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   Table of Contents - Current issue
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October-December 2017
Volume 7 | Issue 4
Page Nos. 139-192

Online since Wednesday, October 11, 2017

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REVIEW ARTICLES  

Minimizing nocebo effect: Pragmatic approach p. 139
Majed Chamsi-Pasha, Mohammed Ali Albar, Hassan Chamsi-Pasha
DOI:10.4103/ajm.AJM_59_17  
The nocebo effect, the inverse of the placebo effect, is a well-established phenomenon, yet under-appreciated. It refers to nonpharmacological, harmful, or undesirable effects occurring after active or inactive therapy. The frequency of adverse events can dramatically increase by informing patients about the possible side effects of the treatment, and by negative expectations on the part of the patient. Patients who were told that they might experience sexual side effects after treatment with β-blocker drugs reported these symptoms between three and four times more often than patients in a control group who were not informed about these symptoms. Nocebo effect has been reported in several neurological diseases such as migraine, epilepsy, multiple sclerosis, Parkinson's disease and neuropathic pain, and in patients with depression. The investigation of the biological and theoretical underpinning of the nocebo phenomenon is at an early stage, and more research is required. Physicians need to be aware of the influence of nocebo phenomenon and be able to recognize it and minimize its effects.
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Metastatic breast cancer: Endocrine therapy landscape reshaped p. 144
Mohamad Adham Salkeni, Samantha June Hall
DOI:10.4103/ajm.AJM_20_17  
Endocrine therapy (ET) of hormone receptor (HR)-positive and human epidermal growth factor receptor 2-(HER2)-negative metastatic breast cancer (MBC) historically focused on estrogen deprivation and antagonism. The identification of several intracellular pathways promoting resistance to antiestrogen therapy led to the introduction of novel endocrine drug combinations that reformed treatment schema and expanded therapeutic options. There is no doubt that efforts to overcome or delay resistance to ET are fruiting, particularly with the introduction of cyclin-dependent kinase 4/6 inhibitors such as palbociclib and ribociclib, and mechanistic target of rapamycin inhibitors such as everolimus. Although still considered incurable by currently available treatment modalities, many patients with MBC nowadays enjoy several years of good quality life coupled with decent tumor control. The diversity of therapies and unusual pattern of side effects can be quite perplexing to the treating physician. The sequence of variable agents and management of side effects, in addition to the timing of initiation of cytotoxic chemotherapy, is among the challenges faced by oncologists. In this review, we shed a spotlight on mechanisms of resistance to ET, and provide a review of landmark studies that have recently reshaped the landscape of treatment options for patients with metastatic HR-positive, HER2-negative MBC. A suggested treatment strategy for newly diagnosed patients is also discussed herein.
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Adnexal masses in pregnancy: An updated review p. 153
Abdullah M Hakoun, Iyad AbouAl-Shaar, Khaled J Zaza, Hussam Abou-Al-Shaar, Mohammad Nour A. Salloum
DOI:10.4103/ajm.AJM_22_17  
Adnexal masses in pregnancy are not commonly encountered. The majority of these masses are discovered incidentally during routine follow-up. However, some of these masses become symptomatic due to their size, location, and impingement of adjacent structures. Several diagnostic modalities can be utilized for the detection of adnexal masses with different sensitivity and specificity rates. The differential diagnosis of adnexal masses discovered during pregnancy is broad and includes both benign and malignant lesions. The management of such lesions has been a subject of debate for years with no consensus regarding the best management plan. Tumor size, site, and the trimester of mass detection are all crucial in management. In this account, we review adnexal masses discovered in pregnancy, the diagnostic modalities utilized for detecting these lesions, their differential diagnosis, and management strategies.
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Cardiac manifestations of Familial Mediterranean fever p. 158
Ahmad Alsarah, Osama Alsara, Heather S Laird-Fick
DOI:10.4103/ajm.AJM_78_17  
Familial Mediterranean fever (FMF) is autoinflammatory disorder characterized by sporadic attacks of fever, peritonitis, pleuritis, and arthritis. It is mainly seen in patients from Mediterranean origins, but it is now reported more frequently in Europe and North America due to immigration. To analyze the data on the cardiovascular manifestations in FMF patients, we searched PubMed using the terms “Familial Mediterranean Fever” or “FMF” in combination with other key words including “cardiovascular diseases” “pericardial diseases” “atherosclerosis” “coronary artery diseases” “cardiomyopathy” “pulmonary hypertension” or “valvular diseases.” suggested several mechanisms to explain the cardiac involvements in FMF including the ongoing inflammation and the amyloid deposits in the heart and vessels' walls at the advanced stages of FMF. The course of these manifestations varies widely, but it can associate with poor prognosis in some cases such as with pulmonary hypertension. Interestingly, Colchicine, which is the cornerstone therapy of FMF, plays a vital role in treating and preventing some of these disorders. In this article, In this article, we will discuss the incidence, pathophysiology, and prognosis of the various cardiac manifestations affecting FMF patients.
