Prevalence and Associated Factors of Toenail Onychomycosis Among Patients with Diabetes in Jordan.

BACKGROUND: Toenail onychomycosis is common in patients with diabetes and it can increase the risk of secondary infections and foot complications. Despite several studies investigating the prevalence and associated factors of toenail onychomycosis from different parts of the world, there are no data from Jordan. OBJECTIVE: To determine the prevalence and the associated factors of toenail onychomycosis among patients with diabetes in Jordan. METHODS: A cross-sectional study was conducted on 375 patients with diabetes at the National Centre for Diabetes, Endocrinology, and Genetics in Amman, Jordan. Several socio-demographic and health-independent variables including foot self-care practices were collected. Toenail onychomycosis was assessed by a specimen culture and microscopic examinations. Descriptive and inferential statistics were used for data analysis. RESULTS: The prevalence of toenail onychomycosis was 57.6% (n=216). Multiple logistic regression revealed four significant associated factors; the presence of neuropathy (ß=1.87, p=0.02), being an ex-smoker (ß=2.69, p=0.01), being treated by both insulin and oral hypoglycemics drugs (ß=1.32, p=0.03), and using antibiotics in the last year (ß=1.78, p=0.02). CONCLUSION: The prevalence of toenail onychomycosis among patients with diabetes in Jordan is high. Regular foot screening and podiatric care are recommended especially among patients with diabetic neuropathy, current treatment by insulin and oral hypoglycemics drugs, previous history of smoking, and previous use of antibiotics.

Factors Associated With Foot Self-Care in Patients With Diabetes-Related High-Risk Feet: A Cross-Sectional Design.

Foot self-care has been commonly studied among people with diabetes. Previous research on foot self-care among those with diabetes-related high-risk feet is almost unavailable or very limited. The current study aims to fill this gap and provide a contemporary unprecedented analysis of this area of specialization. To assess the levels of, and factors associated with foot self-care among people with diabetes-related high-risk feet. A multi-center cross-sectional study from Jordan assessed the foot self-care of 107 participants with diabetes-related high-risk feet. Multiple socio-demographic, physiological, and psychosocial factors were collected, and the Arabic version of the diabetes foot self-care behavior scale was used to estimate the foot self-care of the study population. A multiple linear regression model was employed to identify factors associated with foot self-care. The mean score of foot self-care was 25.4 ± 7.1 (35 is the highest) indicating ~73% of adherence to foot self-care. Factors associated with higher foot self-care were being treated at the King Abdullah University Hospital (ß = .30, P < .01) and reporting higher scores of patients' interpretations about neuropathy physical causes of foot ulcers (ß = ".22," P = .02). People with diabetes-related high-risk feet reported a relatively adequate foot self-care practice. However, clinicians are still required to enhance foot self-care among this population. Health promotion programs may benefit from engaging people in understanding the pathophysiology of diabetes-related foot ulcers to improve foot self-care practices.

Percutaneous Partial Bone Excision in the Management of Diabetic Toe Osteomyelitis.

BACKGROUND: Diabetic foot osteomyelitis affecting the toes is associated with several complications including amputation. Management is variable and include medical therapy alone or coupled with surgery. Removal of infected tissues is a common therapeutic option. However, limited source data are available. This study determines the outcome and complications of percutaneous partial bone excision (PPBE) of infected bone among diabetic patients with toe osteomyelitis. METHODS: This is an uncontrolled experimental prospective study in diabetic patients who underwent PPBE of infected pieces of bone for toe osteomyelitis in the outpatient setting at a single foot clinic. All participants were followed up until the occurrence of wound healing or amputation. RESULTS: Forty-seven patients (mean ± SD age was 62.8 ± 11.6 years) participated. Forty-four patients (93.6%) had complete healing and 3 (6.4%) required toe amputation. The mean (±SD) wound healing time was 11 (±4.6) (range, 7-22) weeks. Diabetes mellitus type 1 and younger age were significantly associated with increased risk for amputation. CONCLUSION: PPBE of infected toes in diabetic patients can be performed successfully and safely in the outpatient clinic. It can also improve healing and avoids inpatient stay. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Live in Front of Students Teaching Sessions (LISTS): a Novel Learning Experience from Jordan During the COVID-19 Pandemic.

