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   Table of Contents - Current issue
Coverpage
October-December 2019
Volume 9 | Issue 4
Page Nos. 123-168

Online since Thursday, October 3, 2019

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REVIEW ARTICLE  

Antithrombotic therapy in patients with atrial fibrillation and coronary artery disease p. 123
Abdelmoniem Moustafa, Mohammad Ruzieh, Ehab Eltahawy, Saima Karim
DOI:10.4103/ajm.AJM_73_19  
Atrial fibrillation and coronary artery disease are commonly coexisting conditions that necessitate the use of an oral anticoagulant as well as dual antiplatelet therapy. Commonly referred to as triple oral antithrombotic therapy (TT), this helps prevent ischemic stroke and myocardial infarction but comes at the expense of an increased risk of bleeding. There is a growing body of evidence that the omission of aspirin from TT has the same preventive efficacy in terms of major adverse cardiacvascular and cerebrovascular events (MACCE) with significantly lower bleeding events. The combination of antiplatelet agents and direct oral anticoagulants (DOAC) is a matter of ongoing research. However, initial studies showed favorable safety profile of DOAC over vitamin K antagonist in combination with antiplatelet agents.
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ORIGINAL ARTICLES Top

The prevalence and associated factors of cigarette smoking and its association with opium use among outpatients in Afghanistan: A cross-sectional study in Andkhoy city p. 129
Mohammad Shoaib Hamrah, Mohammad Hassan Hamrah, Mohammad Hussain Hamrah, Ahmad Edris Hamrah, Toba Dahi, Bagher Pahlavanzade, Abdurrahman Charkazi, Mohammad Hashem Hamrah
DOI:10.4103/ajm.AJM_40_19  
Purpose: The objectives of this study were to estimate the prevalence and associated factors of cigarette smoking and the association between cigarette smoking and opium use among patients visiting an outpatient clinic in Afghanistan. Methods: A cross-sectional study was conducted on consecutive patients aged 18 years and older from January 2018 to April 2018. Data on patients’ sociodemographic characteristics and clinical variables were collected using an interview-based survey. Results: Six hundred and twenty-two patients (391males vs. 231 females) were interviewed for this study. The overall prevalence of current smoking was 50.2% (95% confidence interval [CI]: 46.2–54.2). Males were (odds ratio [OR] = 9.5; 95% CI: 5.3–17.1) more likely to smoke cigarettes than females. The odds of current cigarette smoking increased with having a family member smoker or a friend smoker (OR =3.3; 95% CI: 2.0–5.3). Cigarette smoking was significantly associated with the level of education (illiterate OR = 8.9; 95% CI: 4.0–19.8), primary/private education (OR = 7.8; 95% CI: 3.9–15.6), and secondary education (OR = 4.4; 95% CI: 2.3–8.4), with high school or higher education as the reference group. Rural residents were 3.7 times (95% CI: 2.3–6.2) more likely to smoke cigarette than urban residents. Opium users were 23.0 times (95% CI: 12.5–42.3) more likely to smoke cigarettes than non-opium users. Conclusions: The prevalence of cigarette smoking among patients visiting an outpatient clinic in Afghanistan was high, and there was an association between cigarette smoking and male gender, a family history of smoking or a friend history of smoking, level of education, rural residency, and opium consumption.
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Combination of low-dose glucocorticosteroids and mineralocorticoids as adjunct therapy for adult patients with septic shock: A systematic review and meta-analysis of randomized trials and observational studies p. 134
Paraschos Archontakis Barakakis, Leonidas Palaiodimos, Derlis Fleitas Sosa, Linda Benes, Perminder Gulani, Daniel Fein
DOI:10.4103/ajm.AJM_97_19  
Background: The role of the combination of glucocorticosteroids and mineralocorticosteroids in treating septic shock is not well-defined. The aim of this study was to perform a systematic review and meta-analysis of the randomized controlled trials and observational studies assessing the effect of low-dose hydrocortisone and fludrocortisone on patients with septic shock. Materials and Methods: MEDLINE, Scopus, and Cochrane databases were reviewed. A random effect model meta-analysis was used and I-square was used to assess the heterogeneity. Short-term mortality was chosen as our primary end point. A subgroup analysis was performed including only the randomized controlled trials. Results: A total of 10,550 patients were included in this meta-analysis. Administration of the steroid combination was associated with improved short-term mortality (odds ratio, 0.78, confidence interval, 0.64–0.96), intensive care unit mortality, and shock reversal, without increase in steroid-related side effects, such as secondary infection or gastrointestinal hemorrhage. Conclusion: This systematic review and meta-analysis showed that use of the combination of glucocorticosteroids and mineralocorticosteroids has a beneficial impact on short-term mortality, intensive care unit mortality, and shock reversal, without increasing the incidence of gastrointestinal hemorrhage or superinfection in patients with septic shock, when used as an adjunct treatment to the established standard of care.