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ORIGINAL ARTICLES Top

Awareness of health effects of exposure to secondhand smoke from cigarettes: A cross-sectional study of never-smoked adult primary care patients in Eastern Nigeria p. 164
Gabriel Uche Pascal Iloh, Peace Ifeoma Collins
DOI:10.4103/ajm.AJM_23_17  
Background: Cigarette smoking whether actively or passively is a growing public health problem. Despite the wealth of information on the hazards of active cigarette smoking, awareness of the health effects of passive smoking on human population is often neglected in Nigeria. Aim: The study was aimed at describing the awareness of health effects of exposure to secondhand smoke from cigarettes among never-smoked adult primary care patients in Eastern Nigeria. Materials and Methods: A hospital-based study carried out on a cross-section of 500 adult patients in a primary care clinic in Nigeria. Data were collected using pretested, structured, and interviewer-administered questionnaire. Exposure to secondhand smoke was defined as exposure to cigarette smoke in a never-smoked adult patient in the previous 1 year. Data were analyzed using Statistical Package for Social Sciences version 21 for the calculation of percentages for categorical variables. Bivariate analysis involving Chi-square test was used to test for significance of association between categorical variables at P < 0.05. Results: The age of the respondents ranged from 18 to 74 years, with a mean age of 36 ± 12.4 years. There were 180 (36.0%) males with 320 (64%) females, with a sex ratio of 1.8. Awareness of general health effects of secondhand smoke on adults, children, and pregnant women was 95.6%, 92.8%, and 65.2%, respectively. The most common specific health effects the respondents were aware for adults, children, and obstetric population were lung cancer (95.6%), precipitation of asthmatic condition (92.8%), and delivery of small babies (65.2%), respectively. The predominant source of awareness of information was radio (93.6%). Awareness of general health effects of exposure to secondhand smoke on adults (P = 0.041), children (P = 0.031), and obstetrics population (P = 0.02) was significantly associated with exposure status. Conclusion: The most common health effects of secondhand smoke the respondents had highest awareness were lung cancer, precipitation of asthmatic attacks, and delivery of small babies in adults, children, and obstetric population, respectively. Awareness of general health effects on adults, children, and obstetrics population was significantly associated with exposure status. The current level of awareness should be improved while effort should be intensified to address identified areas of low level of awareness.
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Gluten-free diet among school-age children in Olmsted County, Minnesota p. 171
Eyad Almallouhi, Imad Absah
DOI:10.4103/ajm.AJM_42_17  
Objective: To assess the prevalence of gluten-free diet (GFD) among school-age children in Olmsted County, Minnesota, and compare it with the prevalence of celiac disease (CD) in the same age group. Methods: We performed a population-based study in Olmsted County using a survey to collect information from the six school districts in the county for the academic year 2014–2015. The survey contained questions to (1) assess the prevalence of GFD among school-age children in the public schools of Olmsted County; (2) assess the prevalence of CD among school-age children in Olmsted County; and (3) determine the indications for GFD in these children. We used the infrastructure of the Rochester Epidemiology Project (REP) to calculate the prevalence of CD in children aged 4–18 years in December 2014. Results: Using the REP data, we identified sixty patients with CD in the county aged 4–18 years; the prevalence of CD among school students in 2014 was 193.6/100,000. The prevalence of GFD in Olmsted County children, however, was higher, at 265/100,000 according to the survey from the school districts. The prevalence of GFD was highest in Rochester, the largest city. GFD was more common among children in secondary schools. Conclusion: According to our study, there are more children on GFD than the actual cases of CD in Olmsted County during the study period. This finding could be related to an increased number of children without CD who are following GFD for other indications.
