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   Table of Contents - Current issue
Coverpage
September-December 2017
Volume 5 | Issue 3
Page Nos. 199-287

Online since Monday, August 21, 2017

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EDITORIAL  

Does endotracheal intubation reduce the incidence of cardiopulmonary complications in upper gastrointestinal bleeding? p. 199
Abdulaziz A Al-Quorain
DOI:10.4103/sjmms.sjmms_91_17  
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REVIEW ARTICLES Top

Prophylactic endotracheal intubation in patients with upper gastrointestinal bleeding undergoing endoscopy: A systematic review and meta-analysis Highly accessed article p. 201
Fayez Alshamsi, Roman Jaeschke, Bandar Baw, Waleed Alhazzani
DOI:10.4103/sjmms.sjmms_95_17  
Background: Patients with upper gastrointestinal bleeding (UGIB) often require urgent or emergent esophagogastroduodenoscopy (EGD) and are at risk of complications such as aspiration of gastric content or blood. The role of prophylactic endotracheal intubation (PEI) in the absence of usual respiratory status-related indications is not well established. Methods: We searched Medline, EMBASE, Cochrane Library's Central Register of Controlled Trials (CENTRAL) and SCOPUS from inception through July 2017 without date or language of publication restriction. We included studies that compared PEI with usual care (UC) in patients with acute UGIB, and reported any of the following outcomes: aspiration, pneumonia, mortality and length of stay. We excluded studies in which majority of included patients required intubation due to respiratory failure or decreased level of consciousness. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the quality of evidence for each outcome. Results: We did not identify any randomized trials on this topic. We included 10 observational studies (n = 6068). We were not able to perform any adjusted analyses. PEI was associated with a significant increase in aspiration (OR 3.85, 95% CI, 1.46, 10.25; P = 0.01; I2 = 56%; low-quality evidence), pneumonia (OR 4.17, 95% CI, 1.82, 9.57; P = 0.0007; I2 =52%; low-quality evidence) and hospital length of stay (mean difference 0.86 days, 95% CI 0.13, 1.59; P = 0.02; I2 = 0; low-quality evidence), without clear effect on mortality (OR 1.92, 95% CI, 0.71, 5.23; P = 0.2; I2 = 95%; very low-quality evidence). Conclusions: Low- to very low-quality evidence from observational studies suggests that PEI in the setting of UGIB may be associated with higher rates of respiratory complications and, less likely, with increased mortality. Although the results are alarming, the lack of higher quality evidence calls for randomized trials to inform practice.
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Direct-acting oral anticoagulants: An overview Highly accessed article p. 210
Hatem H Salem
DOI:10.4103/sjmms.sjmms_83_17  
In today's practice, an increasing number of patients are prescribed anticoagulant therapy. Short-term anticoagulation as a primary or secondary prophylaxis of thrombosis is standard of care in many clinical indications. In addition, there has been a significant increase in the number of patients receiving long-term full therapeutic anticoagulation, particularly among patients with atrial fibrillation and those with venous thrombosis having a high risk of recurrence. Therefore, clinicians and patients warmly accepted the timely introduction of non-Vitamin K antagonists to clinical practice. Anticoagulants such as anti-Xaand antithrombin have been found to be effective and safe as compared with the standard of care using low-molecular-weight heparin and warfarin. Importantly, the new anticoagulants exhibit rapid onset of action and do not require regular monitoring, making them convenient and user-friendly. Another interesting and consistent observation is that the new anticoagulants have a lower incidence of intracranial bleeding as compared with warfarin therapy. However, before prescribing these drugs, clinicians should check and periodically monitor the renal function of their patients, particularly when new drugs known to affect renal function are introduced. Clinicians should also be aware that these new anticoagulants cannot be considered as a replacement for warfarin in all indications. For example, warfarin remains the drug of choice in patients with prosthetic valves and in those suffering from the antiphospholipid syndrome. Finally, clinicians should be aware and adhere to the appropriate indications for the use of these new anticoagulants and use them at their approved dosage.
