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   Table of Contents - Current issue
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September-December 2020
Volume 8 | Issue 3
Page Nos. 165-245

Online since Thursday, August 20, 2020

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REVIEW ARTICLE  

Management of diabetic ketoacidosis in adults: A narrative review Highly accessed article p. 165
Mohsen S Eledrisi, Abdel-Naser Elzouki
DOI:10.4103/sjmms.sjmms_478_19  
Diabetic ketoacidosis (DKA) is the most common hyperglycemic emergency and causes the greatest risk for death in patients with diabetes mellitus. DKA more commonly occurs among those with type 1 diabetes, yet almost a third of the cases occur among those with type 2 diabetes. Although mortality rates from DKA have declined to low levels in general, it continues to be high in many developing countries. DKA is characterized by hyperglycemia, metabolic acidosis and ketosis. Proper management of DKA requires hospitalization for aggressive intravenous fluids, insulin therapy, electrolyte replacement as well as identification and treatment of the underlying precipitating event along with frequent monitoring of patient's clinical and laboratory states. The most common precipitating causes for DKA include infections, new diagnosis of diabetes and nonadherence to insulin therapy. Clinicians should be aware of the occurrence of DKA in patients prescribed sodium-glucose co-transporter 2 inhibitors. Discharge plans should include appropriate choice and dosing of insulin regimens and interventions to prevent recurrence of DKA. Future episodes of DKA can be reduced through patient education programs focusing on adherence to insulin and self-care guidelines during illness and improved access to medical providers. New approaches such as extended availability of phone services, use of telemedicine and utilization of public campaigns can provide further support for the prevention of DKA.
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ORIGINAL ARTICLES Top

Association of four missense SNPs with preeclampsia in Saudi women p. 174
Nada Mohammed Aljuaid, Ebtesam Ibrahim Muharram, Nouf Nasser Loqtum, Reem Mohammed Al-Amoudi, Hadiah Bassam AlMahdi, Mohammed Assem Salama, Babajan Banaganapalli, Noor Ahmad Shaik, Ramu Elango, Nabeel Salem Bondagji
DOI:10.4103/sjmms.sjmms_280_19  
Objective: The objective of this study was to investigate the association of rs1051740, rs2234922 (in microsomal epoxide hydrolase 1; EPHX1), rs268 (in lipoprotein lipase; LPL) and rs6025 (in Factor V Leiden; F5) genetic variants with the risk of preeclampsia development in Saudi women. Materials and Methods: This case–control study recruited 233 Saudi women (94 preeclampsia cases and 139 healthy controls) who visited the Gynecology and Obstetrics Departments of two hospitals in Jeddah, Saudi Arabia, for routine postpregnancy clinical follow-ups. All the women underwent thorough clinical and biochemical investigations conducted according to the standard clinical guidelines. Genotyping of the study participants was done using real-time polymerase chain reaction-based TaqMan allelic discrimination assay. The strength of the association between genetic variants and disease development was assessed using chi-square, odds ratio, 95% confidence interval and multifactor dimensionality reduction tests. Result: The minor alleles “G” in rs268 (LPL) and “A” in rs6025 (F5) were absent in Saudi women. The frequencies of rs1051740 and rs2234922 of EPHX1, both in the homozygous and allelic forms, were not significantly different between preeclampsia patients and healthy controls (for all tests, P > 0.05). The multifactor dimensionality reduction analysis also indicated that the interaction between the four studied single-nucleotide polymorphisms (SNPs) had no significant association with preeclampsia risk. Conclusion: This study found that none of the studied genetic variants (neither the single SNP nor the SNP–SNP interactions) explain the development of preeclampsia in the Saudi population. These findings not only underscore the disease heterogeneity but also highlight the need to develop population-specific diagnostic genetic biomarkers for preeclampsia.
