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   Table of Contents - Current issue
Coverpage
July-September 2018
Volume 8 | Issue 3
Page Nos. 67-123

Online since Wednesday, July 11, 2018

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REVIEW ARTICLE  

Prophylactic mastectomy for the prevention of breast cancer: Review of the literature p. 67
Rawan K Alaofi, Mohammed O Nassif, Marwan R Al-Hajeili
DOI:10.4103/ajm.AJM_21_18  PMID:30090744
The high incidence and recurrence rate of breast cancer has influenced multiple strategies such as early detection with imaging, chemoprevention and surgical interventions that serve as preventive measures for women at high risk. Prophylactic mastectomy is one of the growing strategies of breast cancer risk reduction that is of a special importance for breast cancer gene mutation carriers. Women with personal history of cancerous breast lesions may consider ipsilateral or contralateral mastectomy as well. Existing data showed that mastectomy effectively reduces breast cancer risk. However, careful risk estimation is necessary to wisely select individuals who will benefit from preventing breast cancer.
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ORIGINAL ARTICLES Top

Cases of thallium intoxication in Syria: A diagnostic and a therapeutic challenge p. 78
Ibrahim Almassri, Mohamed Sekkarie
DOI:10.4103/ajm.AJM_17_18  PMID:30090745
In mid-March 2015, a mother and her teenage daughter and son from Syria presented to a Syrian American Medical Society (SAMS) refugee clinic in the Beqaa Valley in Lebanon with the chief complaints of hair loss together with weakness and numbness of their lower extremities. They reported that on March 1, a military foe of their relative had given him several boxes of Middle Eastern cookies which were consumed by over 20 members of their families and neighbors. Soon after the consumption, most members of the households developed symptoms including abdominal pain, nausea, vomiting, and constipation. Later, many of the affected individuals, including the three who presented to the clinic, had pain and weakness in the extremities, skin lesions, and hair loss. Two subjects died inside Syria of kidney failure. In this report, we describe the diagnostic challenges faced until the arrival to the diagnosis of thallium intoxication and the therapeutic obstacles to getting adequate therapy. We also report the results of a survey sent to all subjects in the affected households and discuss the context of lawlessness that led to this intoxication and perhaps other cases.
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Qat-induced intestinal obstruction: A case series of a new entity p. 82
Mhd Firas Safadi
DOI:10.4103/ajm.AJM_198_17  PMID:30090746
Background: Qat-induced intestinal obstruction is an acute manifestation of qat chewing which was not described previously in the literature. The aim of this case series is to describe the clinical presentation, the diagnostic and therapeutic measures, and the course of the disease. Methods: This retrospective case series included all patients who presented with qat-induced intestinal obstruction between July 1, 2013, and December 31, 2015. Results: The study included seven patients (five males and two females). The mean age was 41.4 years (22–60 years). All patients presented after 8–12 h of prolonged qat chewing with abdominal pain, severe abdominal distension, and inability to pass stool. Laboratory results were normal apart from slight leukocytosis (<15 × 109/L) in three patients. All patients showed air–fluid levels on the erect abdominal X-ray. The management included intravenous fluids and symptomatic therapy. The symptoms resolved in 1–2 days and the follow-up after 1 week showed no residual complaints. Conclusions: Qat-induced intestinal obstruction is associated with the heavy and prolonged consumption of qat. The presentation mimics acute intestinal obstruction, but the course is benign. Spontaneous resolution with supportive inpatient treatment is the rule.
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Evaluating the efficacy of best practice alerts to improve Clostridium difficile early detection in hospital settings: A 6-month interim analysis of the 2-year prospective study p. 87
Ahmad Kaako
DOI:10.4103/ajm.AJM_85_17  PMID:30090747
Introduction: Clostridium difficile infection (CDI) is a leading cause of hospital-associated gastrointestinal illness with high burden on the health-care system. Design: Observational, retrospective, prospective, pre- and post-intervention study on the incidence and prevalence rates of CDIs. The primary outcome is the healthcare-onset CDIs (HO-CDIs) incidence rate and proportion. Methods: Best practice alerts (BPAs) for CDI were developed in electronic medical records and released on July 13, 2016. When high-risk patients for CDI are identified, BPAs are triggered requiring nurses to order contact isolation and stool studies followed by other subsequent BPAs encouraging providers to de-escalate antibiotics and order probiotics. Data on admission count, patient-days, CDIs categories prevalence, and incidence rates were collected for the 24-month preintervention and will be collected for the 24-month postintervention period. Results: An interim analysis comparing the data from the first 6-month postintervention period with the average 6-month data of the preintervention period showed that short-term BPAs use is associated with significant increase in the overall CDI infection rate (71.47 vs. 38.38, P < 0.0001), incidence rate (53.81 vs. 28.76, P < 0.0001), overall prevalence rate (1.86 vs. 1.32, P = 0.001), and admission prevalence rate (1.10 vs. 0.70, P < 0.0001). Despite the observed overall shift from HO toward CO; no statistically significant difference in the HO-CDI event number and proportion was detected (28 [21.4%] vs. 22 [29.1%], P = 0.094). Conclusion: Short-term BPAs use is associated with significant increase in the overall CDI incidence and prevalence along with a non-statistically significant decline in HO-CDI proportion. Final analysis with full sample size is essential to provide a better picture about the long-term effect.
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Prevalence, diagnosis, and management of iron deficiency and iron deficiency anemia among Syrian children in a major outpatient center in Damascus, Syria p. 92
Issam N Albaroudi, Majed Khodder, Tareq Al Saadi, Tarek Turk, Lama A Youssef
DOI:10.4103/ajm.AJM_169_17  PMID:30090748
Background: Given the public health significance of anemia, the long-term sequelae of iron deficiency anemia (IDA) on children, the expected effect of war on the trends of anemia in Syrian society, and the lack of assessment on the national burden of anemia and/or iron deficiency (ID) data, there is a vital need to investigate all-cause anemia, ID, and IDA in Syria during the crisis. Objective: To investigate the prevalence of ID and IDA in Syrian children, the effectiveness of oral iron supplements in the management of ID, and the diagnostic effectiveness of conventional iron markers. Methods: We conducted a retrospective study on hemoglobin (Hb) levels in 4-month-old to 14-year-old children and a prospective study on hematological (complete blood count, reticulocytes, and reticulocyte Hb content) and biochemical iron indices (serum ferritin, iron, and total iron-binding capacity) of infants visiting the primary care clinic at Children's Hospital in Damascus, Syria. Results: Of the 1128 children in the retrospective study, 648 children (57%) were found to be anemic, with 417 (37%) moderately-severely anemic. The prevalence of ID and IDA in the 135 children of the prospective study was 71.85% and 55.55%, respectively. Infants with ID who underwent a 4–8-week course of oral iron supplementation demonstrated good responsiveness. Except mean corpuscular hemoglobin (MCH), conventional iron markers (i.e., ferritin) routinely used to assess iron status proved unreliable. Conclusion: This study reveals a high prevalence of anemia, ID, and IDA among a group of apparently healthy Syrian children. Our findings necessitate a framework of urgent public health interventions that can address two major limitations; the poor follow-up by the parents and unreliability of the conventional iron diagnostic markers. MCH may represent a simple and cheap ID screening index in children.
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BRIEF REPORT Top