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ORIGINAL ARTICLES Top

Evaluation of response to hepatitis B vaccination in chronic hemodialysis patients p. 218
Samir H Almueilo
DOI:10.4103/1658-631X.213302  
Background: Hemodialysis (HD) patients are at an increased risk of acquiring hepatitis B virus (HBV) infection. Active HBV immunization in these patients is recommended. A response rate in HD patients is variable but generally lower than healthy individuals. Objective: The aim of this study is to assess the response of HD patients to the HBV vaccine and correlate response and long-term immunity to various clinical and biomedical factors. Patients and Methods: One hundred and one patients, with a mean age 48.7 ± 18.5 years, received 40 μg of HBV vaccine administered intramuscularly in the deltoid region at 0, 1, 2 and 6 months. The patients' responses to the vaccine were determined by measuring hepatitis B surface antibody (HBsAb) 6 weeks after the last injection and monitored thereafter at 3-month intervals. Results: Seventy-one patients (70.3%) mounted a response with HBsAb >10 mIU/ml 6 weeks following the fourth dose of vaccine, and thus were considered considered as adequate responders. Forty-nine (48.5%) patients mounted an excellent response with HBsAb >100 mIU/ml 6 weeks after the fourth dose. Thirty patients (29.7%) were nonresponders. Responders were significantly younger than nonresponders (P = 0.01). Gender, hemoglobin level, serum albumin, ferritin, parathyroid hormone level and hepatitis C virus infection had no effect on the response to the vaccine. Similarly, there was no difference in diabetic state and adequacy of HD between the two groups. Fifty-nine patients (88%) had persistent protective antibodies at 1 year, while eight (12%) lost such protection. Predictors of persistent immunity at 1 year were high HBsAb level at the completion of the vaccination regime and, to a lesser extent, young age. Conclusion: A 70% response rate to HBV vaccine was observed in the cohort of this study. Young age predicts a favorable response to HBV vaccine in HD patients. High (>100 mIU/ml) HBsAb levels achieved at vaccine completion predict persistent immunity at 1 year.
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Rate and predictors of 1-year readmission in tertiary psychiatric hospitals p. 224
Afaf Ibrahim Al-Shehhi, Hamed Nasser Al-Sinawi, Sachin Jose, Randa Youssef
DOI:10.4103/1658-631X.213305  
Objective: To obtain the rate of 1-year readmission among psychiatric patients in tertiary centers in Oman and to study the association between readmission and sociodemographic and clinical factors. Methods: This is a retrospective study using data from patients' medical records. All patients aged ≥18 years who were admitted to Al Masarra Hospital and the psychiatric ward at Sultan Qaboos University Hospital over a 6-month period were included in the study. Each patient was followed up for 1 year after discharge to determine whether they had been readmitted during that period. The analysis was conducted as a comparative study between patients with early readmission and those who had not been readmitted during the 1-year period. Fifteen factors were examined for association with readmission within the 1-year period. Results: A total of 466 patients were admitted to the two hospitals during the study period, with 39% of these patients readmitted within 1 year. The univariate analysis revealed that 11 factors were significantly associated with 1-year readmission (P < 0.05). The multivariate logistic regression analysis identified four factors as independent significant predictors for 1-year rehospitalization: male gender, unemployment, nonadherence to medications and a history of previous hospitalization. Conclusion: The rate of 1-year readmission was found to be high, in line with the findings of other studies. Specific sociodemographic factors and clinical factors were strongly associated with early readmission in psychiatric hospitals in Oman. Strategies for aftercare and community psychiatric services need to be implemented.
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Mammographic parenchymal patterns in asymptomatic women p. 232
Halimat J Akande, Bolanle B Olafimihan, Olalekan I Oyinloye
DOI:10.4103/1658-631X.213309  
Background: Breast density has been found to be an independent risk factor for breast cancer. Mammographic breast parenchymal pattern or percent density is mainly a reflection of the proportion of glandular tissue to fatty tissue, and studies have shown that it works synergistically with other risk factors such as nulliparity in predicting breast cancer risk. This study analyses the various mammographic breast patterns and correlates this with some demographic variables and final Breast Imaging Reporting and Data System outcomes of asymptomatic women in our center. Materials and Methods: This is a prospective descriptive study of mammographic breast pattern in 459 females who presented at the breast imaging suite of our institution. Mammography was performed after completion of an assisted administered questionnaire for demographic information. A GE Senographe DMR machine using two standard views (craniocaudal and mediolateral oblique) and additional views were used when necessary. Results: A total of 459 women ranging in age from 34 to 80 years were included in the study, of which 46.6% were in the age range of 41 to 50 years. The scattered fibroglandular pattern was the most common pattern found (44%), and the homogeneous dense pattern was the least common (0.4%). A significant association with age and menopause status was found, while no association was found with age at the time of the woman's first delivery and family history of breast cancer. Conclusion: This study demonstrates that there is a significant association between breast cancer and age and menopause status. However, no correlation was found with the age of women at their first delivery and family history of breast cancer.