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Short-term efficacy of kinesiotaping versus extracorporeal shockwave therapy for plantar fasciitis: A randomized study p. 181
Nihal Tezel, Ebru Umay, Musa Bulut, Aytul Cakci
DOI:10.4103/sjmms.sjmms_624_19  
Background: Plantar fasciitis is a degenerative condition that is one of the most common causes of heel and foot pain. Among noninvasive management of plantar fasciitis, extracorporeal shockwave therapy (ESWT) has been extensively studied and found to be effective, but few studies have assessed the effectiveness of kinesiotaping (KT) method. Objective: This study aimed to show the effectiveness of KT compared with ESWT in the management of plantar fasciitis. Methods: A total of 84 patients with plantar fasciitis were enrolled from a single center and randomized into KT and ESWT treatment groups in a 1:1 ratio (i.e., 42 patients in each group); only one foot was considered for each patient. Both KT and ESWT were applied once a week for 6 weeks. Patients' pain, functional status and quality of life were evaluated with the visual analog scale (VAS), Foot Function Index (FFI) and the Short-Form-36 (SF-36) health survey, respectively. Patients' fat pat and plantar fascia thickness were measured using ultrasonography. All evaluations were performed before and immediately after the 6-week intervention. Results: In the KT group, six patients were lost to follow-up; therefore, the final analysis only included 36 patients. After the intervention, there was a statistically significant improvement in the VAS and SF-36 scores of both groups (P = 0.001), but the FFI score improvement was statistically significant only in the KT group (P = 0.001). In both groups, the mean thickness of plantar fascia decreased after treatment and the mean thickness of the fat pat increased; however, the change was not statistically significant (P = 0.935 and P = 0.832, respectively). Conclusion: Both KT and ESWT treatments improved pain levels and quality of life in patients with plantar fasciitis, but KT also improved functionality. Multicentered studies with larger sample size and longer follow-ups are required to further validate these findings.
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TaqI and ApaI variants of Vitamin D receptor gene increase the risk of colorectal cancer in a Saudi population p. 188
Ayat B Al-Ghafari, Khadijah S Balamash, Huda A Al Doghaither
DOI:10.4103/sjmms.sjmms_357_19  
Background: Polymorphisms in the gene encoding the vitamin D receptor (VDR) affect the protective role of vitamin D against many types of cancers, including colorectal cancer (CRC). Objective: The objective of this study was to assess the effect of four major polymorphisms of the VDR gene (ApaI, TaqI, BsmI and FokI) on the risk of CRC in a Saudi population. Materials and Methods: This case–control study recruited 132 CRC patients from the oncology clinics at King Abdulaziz University Hospital and 124 healthy controls from the blood bank at King Fahad General Hospital, Jeddah, Saudi Arabia, between September 2017 and August 2018. All participants were Saudis and aged 20–80 years. Genomic DNA samples were extracted from the peripheral blood cells and amplified with polymerase chain reaction. The resulting fragments were digested with different endonucleases to reveal the genotypes using the restriction fragment length polymorphism technique. The genotype distribution and allele frequency, odds ratio (OR), risk ratio (RR) and P values were determined with contingency table analysis following Hardy–Weinberg equilibrium equation. Results: For the ApaI single-nucleotide polymorphism (SNP) (rs7975232), only the heterozygous (Aa) genotype increased the risk of CRC (OR = 3.4, RR = 2.3, and P < 0.0001), whereas the TaqI SNP (rs731236) carriers with either the heterozygous (Tt) or homozygous (tt) genotype displayed an increased risk for the disease (OR = 6.18, RR = 4, P < 0.0001; OR = 3, RR = 2.4, P = 0.02, respectively). In contrast, heterozygous (Bb) and homozygous (bb) carriers of the BsmI SNP (rs1544410) had significantly lower risk for CRC (P < 0.0001). Finally, for the FokI SNP (rs2228570), there was no association with CRC risk. Conclusion: This study found that VDR SNPs ApaI and TaqI increase the risk of CRC, whereas BsmI reduces the risk of CRC in the selected Saudi population. Therefore, ApaI and TaqI SNPs could potentially be used as a diagnostic biomarker for CRC. However, the molecular mechanisms by which these variants increase or decrease the risk of CRC need to be investigated.
