Fahd A. Al-Muhanna

Breast cancer in the eastern province of Saudi Arabia.

In the Kingdom of Saudi Arabia (KSA), hospital and population based statistics have shown that breast cancer has the highest crude frequency rate among Saudi women. The scarcity of reports about the disease in the KSA has been the impetus to this analysis about breast cancer in the eastem province of KSA. Data on female patients with invasive breast carcinoma seen at King Fahd Hospital of the University in the eastern province of KSA, were retrospectively reviewed. The analysis intended to examine the pattern of the disease and the outcome for patients. Between 1985 and 1995, 292 patients were identified. Their median age±SD (standard deviation) was 42±10.5 years. Most patients were younger than 50 years (78%) and were predominantly premenopausals (79%). Only 25 (9%) of patients had stage I cancer, whilst 130 (44%), 90 (30%), and 47 (16%) had stage II, III, and IV, respectively. Among patients with known axillary nodal status (242 patients), only 37% were node-negative whilst 32% and 31% had 1–3, and ≥4 positive nodes, respectively. Adjuvant chemotherapy and tamoxifen were commonly offered; nonetheless, other adjuvant modalities were rarely utilised. The median follow-up ±SD of all patients was 62.3±8.9 months: 152 patients (52%) were alive with no evidence of disease, 25 (9%) were alive with evidence of disease, and 115 (39%) were dead from breast cancer or its related complications. The median survival of the entire group was not obtained, but the 10-year projected survival was 55%. For stage I and II patients, 118 (76%) were alive with a projected 10-year actuarial survival of 64%. On the other hand, only 51 (57%) of patients with stage III disease were alive with a median survival of 41.5 months (95% Confidence interval (CI), 18.9 to 51.3). Patients with stage IV disease demonstrated a poor outcome with a median survival of 23.5 (95%, CI 12.2 to 31.4). Multivariate analyses were performed to explore the influence of independent variables on overall survival (OS) for patients with non-metastatic disease. Besides the expected adverse effect of disease progression, the favourable influence of adjuvant chemotherapy and tamoxifen prevailed. The amount of benefit gained from tamoxifen, however, was small. Similar analyses were undertaken to determine the influence of independent variables on progression-free survival (PFS). These analyses ascertained the adverse effects of advanced stage and the favourable impact of adjuvant chemotherapy. Breast cancer in the KSA has features that are distinctive from those of industrialised countries. Survival data, however, were comparable. The favourable influence of adjuvant chemotherapy was evident on both OS and PFS. Adjuvant tamoxifen, however, had little effect. Due to its infrequent use, the role of other adjuvant modalities could not be asserted.

Postmenopausal osteoporosis in Saudi women: A pilot screening.

One hundred and ten radiographs of calcaneum were reviewed for postmenopausal osteoporosis in Saudi women. These patients had presented to the emergency room with unrelated complaints. The mean (+/- SD) age of this group was 58 (+/-8.9) years with a range of 45 to 80 years. Of these eighty-six (76%) patients had osteoporosis; of these, 42 had mild osteoporosis, 31 had frank osteoporosis, and 11 were diagnosed to have sever osteoporosis. Women with severe osteoporosis were significantly older than those with mild (P=0.0417) as those who were normal (P=0.002). This study indicates a high prevalence of postmenopausal osteoporosis in Saudi women and multicenter, large scale screening should be instituted to determine the incidence of postmenopausal osteoporosis among Saudi women.

Medical ethics and tomorrow's physicians: an aspect of coverage in the formal curriculum

Medical ethics has created contentious issues and requires reforms in medical education such as renewed emphasis on formal instruction. The aim here was to review the current status of bioethics teaching in medical schools, determine Saudi students’ perception of its coverage in the formal curriculum and make recommendations. Using a self-administered questionnaire in a cross-sectional study, undergraduate students’ opinion about medical ethics coverage was obtained. Fourteen clinical departments and 201 students were studied. Only 46% of respondents were satisfied with the current coverage of ethical issues in the formal curriculum; 23% were unaware of the value of the subject. Students’ approval rate was highest in Neurology and Psychiatry (70%). The study confirmed inadequate formal instruction on medical ethics in a developing country. Five recommendations are made. At admission, students’ integrity and character should be assessed. Bioethics should be taught in clinical settings. In the Islamic world, medical curricula should include the Islamic code of medical ethics. Peers, nurses and patients should evaluate graduates’ performance in ethics at the bedside. Evidence-based assessment and continuous quality improvement are required to maintain the requisite standard.