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Prevalence of self-reported medical conditions among dental patients p. 238
Mukhatar A Javali, Mohasin A Khader, Nabeeh A Al-Qahtani
DOI:10.4103/sjmms.sjmms_78_16  
Background: In general, it is important to assess the medical history of patients before initiating any treatment. In particular, patients seeking dental treatment could possibly have significant medical conditions that may affect the diagnosis and/or alter the treatment provided. However, many dentists assume that their patients are systemically healthy, and thus they do not record the medical history of their patients. Aim and Objective: This study aimed to determine the prevalence of medical conditions in patients seeking periodontal treatment at the dental teaching hospital of King Khalid University. Materials and Methods: Upon presentation at the periodontal clinics of the dental teaching hospital of King Khalid University, Asir Region, Saudi Arabia, patients' history from medical records was screened. Results: The medical history was taken for 455 periodontal patients. The most frequently encountered medical conditions were diabetes mellitus and hormonal disorders, followed by respiratory diseases and cardiovascular diseases. Conclusion: The results of our study found a high prevalence of medical conditions among patients seeking periodontal treatment, thereby highlighting the need to record patients' medical and dental care history in detail.
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Clinicopathologic patterns of adult renal tumors p. 242
Abdulkader M Albasri, Abeer A El-Siddig, Akbar S Hussainy, Ahmed S Alhujaily
DOI:10.4103/sjmms.sjmms_87_16  
Background and Aim: Adult renal tumors (ARTs) are rare as compared with tumors of other organs and systems; however, it is important to have demographic and pathology data of rare tumors, including ART. No such data are available from the Kingdom of Saudi Arabia (KSA). Therefore, we aimed to study the demographic and pathological data of ART from King Fahad Hospital, Al-Madinah, KSA. Materials and Methods: This is a retrospective study of computerized data from the histopathology laboratory of King Fahad Hospital during a 10-year period (January 2006–September 2015). Results: There were 42 cases of ART, comprising 28 males and 14 females (male:female ratio of 2:1). The study group ranged in age from 17 to 83 years, with a mean of 54.5 years. In the study cohort, 93% of the patients had malignant tumors and 7% had benign lesions. Renal cell carcinoma (RCC) accounted for 85.8% of cases, followed by squamous cell carcinoma and sarcoma. The benign tumors recorded in our series were oncocytoma (4.7%) and angiomyolipoma (2.4%). The tumor size of RCC ranged from 4 to 17 cm, with a mean of 7.4 cm. The majority of patients (68%) had Fuhrman Grade II tumor. Gross capsular invasion, renal vein invasion and lymph node metastases were present in one case each. Conclusion: We conclude that the pathological findings of ART from the Madinah region are in concordance with studies in national and international literature.
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Depression in patients with systemic lupus erythematosus: A multicenter study p. 248
Ibrahim Abdulrazag Al-Homood, Narges E Omran, Abdulrahman S Alwahibi, Maha Aldosoghy, Amal Alharthy, Ghassan S Aljohani
DOI:10.4103/sjmms.sjmms_79_16  
Background and Objective: Neuropsychiatric disorders including depression are common clinical manifestations of systemic lupus erythematosus (SLE). Depression in patients with SLE is under-recognized, although it is a treatable clinical entity. The present study aimed to determine the prevalence of depression and identify the relationship between depression and SLE disease characteristics. Patients and Methods: This multicenter cross-sectional study was conducted in the rheumatology clinics of four tertiary referral hospitals in Saudi Arabia between April and September 2014. Patients' demographic data and SLE disease characteristics such as disease duration, severity and drug treatments were collected. A validated Arabic Beck Depression Inventory (BDI) score was used to estimate the prevalence of depression. Results: A total of 68 patients with SLE (64 women, 4 men) were enrolled in the study. Forty-six (67.6%) patients were found to have BDI scores indicating depression; of them, only four patients (8.7%) were receiving antidepressant treatments. Higher prevalence of depression was associated with steroid treatment (P = 0.046). Conclusions: The study results revealed high prevalence of depression among Saudi patients with SLE. Most of the study population were not adequately treated, suggesting inadequate recognition and treatment of depression in SLE.