Knowledge, attitude, and practices associated with the diagnosis and management of skin and soft-tissue infections among medical students, residents, and attending physicians p. 104
Norman Beatty, Jessica August, Joe Anthony Saenz, David E Nix, Kathryn R Matthias, Mayar Al Mohajer
DOI:10.4103/ajm.AJM_200_17  PMID:30090749
Skin and soft-tissue infections (SSTIs) are commonly encountered by medical students, residents, and trainees. The Infectious Diseases Society of America (IDSA) has updated its recommendations regarding SSTI diagnosis and management in June 2014. We assessed knowledge, attitude, and practices toward diagnosis and management of SSTIs using an online survey. We disseminated the survey to medical students, residents, and attending physicians practicing in family and internal medicine department at a university-based hospital. A total of 103 surveys were completed out of 121 sent (85.1%) between July 2015 and March 2016. There were nine medical questions in the survey. The mean of correct answers was 4.5/9 ± 2.0. Medical knowledge correlated with the level of education (P < 0.001) but not with subspecialty (P = 0.97). Around 35% were familiar with the updated IDSA guidelines pertaining to SSTIs. The majority (85%) responded that the hospital staff would benefit from additional training and 75% agreed that more antibiotic stewardship education is needed. Our study shows that there are significant opportunities for development among students and physicians who encounter SSTIs.
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CASE REPORTS Top