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Prevalence of intestinal parasitic infections among university female students, Gaza, Palestine p. 143
Adnan Al-Hindi, Amira A Redwan, Ghada O El-egla, Razan R Abu Qassem, Ayed Alshammari
DOI:10.4103/ajm.AJM_8_19  
Background: The intestinal parasites are still endemic among children, women, and men in Gaza Strip. Objectives: To the best of our knowledge, this is the first study of intestinal parasites among young female students of Islamic University of Gaza to report the existence and prevalence of intestinal parasites. Methods: A total of 305 stool samples were collected from female students in all faculties and were examined by wet mount and formal ether sedimentation technique. Results: This study showed that the overall prevalence of intestinal parasites was 20.6%. The detected intestinal parasites were as follows: Entamoeba histolytica/dispar (7.5%), Giardia lamblia (4.9%), Ascaris lumbricoides (0.3%), Entamoeba coli (2.6%), Dientamoeba fragilis (1.0%), and Blastocystis hominis (3.9%). Science students showed the highest prevalence for parasitic infections (35.3%), and married students (16.7%) had higher prevalence than single students (6.5%). Conclusion: It was concluded that female students also are under risk of gaining parasitic infection in spite of their education. It is recommended that university students should be subjected to regular medical examinations for parasitic infections.
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Are cardiac patients in Saudi Arabia provided adequate instructions when they should not drive? p. 148
Rami M Abazid, Mohammed Ewid, Hossam Sherif, Osama A Smettei, Abdul Salim Khan, Abdullah A Altorbag, Mohammad F Alharbi, Abdulrahman N Aljaber, Suliman M Alharbi, Nora A Altorbak, Sarah A Altorbak, Ahmad Almeman
DOI:10.4103/ajm.AJM_69_19  
Objective: Driving capability can be significantly affected by different heath disorders; cardiovascular diseases (CVDs) should be considered when assessing patients for medical fitness to drive (MFTD). The aim of this study was to evaluate the awareness of Saudi patients about driving recommendations and to assess the incidence of motor vehicle accidents (MVAs) among cardiac patients. Materials and Methods: We conducted a cross-sectional survey-based study. Male patients diagnosed with CVDs and who were visiting outpatient departments were invited to complete a questionnaire regarding their awareness of driving recommendations. Patients’ demographics, clinical diagnosis, echocardiography parameters, and time-to-CVD diagnosis were all obtained from the patients’ medical records. Women were excluded because it was illegal for women to drive in Saudi Arabia during the study period. Results: In total, 800 men were included, with a mean age of 54 ± 12 years. Driving counseling had been provided to 241 participants (30%). Of these, 207 (25%) were advised not to drive for a period of between one week and six months. Five percent of the patients had a history of MVAs during the follow-up period of 6.2 ± 4 years. We found that the presence of a dyspnea ≥2, according to the New York Heart Association (NYHA), and a history of loss of consciousness (syncope/pre-syncope) were significantly associated with accidents (46% vs. 20%, P < 0.0001 and 41% vs. 10%, P < 0.0001, respectively). Conclusion: Patient–physician discussion about MFTD was only performed with 30% of the patients with CVDs in Saudi Arabia. Dyspnea NYHA class ≥2 or a prior history of syncope were significantly associated with the incidence of MVAs.
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Trends in the performance of Syrian physicians in the National Resident Matching Program® between 2017 and 2019 p. 154
Muhammad Alsayid, Iman S Jandali, Fares Alahdab
DOI:10.4103/ajm.AJM_140_19  
Purpose: International medical graduates (IMGs) make up one-fourth of the physician workforce in the US and a significant proportion of them come from Syria. The aim of this study was to assess the performance of Syrian physicians seeking residency positions in the US and to examine the effects of visa restrictions on their Match outcome. Methods: An online survey administered to IMGs from Syria was used to probe their residency application characteristics as well as their experiences with visa restrictions. We evaluated the factors that affected their Match outcome and number of interviews offered to applicants. Results: A total of 223 IMGs from Syria completed the survey with an average match rate of 70.4% (76.6% in 2017 vs. 69.9% in 2018 vs. 64.4% in 2019). The proportion of applicants who required visas was 29.2%. In a multivariate analysis, higher USMLE Step 2CK score increased the match rate, whereas requiring a visa and failure in any USMLE exam decreased the match rate. Among those requiring visa, the match rate decreased from 78.6% in the cycle before the travel ban (2017) to 64.9% in the cycles following the travel ban (2018 and 2019) (P = 0.22). Similarly, the total number of interviews offered to these applicants decreased significantly following the travel ban (9.4 [7.5] vs. 6.2 [5.3], P = 0.04). Conclusion: Syrian IMGs seeking residency positions in the US have a higher match rate than non-US IMGs. Requiring a visa and failing any USMLE exam negatively impacted the match rate and number of interview invitations to Syrian applicants.
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CASE REPORTS Top