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Patient's bill of rights: Is it a challenge for quality health care in Saudi Arabia? p. 254
Mohamed S Mahrous
DOI:10.4103/sjmms.sjmms_147_16  
Background: Increasing interest in patients' rights and the certainty of its impact on the quality of patient care has led to extensive research in both developed and developing countries. In 2006, the Government of Saudi Arabia publicized the Patient's Bill of Rights (PBR) that was aimed at improving patients' and health-care professionals' experience, with a focus on the quality of care provided. Objective: To determine the degree of awareness of rights among patients admitted to hospitals in Al-Madinah Al-Munawarah. The results would help policymakers understand the impact of patients' rights, and thus provide them with evidence to provide quality health-care service delivery and patient care through patients' rights. Methodology: This is an observational, analytical, cross-sectional study implemented in Al-Madinah Al-Munawarah, Saudi Arabia, using a self-administered questionnaire. Results: The study had a response rate of 83.01% and found an association between gender and knowledge for the selected items of patients' rights. However, there was no statistically significant difference between the knowledge of males and females regarding the consent form, with an awareness rate of 90% among the total sample size. However, almost half had never heard about patients' rights. Conclusion: This study shows that in Al-Madinah Al-Munawarah, Saudi Arabia, there is a low level of awareness among patients admitted to hospitals regarding their rights. Further, it was found that wall placards, mass media and health-care providers are important sources of knowledge regarding patients' rights. Health-care policymakers in Saudi Arabia should recognize the importance of patients' rights as means of providing better quality care and a higher rate of patient satisfaction by establishing measures to tackle obstacles that may impede the implementation of PBR.
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Reducing hospital-acquired infection rate using the Six Sigma DMAIC approach p. 260
Ahmed Al Kuwaiti, Arun Vijay Subbarayalu
DOI:10.4103/sjmms.sjmms_98_16  
Background: Hospital-acquired infection (HAI) is one of the most common complications occurring in a hospital setting. Although previous studies have demonstrated the application of data-driven Six Sigma DMAIC (Define, Measure, Analyze, Improve and Control) methodology in various health-care settings, no such studies have been conducted on HAI in the Saudi Arabian context. Objective: The purpose of this research was to study the effect of the Six Sigma DMAIC approach in reducing the HAI rate at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia. Methods: Historical data on HAI reported at inpatient units of the hospital between January and December 2013 were collected, and the overall HAI rate for the year 2013 was determined. The Six Sigma DMAIC approach was then prospectively implemented between January and December 2014, and its effect in reducing the HAI rate was evaluated through five phases. The incidence of HAI in 2013 was used as the problem and a 30% reduction from 4.18 by the end of 2014 was set as the project goal. Potential causes contributing to HAI were identified by root cause analysis, following which appropriate improvement strategies were implemented and then the pre- and postintervention HAI rates were compared. Results: The overall HAI rate was observed as 4.18. After implementing improvement strategies, the HAI rate significantly reduced from 3.92 during the preintervention phase ( first quarter of 2014) to 2.73 during the postintervention phase (third quarter of 2014) (P < 0.05). A control plan was also executed to sustain this improvement. Conclusion: The results show that the Six Sigma “DMAIC” approach is effective in reducing the HAI rate.