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Role of glucuronidation pathway in quetiapine metabolism: An in vivo drug–drug interaction study between quetiapine and probenecid p. 196
Haseeb Sattar, Sarmad Sheraz Jadoon, Ni Yang, Shihong Li, Mingzhen Xu, Yong Han, Adil Ramzan, Weiyong Li
DOI:10.4103/sjmms.sjmms_441_19  
Background: Uridine 5'-diphospho-glucuronosyltransferase (UGT) enzymes play a significant role in the metabolism of quetiapine, and coadministration with a UGT inhibitor/inducer drug may change its pharmacokinetic profile. Objective: The objective of this study was to assess the impact of probenecid, a UGT enzyme inhibitor, on the pharmacokinetic profile of quetiapine. Materials and Methods: Twelve treatment-naïve, 7-week-old male Sprague–Dawley rats (weighting 161 ± 22 g) were randomly and equally divided into control, quetiapine-alone and quetiapine plus probenecid groups. The quetiapine plus probenecid group received a single oral dose of probenecid (50 mg/kg) followed by 50 mg/kg of quetiapine; the quetiapine-alone group only received 50 mg/kg of quetiapine. Blood samples (0.2 ml) were collected from all rats after 0, 0.25, 0.5, 1, 2, 4, 6, 8, 10, 12 and 24 h of the drug administration in heparinized tubes. The pre-established liquid chromatography–mass spectrometry method was utilized to ascertain the plasma concentration of quetiapine and the control group was used to prepare the controlled standard. Results: Significant pharmacokinetic differences were observed between the quetiapine-alone and quetiapine plus probenecid groups in terms of Cmax (392 ± 209 vs. 1323 ± 343 ug/L, respectively, P = 0.004), AUC0-∞ (P = 0.04) and Tmax (P = 0.004). Further, in the combined drug group, there was a decrease in drug clearance (CL/F) (from 27 ± 11 to 16 ± 3 L/h/kg; P = 0.005) and an increase in the volume of distribution (Vd) (P = 0.01), but there was no significant difference between both groups in terms of half-lives (P = 0.27). No significant within-group variability of pharmacokinetic parameters was observed (P = 0.25). Conclusion: The results of this animal study suggest that glucuronidation by UGT enzyme system may also play an important role in quetiapine metabolism, which, if proven in future human studies, would imply that the bioavailability and pharmacokinetic parameters of quetiapine may require alterations when co-administered with probenecid to avoid development of quetiapine toxicity.
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Antibacterial activity of Ritchiea albersii Gilg and Cynoglossum amplifolium leaves extracts against selected bacteria p. 201
Hizkel Engiso, Teshale Worku, Dejen Nureye, Mohammed Salahaddin, Workineh Woldeselassie, Solomon Hambisa, Nymathullah Sharief
DOI:10.4103/sjmms.sjmms_276_19  
Background: The increase in antimicrobial resistance worldwide has necessitated the search for alternative therapeutic agents. The leaf extracts of Ritchiea albersii and Cynoglossum amplifolium have been used as traditional medicine for the management of eye, ear and wound infections in Ethiopia. Objective: The objective of the study was to evaluate the antibacterial activity of R. albersii and C. amplifolium against three common bacteria. Materials and Methods: In this experimental study, the antimicrobial properties of 80% methanol, chloroform and acetone extracts of R. albersii and C. amplifolium were evaluated against two Gram-positive bacteria (Staphylococcus aureus ATCC 25923 and Streptococcus pneumoniae ATCC 49619) and one Gram-negative bacterium (Escherichia coli ATCC 25922) using the agar-well diffusion method. Ciprofloxacin 0.05 mg/disc was used as a positive control. Furthermore, a preliminary phytochemical study was carried out. Results: The zones of inhibition shown by all extracts of the two plants against the tested bacteria were significantly lesser (P < 0.05) than the standard drug. E. coli and S. aureus were the most susceptible strains for most extracts studied. The acetone extract of R. albersii exhibited a higher inhibitory effect (P < 0.05) against S. pneumoniae (16 mm) and E. coli (19 mm) compared with its methanol extract. The chloroform extract of R. albersii was more effective than its methanol extract (P < 0.05) against all tested bacteria. The acetone extract of C. amplifolium displayed a higher inhibitory effect (20 mm) against E. coli than its methanol and chloroform extracts. Conclusions: The leaf extracts of R. albersii and C. amplifolium exhibited broad-spectrum antimicrobial activity, highlighting their potential as phytotherapeutic drugs in preventing and treating infections caused by S. aureus, S. pneumoniae and E. coli. Further investigations for isolating specific compounds and elucidating mechanisms are required to address the need for novel antibacterial drugs.