Objective: The COVID-19 pandemic uncovered innovative approaches in medical education. Modifications are needed to overcome the drawbacks of pure online teaching. Our study aimed at testing a hybrid method of live online practical anatomy sessions in which an element of face-to-face teacher-student interaction is maintained. Methods: We performed an experiment with a one-group design in which medical and medical laboratory sciences students were taught different practical anatomy topics using either purely online or live in front of students teaching sessions (LISTS). Students' performance and perceptions were quantitatively assessed. Results: For 108 medical laboratory sciences students, the mean quiz scores were significantly higher for the topics taught by the LISTS approach (p = 0.025). For two groups of 13 and 17 medical students, the performance in exams was significantly higher for the topics taught using the LISTS method (p = 0.000 and 0.011, respectively) with large effect sizes. Students' perceptions of preference, enjoyment, and satisfaction were all in favor of LISTS. Conclusions: Our results confirmed that keeping at least a minimum of interaction between the teacher and students can have a significant improvement in the performance and engagement in practical anatomy sessions for health professionals. The results indicate that the extra effort of LISTS was worth it.

Self-Reported Obsession Toward COVID-19 Preventive Measures Among Undergraduate Medical Students During the Early Phase of Pandemic in Jordan.

Background: Coronavirus disease 2019 (COVID-19) pandemic and its associated precautionary measures have substantial impacts not only on the medical, economic, and social context but also on psychological health. This study aimed to assess the obsession toward COVID-19 preventive measures among undergraduate medical students during the early phase of the pandemic in Jordan. Methods: Online questionnaires were distributed between March 16, 2020 and March 19, 2020. Socio-demographic characteristics were collected, and self-reported obsession toward COVID-19 preventive measures was assessed using a single question.COVID-19 knowledge, risk perception, and precautionary measures were evaluated using scales. Using the chi-square test, Student t-test, and one-way ANOVA, we assessed the differences in the obsession of students with socio-demographic characteristics and scores of the scales. Results: A total of 1,404 participants (60% were female participants) completed the survey with a participation rate of 15.6%. Obsession with preventive measures was reported by 6.8%. Obsession was significantly more common among women (9.2%) than men (3.3%) and students who attended COVID-19 lectures (9.5%) than those who did not attend such lectures (5.8%) (p < 0.001 and p = 0.015, respectively). Obsessed participants reported significantly higher levels of COVID-19 knowledge (p = 0.012) and precautionary measures (p < 0.001). COVID-19 risk perception had a mild effect size difference but with no statistical significance (p = 0.075). There were no significant differences in the academic levels of participants (p = 0.791) and universities (p = 0.807) between students who were obsessed and those who were not. Conclusions: Obsession is one of the significant but unspoken psychological effects of COVID-19 precautionary measures among undergraduate medical students. Medical schools should be equipped with means to handle pandemic psychological effects.

The usefulness of histopathology examples in teaching practical histology for medical students: A CONSORT-compliant randomized crossover trial.

BACKGROUND: Teaching histology as an image-intensive discipline is a major challenge to medical teachers. We compared knowledge retention and student preference after performing comparison-based and traditional methods of teaching practical histology. METHODS: We performed a crossover randomized controlled trial. Eighty nine first-year and 37 second-year medical students were randomly assigned to comparison-based or traditional classes in which PowerPoint slides were used. Each teaching approach was then switched to another group for a second tissue set. Quantitative assessment was performed using multiple-choice questions and a questionnaire. RESULTS: The first-year students' overall examination scores were significantly higher in the comparison-based approach compared to the traditional approach for both tissue sets, with a large effect size. Interestingly, even for the second-year students, a significantly higher overall score for one set of tissue samples was observed in the comparison-based approach compared to the traditional approach. The students' responses to all the elements in the questionnaire were significantly in favor of the comparison-based approach. CONCLUSION: Our findings indicate that the simple implementation of a few histopathology examples can yield a tremendous improvement in first-year medical students' understanding, enjoyment, and engagement in practical histology classes.

The Frequency and Risk Factors of Diabetic Foot Ulcer Recurrence Among Jordanian Patients with Diabetes.