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CASE REPORTS Top

Common findings in blunt thyroid fracture p. 267
Muneera Al-Khalifa, Fatima Buali, Mohamed Alshehabi
DOI:10.4103/1658-631X.213306  
Although blunt neck trauma is known to be rare, occurring in approximately 5% of all neck traumas, undiagnosed cases may have a devastating outcome. Physicians need to fully understand the mechanism of the injury and the external laryngeal trauma signs. A physician's precise diagnosis and proper management are necessary to avoid long-term complications or death. Although blunt laryngeal injuries are uncommon, prompt recognition of the subtle signs is crucial to avoid the catastrophic complications associated with such injuries. This case report aims to demonstrate the symptoms and signs of laryngeal injury in a young healthy male following a road traffic accident.
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Bronchiectasis and focal segmental glomerulosclerosis in rheumatoid arthritis p. 271
Arunabha D Chaudhuri, Sumit R Tapadar, Saurav Kar, Sayantan Saha
DOI:10.4103/1658-631X.213303  
A 28-year-old male patient who was a nonsmoker presented with bilateral symmetrical polyarthritis and polyarthralgia, suggestive of rheumatoid arthritis (RA), along with shortness of breath, fever and cough, suggestive of chronic renal failure and nephrotic range proteinuria. The chest radiograph was suggestive of panacinar emphysematous changes with bilateral central bronchiectasis. The patient reported that two of his brothers had died in their third decade because of renal failure. Renal biopsy showed focal and segmental glomerulosclerosis (FSGS). FSGS with panacinar emphysema and bronchiectasis is a rare entity in RA patients, and considering the possibilities of a familial pattern of FSGS, transient receptor potential cation channel 6 channelopathy was the most valid diagnosis.
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Spontaneous tubercular enterocutaneous fistula p. 275
Mudassar Shah, Munir A Wani
DOI:10.4103/1658-631X.213301  
Spontaneous enterocutaneous fistula can occur in patients with Crohn's disease, malignancy, typhoid or radiation exposure. Tuberculosis is a rare cause of enterocutaneous fistula. A 60-year-old female with no significant previous history presented with a feculent discharge from a fistulous opening on the right gluteal region for 3 months. There was also a history of extrusion of multiple Ascaris worms through the opening. Abdominal ultrasonography showed no intraperitoneal fluid collections. A contrast-enhanced computed tomography of the abdomen, magnetic resonance (MR) imaging and MR fistulogram revealed cortical destruction of the right iliac bone with fluid coursing along a tract, from the small gut loops attached to bone internally through the iliac bone to the soft tissues in the right gluteal region before opening on the skin. A biopsy from the tissue of the fistula site revealed tuberculosis. The patient responded well to conservative management and was discharged after 4 weeks.
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Sudden visual loss as an initial manifestation of chronic myeloid leukemia p. 278
Ahmed N Buzaid, Ali M Al-Amri
DOI:10.4103/sjmms.sjmms_35_16  
Chronic myelogenous leukemia (CML) is a pluripotent stem cell disease characterized by anemia, granulocytosis and granulocytic immaturity, basophilia, thrombocytosis and splenomegaly. It is associated with a reciprocal chromosomal translocation t (q34; q11), resulting in a breakpoint cluster region–Abelson fusion gene (Philadelphia chromosome). Ophthalmic manifestations as the first and the only presentation of CML in patients are very rare. Ocular lesions in CML patients are frequently asymptomatic, and thus all patients should undergo an eye evaluation at the initial diagnosis. Here, we report a previously healthy 36-year-old Saudi male who initially presented with progressive loss of vision. On examination, he was found to have a bilateral retinal hemorrhage. The investigations revealed findings consistent with CML. The patient was treated with tyrosine kinase inhibitors, and he had complete remission, including full recovery of his vision.
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LETTERS TO THE EDITOR Top

Luteoma of pregnancy masquerading as ectopic pregnancy: Lessons learnt p. 281
Ruchi Rathore, Akshi Katyal, Shilpi , Namrata Nargotra
DOI:10.4103/sjmms.sjmms_50_17  
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Early-onset evans syndrome in a 4-month-old infant: A case report and review of literature p. 284
Mahmood D Al-Mendalawi
DOI:10.4103/sjmms.sjmms_60_17  
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IMAGE QUIZ Top

An overlooked dermatosis p. 285
Manal Al Rabai
DOI:10.4103/sjmms.sjmms_75_17  
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