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Histologic reliability of tissues from embalmed cadavers: Can they be useful in medical education? p. 208
Abdulaziz K Abuhaimed, Abdulaziz M Almulhim, Faris A Alarfaj, Salam S Almustafa, Khulood M Alkhater, Mohammed J Al Yousef, Methal I Al Bayat, Mohammed Madadin, Ritesh G Menezes
DOI:10.4103/sjmms.sjmms_383_19  
Background: Current trends in medical curricula are shifting from teaching histology and pathology as stand-alone disciplines. Therefore, it would be useful to examine the potential value of integrating these into the anatomical dissection experience. Objectives: The aim of this study was to assess the histologic reliability of tissues taken from embalmed cadavers in an anatomy laboratory. Materials and Methods: A total of 112 tissue samples were obtained using standard autopsy techniques from various organs (heart, lung, thyroid, skeletal muscle, bone and skin) of 11 cadavers available at the anatomy laboratory of Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia, in 2019. Samples were prepared using the standard paraffin procedure followed by cutting sections at 4-μm thickness and staining with standard hematoxylin and eosin stain. Using predefined criteria, the quality of the samples was evaluated by two board-certified histopathologists and each slide was categorized as good, satisfactory or poor. Results: Overall, 34.2% and 60.3% of the slides were of good and satisfactory quality, respectively. A significant difference in tissue quality was found between various organs. Thick skin and bone tissues had the highest “good” rating (84.6% and 81.8%, respectively), while thyroid and lung tissues had the highest “poor” rating (20% and 13.6%, respectively). Conclusion: Most of the tissues acquired from the embalmed cadavers were of good or satisfactory quality, thereby indicating the beneficial use of histological tissue from cadavers for educational purposes. Future research into how these findings translate into meaningful medical education would be beneficial.
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CASE REPORTS Top

A case report of twin pregnancy with hydatidiform mole and co-existing live fetus p. 213
Alokananda Ray, Sarita Kumari
DOI:10.4103/sjmms.sjmms_332_19  
Complete hydatidiform mole with co-existing live fetus (CHMF) is a rare and high-risk pregnancy usually seen with ovulation induction protocols. These pregnancies are complicated with vaginal bleeding, pre-eclampsia, miscarriage, preterm delivery, fetal demise and the risk of gestational trophoblastic neoplasia (GTN). Here, we describe a case of CHMF and a second case of monozygotic twins: partial mole with live fetuses. The pregnancies were conceived after clomiphene citrate ovulation induction. Both cases presented with vaginal bleeding and hyperemesis in the early mid-trimester. The diagnosis was based on history, examination, ultrasound findings and high serum beta-human chorionic gonadotropin (βHCG) levels. A CHMF can be differentiated from a singleton partial molar pregnancy with similar ultrasound appearance by amniocentesis and karyotyping of the live fetus, which is a normal diploid. After adequate counseling, both women refused prenatal karyotyping and underwent the termination of pregnancy. The method of termination needs to be carefully decided. Surgical evacuation maybe difficult due to the well-formed fetus in the second trimester, and uterotonic agents can be associated with the risk of trophoblastic embolization and GTN. Termination with misoprostol followed by ultrasound-guided suction evacuation was successfully done in both cases. Histopathology and karyotyping confirmed the diagnosis of CHMF in the first and partial mole in the second case. βHCG normalized within 7 weeks postevacuation in both, with no increased risk of trophoblastic embolization or GTN. More studies are needed on the methods of termination in such pregnancies. Medical termination with misoprostol appears to be a viable option, though the optimal dosage is yet to be defined.