BACKGROUND: Diabetic foot is a major public health problem and their complications are an imperative cause of morbidity and mortality in diabetes. OBJECTIVE: To evaluate the rate of recurrence of foot ulcers post two years of follow-up, including the associated risk factors in the patients attending the diabetic foot clinic at the National Center for Diabetes, Endocrinology, and Genetics (NCDEG), Amman, Jordan. METHODS: A historical cohort design was adopted for the patients who presented for the first time to the diabetic foot clinic at the NCDEG. Every patient who came to the clinic was reviewed by using his or her medical files with respect to diabetic foot-related complaints. Patients were classified under four categories: (1) Recurrent foot ulcers (2) chronic foot ulcer (3) free of recurrence, and (4) no foot ulcers. Among the four groups, group 1 (recurrent foot ulcers, n=76) and group 3 (free of recurrence, n=54) were included for the analysis. RESULTS: Among the 141 patients who presented to the diabetic foot clinic during the two-year study period, 76 (53.9%) of them experienced ulcer recurrences, 54 (38.3%) were recurrence-free, and 11 (7.8%) had chronic ulceration. The two-year recurrence rate was 58.5%. The presence of deformity and osteomyelitis were the statistically significant independent risk factors for recurrent foot ulceration. CONCLUSION: This study of recurrences was clearly related to the type and complications of the ulcers rather than to the other variables. Recurrent foot ulceration is linked to the presence of osteomyelitis and/or deformities.

Engagement of Jordanian Physicians in Continuous Professional Development: Current Practices, Motivation, and Barriers.

BACKGROUND: Mandatory relicense of all physicians in Jordan went into effect at the beginning of May 2018. The bylaw states that all physicians should engage in Continuing Professional Development (CPD) in order to upgrade their knowledge and maintain competency as a prerequisite to renew their license every 5 years. The characteristics of effective CPD are different from one country to another. Jordan has decided to link CPD to mandatory relicense; however, no research has been done to identify the factors that influence CPD offerings, needs, practices, experiences, and effectiveness in the healthcare sector in Jordan. This paper reviews the history of CPD and CME, and the different options to upgrade and improve the competence of physicians. It explores the current practices, motivation, and barriers for physicians to get engaged in CPD activities in Jordan. PURPOSE: The purpose of this research was to provide a better understanding of the state of CPD in the healthcare sector in Jordan with a view to informing the development of Jordan's first CPD framework. The findings of this research will provide policymakers with baseline information concerning current CPD practices, experiences, and attitudes of physicians towards CPD, and enablers and contributors to effective CPD in Jordan. METHODS: Stratified clustered self-selected participants that represented physicians working at all healthcare sectors in Jordan were used in this study. A structured pre-tested self-reported questionnaire was used to collect the data. A total of 457 physicians were included in the sample according to one-proportion sample size calculation method, and they were distributed among the healthcare sectors based on their shared proportions. CONCLUSION: Despite considerable evidence supporting the role of CPD in maintaining competency of physicians, participating in CPD activities in Jordan is compromised by lack of mandatory laws and barriers related to staff shortage, heavy workload, limited funds, lack of time, and cost. Personal interests and career progression are the top motivators for CPD. Most Jordanian physicians are interested in CPD activities related to health/medical informatics and enhancing their skills in evidence-informed practice. We recommend that future interventions and health policy directions should be informed by these findings in order to optimize uptake of CPD programs in Jordan.

Anxiety and Depression Among Adult Patients With Diabetic Foot: Prevalence and Associated Factors.

BACKGROUND: Diabetic foot is a frequent complication of diabetes mellitus with subsequent disturbances in the daily life of the patients. The co-existence of depression and anxiety among diabetic foot patients is a common phenomenon and the role of each of them in perpetuating the other is highlighted in the literature. Our study aimed to determine the prevalence rates of anxiety and depression, and to examine the associated risk factors among diabetic foot patients. METHODS: This is a cross-sectional study. A total of 260 diabetic foot patients in the Diabetic Foot Clinic at the National Center for Diabetes, Endocrinology and Genetics (NCDEG), Amman, Jordan, participated in the study. Sociodemographic and health data were gathered through review of medical charts and a structured questionnaire. Depression and anxiety status were also assessed. The Generalized Anxiety Disorder Scale (GAD-7) was used to screen for anxiety and the Patient Health Questionnaire (PHQ-9) was used to screen for depression. A cutoff of ≥ 10 was used for each scale to identify those who tested positive for anxiety and depression. RESULTS: Prevalence rate of anxiety was 37.7% and that of depression was 39.6%. Multiple logistic regression analysis showed that anxiety is positively associated with duration of diabetes of < 10 years (P = 0.01), with ≥ three comorbid diseases (P = 0.00), and HbA1c level of > 7% (P = 0.03). Multiple logistic regression analysis also showed that depression is positively associated with patients of < 50 years of age (P = 0.03), females (P = 0.01), current smokers (P = 0.01), patients with foot ulcer duration ≥ 7 months (P = 0.00), with ≥ three comorbid diseases (P = 0.00) than their counterparts. CONCLUSIONS: Anxiety and depression are widely prevalent among diabetic foot patients. Mental health status of those patients gets even worse among those suffering other comorbid diseases, which was a finding that requires special attention in the management of patients with diabetic foot.