Delayed bilateral obturator nerve injury due to compressing bilateral pelvic lymphoceles after robot-assisted laparoscopic radical prostatectomy and bilateral lymphadenectomy for prostatic carcinoma p. 107
Ayman Aljomaa
DOI:10.4103/ajm.AJM_215_17  PMID:30090750
A clinically significant obturator nerve injury is uncommon after robot-assisted radical prostatectomy and lymphadenectomy. If the injury is due to a direct intraoperative event such as transection or stretching of the nerve, the patients present typically in the immediate postoperative period. On the other hand, an indirect injury through compression of the nerve through a pelvic fluid collection (hematoma or lymphocele) progresses insidiously and delays the presentation of these patients making a dilemma in recognizing these patients and differentiating them from those with other causes of neurological deficits. A delay in the correct management of the compressing collections may negatively affect the neurological function of the patient. We demonstrate a 61-year-old male who presented with pain and motor weakness of obturator origin 1 week after robot-assisted radical prostatectomy and lymphadenectomy for prostatic cancer. The computed tomography scan showed bilateral pelvic lymphoceles possibly compressing the obturator nerves. The neurological function has improved after evacuation of these collections. This case emphasizes the importance of considering delayed postsurgical compression of the obturator nerve in our differential diagnosis when patients present with typical signs and symptoms of obturator nerve injury after robot-assisted radical prostatectomy and lymphadenectomy. Early diagnosis and evacuation of these collections would improve the neurological outcome.
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Aggressive orbital rhabdomyosarcoma in adulthood: A case report in a public hospital in Damascus, Syria p. 110
Tagrid Younes Ahmad, Hasan Nabil Al Houri, Abdullah Nabil Al Houri, Nagham Younes Ahmad
DOI:10.4103/ajm.AJM_62_18  PMID:30090751
Orbital rhabdomyosarcoma (RMS) is a highly malignant tumor that originates mainly from mesenchymal tissue. It is considered a rare childhood malignancy; therefore, presentation in adulthood is scarce. In this case report, a 36-year-old male patient presented with a rapidly progressive RMS of the left orbit. The patient was treated in a different institution with radiochemotherapy with good response. However, relapse occurred after 2 months of completing the course, as rapid growing proptosis. Computed tomography scan revealed a lesion in the left orbit with invasion of the left ethmoid cells and the left maxillary sinus. Exenteration of the left orbit with the left partial maxillectomy and ethmoidectomy was performed. RMS is a highly aggressive malignancy that should be considered in any orbital mass that progresses rapidly. Surgery should be the first line in treatment. Delay in diagnosis and inappropriate treatment negatively affects the outcome.
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Human menopausal gonadotropin-induced bioprosthetic valve thrombosis p. 114
Rami Mahmood Abazid, Mohamed Shoman, Osama A Smettie, Osama A Elamin
DOI:10.4103/ajm.AJM_83_18  PMID:30090752
Bioprosthetic valve thrombosis (BPVT) is a rare but potentially life-threatening complication. Human menopausal gonadotropin (hMG) is commonly used for ovulation induction and has been associated with arterial and venous thrombosis. We reported a case of BPVT related to in vitro fertilization in a 39-year-old female, who underwent redo mitral valve replacement. To the best of our knowledge, this is the first case of hMG-induced BPVT in a young female patient.
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Chiclero's ulcer: An unusual presentation of Leishmania tropica in Syria Highly accessed article p. 117
Alexey Youssef, Samar Yaseer, Rim Harfouch, Maya Marouf, Foz Hasan
DOI:10.4103/ajm.AJM_145_17  PMID:30090753
Cutaneous leishmaniasis (CL) has been an endemic disease in Syria for decades. The first reports of CL from the Syrian city Aleppo date back to the 17th century. The recent crisis has further empowered the spread of this infection not only in Syria, but also in the neighboring countries. Here, we describe a case of a 67-year-old patient with a 6-month, nonhealing ulcerative lesion of the left auricle. It was initially diagnosed as either a squamous or a basal cell carcinoma. However, the biopsy revealed an unexpected finding of Leishmania amastigotes in the histiocytes. Consequently, CL of the auricle, chiclero's ulcer, was diagnosed. Polymerase chain reaction, in turn, revealed Leishmania tropica to be the causing factor; a rather rare one for chiclero's ulcer. The lesion completely resolved after a 3-week glucantime regimen, without any recurrence after an 8-month follow-up.
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LETTER TO THE EDITOR Top

Promoting an academic culture in the Arab world p. 120
Khaled Moustafa
DOI:10.4103/ajm.AJM_166_17  PMID:30090754
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