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Pediatric care during a short-term medical mission to a Syrian refugee camp in Northern Jordan Highly accessed article p. 176
Kenneth L Abbott, Catherine A Woods, Dahlia A Halim, Henna A Qureshi
DOI:10.4103/ajm.AJM_100_17  
Introduction: The Syrian refugee crisis, now in its 6th year, has displaced millions. Refugees depend on support from host nation governments and humanitarian organizations like the Syrian American Medical Society (SAMS). We describe the delivery of pediatric care during a SAMS short-term medical mission to a refugee camp in Northern Jordan. Methods: The medical mission team encompassed dozens of specialties. Teams visited many sites, including the Zaatari refugee camp near the Syrian border. For this study, we gathered quantitative data from one physician who provided pediatric care and anecdotes from multiple SAMS physicians who provided pediatric care in Zaatari during the same time period. The physician supplying the quantitative data recorded age, diagnoses, and prescriptions for each patient. Results: The physician saw an average of 69 patients per day. Many of these were children aged 0–4 years. At least one diagnosis was recorded for 73.9% of patients, and at least one prescription was recorded for 85.5% of patients. Discussion: Most presenting complaints involved acute infectious illnesses, but these seemed preventable and related to refugees' living situations. Mental health assessment was difficult. Referrals proved important for evaluation and management of both acute and chronic conditions. For the short term, we emphasize the importance of effective liaison with refugee camp authorities and outside health-care organizations. For the long term, we recommend increased health-care infrastructure development and more emphasis on preventative care. Conclusion: With this study, we provide new quantitative and qualitative insights into pediatric care during a short-term medical mission to a Syrian refugee camp in Northern Jordan.
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Can acute-phase response biomarkers differentiate infection from inflammation postpediatric cardiac surgery? p. 182
Bana Agha Nasser, Abdu Rahman Mesned, Mohamad Tageldein, Mohamed S Kabbani, Nada Siddig Sayed
DOI:10.4103/ajm.AJM_51_17  
Background: Infection is a common serious complication postpediatric cardiac surgery. Diagnosis of infection after cardiopulmonary bypass (CPB) is difficult in the presence of surgical stress, hemodynamic instability, and inflammatory reaction. Aim: The purpose of this study is to investigate the value of available inflammatory biomarkers and its validity to differentiate infection from inflammation postpediatric cardiac surgery and to find the trend and the change in the level of these biomarkers shortly after cardiac surgery. Methods: We conducted a prospective study that included all children who underwent cardiac surgery in Prince Sultan Cardiac Centre-Qassim from November 2013 to October 2015. C-reactive protein, erythrocyte sedimentation rate, white blood cell count, and neutrophil count were measured for all patients presurgery, 4 consecutive days postsurgery, and predischarge. Patients were divided into two groups (the infected and the noninfected group). We compared the level of biomarkers between both groups. Then, we further analyzed the effects of CPB and preoperative steroid on postoperative inflammatory biomarker levels. Collected data were then reviewed and analyzed. Results: There were 134 pediatric cardiac patients included during the study period. Group 1 (bacterial negative culture group) had 125 cases and Group 2 (bacterial positive culture group) had nine cases. We found no statistically significant difference in inflammatory biomarker elevation between both groups. Only Group 2 had higher (RACHS) Risk adjustment for congenital heart surgery score, more ventilator days, and more drop in platelet count on the 2nd and 3rd postoperative days in comparison with the noninfected group 1. Both groups of patients who were in on and off CPB had the same level of inflammatory biomarkers with no significant differences. Giving corticosteroid preoperatively did not affect the trend of biomarker elevation and made no difference when it was compared to the group of patients who did not receive corticosteroid before surgery. Conclusion: Common inflammatory biomarkers cannot differentiate between infection and inflammation within the first 5 days postpediatric cardiac surgery as these reflect the inflammatory process rather than infection. Trend is more important than single reading.
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A new primary health-care system in the Syrian opposition territories: Good effort but far from being perfect p. 189
Tarek Alsaied, Abdullah Mawas, Fatima Al Sayah, Maher Saqqur, Abdulrazzak Kental
DOI:10.4103/ajm.AJM_67_17  
Objectives: The primary health-care system in Syria has suffered a great deal of damage over the past 6 years. A large number of physicians and health-care providers have left the country. The objectives of this study are to describe our experience in establishing a primary health-care system in the opposition territories (OTs) in Syria and report the most common treated diseases. Methods: The administrative databases of ten primary care centers in the OT from January 2014 to December 2015 were reviewed. All patients' encounters, including children and adults, in these centers were included in the study. Results: Within the study period, the ten centers served 46,039 patients encounter per month (and average of 4600 patients encounters per center per month). A high number of communicable diseases were noted. Cutaneous leishmaniasis was the most common communicable disease (1170 cases a month). Tuberculosis was treated in 14 patients a month. Other infectious diseases that were almost eradicated before the crises were seen increasingly (29 mumps cases/month, 6 measles cases/month, and 34 cases of typhoid fever/month). Conclusion: The primary health-care system in Syria has been greatly damaged, and tremendous efforts are ongoing to provide access to various basic health-care services including primary care services. Despite these efforts, the current system is very vulnerable and not sustainable. This study summarizes basic health services provided by primary health-care centers in Syrian OTs.
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