β 2 -adrenergic receptor gene polymorphisms in normal and in patients with myocardial infarction in the eastern province of Saudi Arabia

Introduction: Single nucleotide polymorphisms (SNPs) of the β2 -adrenergic receptor (β2 -AR) gene have been implicated in the pathogenesis of cardiovascular diseases. This study evaluated two β2 -AR SNPs in association with myocardial infarction (MI), namely arginine-glycine (G16R) substitution at codon 16 and glutamine-glutamic (Q27E) substitution at condon 27. Objectives: Therefore, our main objective was to determine the association of these two SNPs among patients with MI with and without type 2 diabetes (T2D). Materials and Methods: Blood samples were collected from 201 MI patients with and without diabetes and from 115 controls and the β2 -AR gene polymorphisms at codon 16 and codon 27 were assessed by restriction fragment length polymorphism. The χ2 test was used to compare differences between groups. Results: The SNPs did not deviate significantly from Hardy-Weinberg equilibrium in the control population. The allele and genotype frequencies of the β2 -AR gene polymorphism at codon 16 (G16R) was significantly different between MI cases and controls (χ2 = 10.495, P < 0.05 and χ2 = 8.849, P < 0.05, respectively). No significant difference in genotype and allele frequencies at codon 27 was shown between these two groups (χ2 = 2.661, P ≥ 0.05 and χ2 = 1.587, P ≥ 0.05, respectively). When the MI patients with and without T2D were pooled together, genotype distribution was different between cases and controls at codon 16 (χ2 = 4.631, P = 0.099) and codon 27 (χ2 = 7.247, P = 0.027). However, no significant differences were found in allele frequencies for codon 16 and codon 27 between the two groups (χ2 = 0.628, P = 0.428; χ2 = 0.33, P = 0.565, respectively). Conclusion: Our findings indicate a moderate association of the β2 -AR G16R gene polymorphism with MI suggesting that this gene plays a universal role in the development of MI across ethnicities. However, there was no association of β2 -AR G16R gene polymorphism with diabetic patients with MI.

Unresolved issues and current concepts in management of primary glomerulonephritis.

The successful treatment of primary glomerulonephritis (GN) presenting with nephrotic syndrome in adults depends heavily on an accurate diagnosis. A successful diagnosis depends on a correct approach, combining light microscopy, immunofluorescence, and other special staining of renal biopsy material examined by a trained nephropathologist. A good clinical history and serological tests easily rule out possible secondary causes (for example, infection, autoimmune, metabolic or toxic) in most cases. Unfortunately, these procedures are not put into practice in most cases in developing countries, resulting in missed diagnosis and unnecessary steroid and immunosuppressant therapy with its inherent morbidity. Following the emergence of IgA and IgM nephropathies as very common forms of glomerular disorders in some countries, immunofluorescence has become absolutely necessary for their diagnosis. Moreover, a recent meta-analysis has defined different treatment protocols for minimal change nephropathy, focal segmental glomerulosclerosis, membranous nephropathy, and IgA nephropathy for a better outcome. This article emphasizes and elaborates on these issues for proper management of primary GN.

A Clinicopathologic Study of Glomerular Disease: Experience of the King Fahd Hospital of the University, Eastern Province, Saudi Arabia

Published studies from different centers in Saudi Arabia have reported contradicting results regarding glomerular lesions. In this retrospective study, we report our experience in King Fahd Hospital of the University at Al-Khobar in the Eastern province, including a description of the morphologic and clinical characteristics of primary and secondary glomerular disease. The study included 233 renal biopsies obtained from patients presenting with glomerular manifestations over a period of 23 years (1986–2008), investigated by light microscopy, immunofluorescence (149 cases) and electron microscopy (34 cases). One hundred and eighty-seven cases (80.3%) were primary glomerulonephritides. Minimal change glomerulopathy was the most common type of primary glomerulonephritis found (29.4% of primary glomerulonephritides), followed by mesangioproliferative glomerulonephritis (19.8%), and focal/segmental glomerulosclerosis (15.5%). Membranoproliferative glomerulonephritis was found in 9.6% of cases, membranous glomerulopathy in 8.6%, IgA nephropathy in 6.4%, end-stage glomerulopathy in 5.9%, crescentic glomerulonephritis in 3.2%, and IgM nephropathy in 1.6%. Of the secondary glomerulonephritides (46 cases constituting 19.7% of the biopsies), lupus nephritis was the most frequently diagnosed disease (71.7% of secondary glomerulonephritides). Diabetic glomerulosclerosis was found in 10.9% of cases, amyloidosis in 6.5%, and Alport syndrome in 4.3%. Wegeners granulomatosis, Henoch-Schonlein purpura nephritis and hypertensive nephrosclerosis each represented 2.2% of cases (one case each). Other than a significantly higher incidence of minimal change glomerulopathy and lupus nephritis (p

Percutaneous Subclavian Vein Catheterization for Hemodialysis: A Report of 57 Insertions

The authors report an analysis of 57 subclavian vein catheterizations for hemodialysis. A total of 51 pa tients (34 men, 17 women) kept the Cobe single- and double-lumen cathe ters for 1,726 days. The youngest pa tient was eighteen and the oldest sev enty-two years of age. There were no catheter-related deaths. Complica tions were encountered in 9 patients. The only life-threatening complica tion was cardiac arrest, which oc curred during flushing of the catheter. The patient was successfully revived. The other complications were pneumothorax and hydrothorax in 1 patient, catheter site infection in 5 patients, and arrhythmias in 2 pa tients, which stopped after readjust ment of the catheter tips. Their experience indicates that percutaneous subclavian vein cathe terization is safe and provides quick access for hemodialysis with no mor bidity and mortality if done correctly, patiently, and meticulously. The au thors believe that this should be the first choice in patients with reversible renal failure and in patients with chronic renal failure, who are usually elderly and medically compromised, till a permanent vascular access is ready for use.