lumbar spine than in femoral neck bone. CONCLUSION: Our results showed that BMD in adult Saudi female patients with osteomalacia was markedly affected probably due to specific constitutional and environmental factors (inadequate exercise, lack of sun exposure and lack of intake of milk and dairy products). In addition, lumbar BMD and serum calcium appeared to be better markers to monitor therapy. Bone scan helped in demonstrating disease activity, the presence of pseudofractures.

Osteoporosis in postmenopausal Saudi women using dual x-ray bone densitometry.

OBJECTIVE: A pilot study to estimate the prevalence of osteopenia and osteoporosis in postmenopausal Saudi women. METHODS: Lumbar spine bone density was measured in 830 postmenopausal Saudi women 50-80 years of age (average 59 years), using dual x-ray absorptiometry (DXA) at the King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia between 1989 and 1999. RESULTS: The results of the bone mineral density (BMD) in gm/cm2 were compared to the peak bone density (PBD) in healthy young women (T-score). Based on the definition of World Health Organization (WHO), the T-score value was considered for analysis. Accordingly, 248 (29.9%) subjects showed normal result, mean BMD of 1.117 +/- 0.13 and T-score of -0.66 SD; while 254 (30.6%) subjects showed osteopenia, mean BMD of 0.983 +/- 0.11 and T-score of -2.4 SD and 328(39.5%) subject showed osteoporosis, mean BMD of 0.767 +/- 0.11 and T-score of -3.4 SD. When the 830 subjects were analyzed by decades, there were 42.3% normal, 33.4% osteopenia and 24.3% osteoporosis in age 50-59 years; 11% normal, 27% with osteopenia and 62% with osteoporosis in age 60-69 years while in older age 70-79 years only 4.6% had normal BMD, 21.5% had osteopenia and 73.8% had osteoporosis. CONCLUSION: Osteopenia and osteoporosis are common among postmenopausal Saudi women and should be considered as a matter of public health. Bone densitometry should be used to assess the severity of bone loss, identify those who need therapy and for follow up and early diagnosis of those with osteopenia in order to institute proper therapy and avoid future osteoporosis.