Performance of chloride/phosphate test in patients with primary hyperparathyroidism. Is it related to calcium level?

OBJECTIVE: To examine the sensitivity of the chloride/phosphate (Cl/PO4) ratio with a cut-off point of >33 as a diagnostic test for primary hyperparathyroidism (pHPT) in surgically proven patients, and its performance at different calcium levels. METHODS: This is a retrospective medical records based study. Data of 120 patients diagnosed with pHPT, already operated in the Department of Surgery, Cisanello Hospital, Pisa, Italy between March 2010 and June 2011 were reviewed. They were divided into 4 subgroups according to their calcium levels. The Cl/PO4 ratio was measured for each patient, with a cut-off point of 33, sensitivity of Cl/PO4 test was measured. Test sensitivity was calculated for each subgroup, and a correlation with the parathyroid hormone (PTH) level was investigated. Performance of the equation was tested for the normocalcemic patients with a suitable control group. RESULTS: The sensitivity of Cl/PO4 ratio for the whole group was 0.883 (0.809-0.932). The sensitivity was 0.9340 (0.857-0.973) for patients with serum calcium above normal levels. A similar result of 0.933 (0.830-0.978) was demonstrated for the subgroup with hypercalcemia <1 (mg/dL) above normal level. Normocalcemic patients constituted 24%; for this subgroup, the sensitivity test was 0.724 (0.562-0.887), specificity was 0.763 (0.628-0.898), positive predictive value was 0.700 (0.536-0.864), and negative predictive value was 0.784 (0.651-0.916). No correlation was identified between the performance of formula and serum PTH level. CONCLUSION: The Cl/PO4 test seems to be a good tool to anticipate pHPT and showed a fair performance in normocalcemic patients.

Unusual association between adrenal leiomyoma and autoimmune disease.

Adrenal leiomyoma is a rare solid tumor of unknown etiology. Here, we present a case of a 38-year-old woman, a known case of Hashimoto's thyroiditis, presented with right adrenal mass incidentally discovered by computed tomography imaging. The mass was non-functioning according to laboratory results, but because the mass increased in size in a follow up visit, she underwent right adrenalectomy. The histological findings confirmed the diagnosis of adrenal leiomyoma, which was supported by a panel of immunohistochemical stains. Surprisingly, there was a dense lymphocytic infiltrate in the background of the tumor, forming germinal centers. Although most of the reported adrenal leiomyoma cases are associated with immune deficiency, none of the previous cases was associated with an autoimmune disease.1 We report a case of an unusual adrenal leiomyoma with a dense lymphocytic infiltrate.

Rupture of spleen post colonoscopy.

We review an interesting case of elective colonoscopy for rectal bleeding in a 68-year-old woman complicated by splenic rupture. She was managed by aggressive fluid and blood resuscitation followed by splenectomy. She had a smooth recovery and was discharged home 4 days after admission. The extreme rarity and interesting clinical course of the patient are discussed.

Detection of combined genomic variants in a Jordanian family with familial non-autoimmune hyperthyroidism.