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Three-factorial genetic thrombophilia with recurrent thrombotic events in a Saudi patient: A case report p. 217
Osama A Al Sultan, Eman A Al Ibrahim
DOI:10.4103/sjmms.sjmms_231_18  
Thrombophilia is caused by several genetic and acquired factors. Existence of more than one genetic factor may increase the risk of developing recurrent thrombotic events. Here, we present a case of a 48-year-old male with a known history of deep venous thrombosis and a known mutation in factor V Leiden combined with mild protein S deficiency, who presented with a painful swelling in the left leg. Moreover, the patient had a history of diabetes, dyslipidemia and obesity. Prothrombin time and platelet count were within the normal range. The international normalized ratio and activated partial thromboplastin time were 3.21 and 36.7 s, respectively. The Doppler study showed a thrombus in the saphenous vein, and complementary genetic screening investigations revealed heterozygous mutation for prothrombin (G20210A). A diagnosis of multifactorial genetic thrombophilia was established. The patient was treated with warfarin, which resulted in significant improvement in the follow-ups, and at the time of reporting this case, there were no clinical or biological signs of thrombosis. The presence of multiple hereditary and acquired thrombophilic factors is a rare clinical presentation that requires close monitoring, for which a lifelong anticoagulation therapy should be discussed based on the clinical response of the patient.
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Mesenteric vasculitis as a rare initial presentation of systemic lupus erythematosus: A case report p. 223
Abdullah Mohammed Alshehri, Hanady Mohammed Alhumaidi, Yahia Modawi Asseri, Mohamed Elbagir K. Ahmed, Haider A Omer
DOI:10.4103/sjmms.sjmms_206_19  
Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease that can also affect the gastrointestinal tract (GIT). The GIT symptoms are common in SLE patients, occurring in up to 40%–50% of the patients and may involve almost any organ along the GIT. Abdominal pain is the most common symptom, and an important cause of this is lupus mesenteric vasculitis (LMV). LMV is a very rare presentation of SLE, and in some cases, can precede the typical manifestations of SLE. Here, we report such a case where a 30-year-old Saudi woman presented clinically with a 2-week abdominal pain and diarrhea; the patient had not previously been diagnosed with SLE. Laboratory investigations and abdomen computed tomography imaging confirmed the diagnosis of LMV. Early recognition of this condition and its proper management improve the outcome of this serious rare initial presentation of SLE.
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CLINICAL GUIDELINES Top

Saudi lymphoma group's clinical practice guidelines for diagnosis, management and follow-up of patients with various types of lymphoma during the Coronavirus Disease 2019 pandemic p. 227
Musa Alzahrani, Mubarak M Al-Mansour, John Apostolidis, Ahmed Barefah, Reyad Dada, Ayman Alhejazi, Yasir Alayed, Ibraheem Motabi, Mansoor Radwi, Hani Al-Hashmi
DOI:10.4103/sjmms.sjmms_457_20  
The Saudi Lymphoma Group had previously published recommendations on the management of the major subtypes of lymphoma. However, the effect the currently ongoing coronavirus disease 2019 (COVID-19) pandemic has on the management of patients with lymphoma has been paramount. Therefore, the Saudi Lymphoma Group has decided to provide clinical practice guidelines for the diagnosis, management and follow-up of patients with various types of lymphoma during the COVID-19 pandemic.
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LETTERS TO THE EDITOR Top

Barriers to preparation of case reports among Japanese general practitioners p. 239
Tsuneaki Kenzaka, Momoka Kamada
DOI:10.4103/sjmms.sjmms_604_19  
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Empagliflozin-induced euglycemic diabetic ketoacidosis in type 2 diabetes mellitus p. 241
Muneerah M Albugami, Mohammed Ahmed, Dhari Alobaid
DOI:10.4103/sjmms.sjmms_325_20  
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ARABIC ABSTRACTS Top

Arabic Abstracts p. 243
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