Nonmetastatic renal cell carcinoma presenting with persistent cough: Case report with literature review p. 160
Mohd Amer Alsamman, David Draper
DOI:10.4103/AJM.AJM_47_19  
Renal cell carcinomas (RCC), constitute 80– 85% of primary renal neoplasms. The classic triad of RCC (flank pain, hematuria, and a palpable abdominal renal mass) occurs in approximately 9% of patients; it strongly suggests locally advanced disease. RCC may also be associated with a number of paraneoplastic syndromes. These are typically due to ectopic production of various hormones. We present a 69-year-old male patient previously healthy presented to the emergency department with recurrent persistent cough. A non-metastatic RCC was incidentally discovered. Eventually, he underwent left radical nephrectomy. One year has passed with no cough. This is a rare and unusual presentation of RCC that falls under the category of paraneoplastic syndrome with review of similar reported cases and summary of all paraneoplastic syndromes associated with RCC in literature.
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Gemella endocarditis: A case report and a review of the literature p. 164
Dima Youssef, Ibrahim Youssef, Tariq S Marroush, Mamta Sharma
DOI:10.4103/AJM.AJM_3_19  
Infective endocarditis (IE) remains a prevalent disease with a high rate of morbidity and mortality. Recent changes have been noted in the profile of causative microorganisms. In this report, we describe a case of Gemella-related endocarditis and review the related literature. Our patient was an 81-year-old man who presented with dyspnea and fatigue. His initial examination revealed a new systolic murmur. Echocardiogram revealed moderate mitral regurgitation with 1-cm mass on the anterior mitral leaflet, and blood cultures grew Gemella haemolysans. Penicillin and gentamicin were initiated, and workup for possible source was positive for a colonic polyp with high-grade dysplasia. The patient subsequently developed cardiogenic shock and severe pulmonary edema. Comfort care measures were initiated, and he passed away thereafter. We reviewed PubMed for cases of Gemella-related endocarditis. We found 65 documented cases and added our patient’s case to the analysis. Seventy-two percent of the cases occurred in men. The mean age was 51 years and 42% of the patients were older than 60 years. Fever was the most common presenting symptom and most of the cases presented subacutely. The mitral valve was the most affected site and 50% of the patients required surgical intervention. G. morbillorum was the most common subtype and a total of four cases were found to be associated with colorectal neoplasm. As a conclusion, Gemella species rarely cause IE. The absence of a clear source of bacteremia warrants further evaluation for a gastrointestinal source. The infection can be destructive and must be promptly treated to avoid complications.
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