Five patients, four brothers and their paternal aunt, presented with a history of overt hyperthyroidism and goiter. Hyperthyroidism in this family was remarkable for its poor response to carbimazole (30-50 mg/d). The thyroid ultrasound showed a diffusely enlarged gland in all the affected members, and thyroid stimulating antibodies (TSAB) were negative. Screening for germline mutations in thyroid stimulating hormone (TSH) receptor (TSHR) gene was performed by direct sequencing of genomic DNA extracted from peripheral blood leukocytes of all family members. The sequence analysis of all TSHR gene exons and intron borders revealed two genomic variants. The first was a single nucleotide polymorphism (SNP) within exon seven (Asn187Asn), whereas the other was located in intron seven (IVS7+68TG). All affected members, two asymptomatic brothers with sub-clinical hyperthyroidism, and their father were heterozygous for those two genomic variants. Anti-thyroid drug treatment for several months successfully relieved symptoms in one subject, whereas the remaining patients required total thyroidectomy to control their disease. This is the first Jordanian family with familial non-autoimmune hyperthyroidism, with mutations affecting the TSHR gene.

Islet transplantation: the quest for an ideal source.

The progress of islet transplantation as a new therapy for patients with diabetes mellitus depends directly upon the development of efficient and practical immunoisolation methods for the supply of sufficient quantities of islet cells. Without these methods, large scale clinical application of this therapy would be impossible. Two eras of advances can be identified in the development of islet transplantation. The first was an era of experimental animal and human research that centered on islet isolation procedures and transplantation in different species as evidence that transplanted islets have the capability to reverse diabetes. The second was the era of the Edmonton protocol, when the focus became the standardization of isolation procedures and introduction of new immunosuppressive drugs to maintain human allograft transplantation. The quest for an alternative source for islets (xenographs, stem cells and cell cultures) to overcome the shortage of human islets was an important issue during these eras. This paper reviews the history of islet transplantation and the current procedures in human allotransplantation, as well as different types of immunoisolation methods. It explores novel approaches to enhancing transplantation site vascularity and islet cell function, whereby future immunoisolation technology could offer additional therapeutic advantages to human islet allotransplantation.

Accuracy of single versus combined use of ultrasonography or computed tomography in the localization of parathyroid adenoma.

OBJECTIVE: To assess the accuracy of a single versus combined use of ultrasound (US), or computed tomography (CT) in the localization of diseased parathyroid glands. METHODS: Forty-one patients with hyper-parathyroidism treated surgically between January 2000 to December 2005 at Jordan University Hospital, Amman, Jordan were included in this study. Preoperative ultrasonographic and CT findings were reviewed and compared to the intraoperative and pathologic diagnosis of diseased parathyroid glands. RESULTS: The mean age of patients was 46 years (range 16-70; 15 males and 26 females). Parathyroid adenoma was confirmed in 33 patients and hyperplasia of the parathyroid glands in 8 patients. Preoperative evaluation was carried out in 32 patients (CT scan), and in 23 patients (US). In 18 cases, the diagnosis of parathyroid disease was based on CT findings alone and in 9 patients the diagnosis was based on single US findings. Combined CT and US evaluation was carried out in 14 cases and accurate localization was reached in 12 cases yielding 86% sensitivity and 100% positive predictive value. The independent use of these techniques alone resulted in low (39%) sensitivity for US and high (78%) sensitivity values for the CT. CONCLUSION: Neck CT scan evaluation has almost an equivalent sensitivity to combined CT and neck US in the preoperative localization of diseased parathyroid glands, however the combined use of these techniques provides the best diagnostic accuracy.

Diabetic foot disease.

OBJECTIVE: To review the spectrum of foot problems in patients with diabetes and the underlying etiologic factors. METHODS: In this review, the term "diabetic foot disease" (DFD) will be used (previously referred to as simply "diabetic foot"). The relevant anatomy of the foot is discussed, the clinical evaluation and severity of DFD are outlined, and the role of both systemic control and local measures in the management of DFD is addressed. RESULTS: DFD is linked with a wide variety of etiologic associations, pathologic forms, and clinical severity. The causes of DFD include such factors as diabetic neuropathy, vascular insufficiency, and the presence of underlying bone deformity. The pathologic forms range from superficial skin lesions, soft tissue infections, joint swellings, and deformities to frank necrosis and gangrene. The clinical severity ranges from mild, self-resolving disease to fulminant, rapidly progressive disease that usually eventuates in amputation. The heterogeneity of patients whose illness is grouped collectively under the diagnosis of DFD has contributed to the persisting confusion and controversy regarding the optimal classification system for diabetes-related foot problems and their appropriate management. CONCLUSION: Optimal management of DFD involves a multimodality approach directed at regular foot care, blood glucose control, and early recognition of foot problems. Appropriate surgical management, administration of systemic antibiotics, and off-loading techniques are necessary to prevent the progression of DFD.

Topical phenytoin ointment increases autograft acceptance in rats.

OBJECTIVE: To examine the effectiveness of topical phenytoin in preserving the skin viability and increasing acceptance rate of autograft. METHODS: We conducted this study in the Central Laboratory Animal House of Jordan University of Science and Technology, Irbid, Jordan during the period from September 2004 to June 2005. Forty-two rats were divided into 2 equal groups; full thickness dorsal skin wound (4 cm2) was created in the rats. Twenty-one rats were treated with phenytoin (10% w/w ointment), the other 21 (control) were treated with standard dressing and Vaseline. An autograft was performed one week after treatment. Rats were examined for the presence of healthy granulation tissue, reduction in wound surface dimensions, and time for complete graft attachment. RESULTS: Phenytoin ointment had significantly increased wound bed viability and the rate of graft acceptance (p-value <0.0001). Twenty rats had successful grafting (10% phenytoin); while only 3 rats out of the 21 control had successful grafts. The mean time to complete graft attachment and hair growth in the grafted skin was 6.6 +/- 0.5 days. The mean wound contraction measurements (taken just before grafting) were as follow: control group 59.2 +/- 11.6%, and phenytoin group 55.7 +/- 9.2, difference in skin contractility was not statistically significant. Skin viability was evident by increased vascularity and granular tissue formation at the edges of the wound. CONCLUSION: Phenytoin appears to be an effective method for enhancing the take of the full-thickness skin graft. Further clinical use and evaluation of topical phenytoin ointment in skin grafting are merited.

Diabetic foot infection.

Diabetic foot infection DFI is simply defined as suspected or documented infection of the tissues that comprise the foot of a diabetic patient. Diabetic foot infection is often caused by introduction of an infection into the otherwise sterile soft tissues of the foot through a minor skin break down. Diabetic foot infection may be mild usually restricted to the uppermost layers of the skin, moderate extending down to the soft tissues of the foot or severe infection associated with systemic toxicity or metabolic instability. The paper reviews the types of DFI, pathophysiology, microbiology of DFI, relevant anatomy of the foot, clinical evaluation, measures of severity of DFI, the role of radiological investigations, and the role of early surgical intervention in the prevention of progressive foot infection and limb salvage. It is concluded that the diagnosis of DFI should be suspected at an early stage based on the presence of local signs of inflammation with or without systemic signs of toxicity or metabolic instability. Optimal treatment of DFI requires a multimodality approach directed at controlling hyperglycemia, administration of systemic antibiotics, and local wound management to prevent the spread and dissemination of infection.

The spectrum of bone disease in Jordanian hemodialysis patients.

OBJECTIVE: To evaluate the spectrum of mineral abnormalities and bone disease (BD) in hemodialysis patients at Jordan University Hospital (JUH), Amman, Jordan. METHODS: A cross-sectional study was conducted among 63 patients (38 males and 25 females), mean age 44.19 years (range 17-76 years), with chronic kidney disease (CKD) on regular hemodialysis at JUH between November 2004 and April 2005. All patients have undergone complete blood count, chemistry profile, alkaline phosphatase, serum albumin, intact parathyroid hormone (iPTH) and plain x-rays. RESULTS: Bone disorders were identified in 45 patients on x-rays (70%). Osteopenia was found in 43 patients (68.3%), subperiosteal resorption in 24 patients (38.3%) and metastatic calcification in 22 patients (35%). Hypocalcemia was found in 28.6% and hypercalcemia in 7.9%. All patients were taking calcium carbonate, and 55.5% of patients were on vitamin D supplements. The calcium levels in 63.5% and the phosphorus levels in 50.8% of patients were within the recommended guidelines of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI). Serum i-PTH level was above 300 pg/ml high turnover bone disease in 24.6% of patients, 21.3% had iPTH of 150-300 pg/ml target, and 44.3% had i-PTH levels below 100 pg/mL suggesting a dynamic bone disease. Patients with severe bone disease had a statistically significant higher iPTH levels (p<0.005). CONCLUSION: Bone disease and mineral abnormalities are common in hemodialysis patients at JUH. Earlier detection of bone disease and better overall management strategy may reduce the frequency and severity of bone disease in CKD patients in Jordan.