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   Table of Contents - Current issue
Coverpage
October-December 2020
Volume 10 | Issue 4
Page Nos. 133-251

Online since Tuesday, October 13, 2020

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EDITORIAL  

Do we know enough about human immunodeficiency virus and COVID-19 coinfection? p. 133
Ali M Alabbadi, Mousa A Al-Abbadi
DOI:10.4103/ajm.ajm_210_20  
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REVIEW ARTICLES Top

Palestinian strategies, guidelines, and challenges in the treatment and management of coronavirus disease-2019 (COVID-19) p. 135
Hatem A Hejaz
DOI:10.4103/ajm.ajm_171_20  
Background: Coronavirus disease-2019 (COVID-19) outbreak is a global concern and the World Health Organization (WHO) has declared it as a Public Health Emergency of International Concern. The Palestinian Authority (PA) has quickly and effectively responded to the outbreak of COVID-19, using an internationally and nationally coordinated, to contain the spread of the virus within the borders. The PA approaches are containment and suppression, which is designed to protect the citizens from infection while also mitigating the stress on the health care system. The PA immediately declared a State of Emergency when the first cases in Palestine were diagnosed on 5 March 2020 and launched robust national containment measures to encourage the citizens to protect themselves and follow the guidance. Objectives: There is currently no vaccine or effective treatment for COVID-19, the treatment is either supportive and/ or the treatment of symptoms. Several strategies in the treatment of the disease were applied including medications. This review aims to summarize the different strategies, guidelines, challenges, and treatments used against COVID-19 worldwide and in Palestine. Materials and Methods: Different literature and guidelines among different databases were searched. Literature reviewing was conducted using the following search engines, Google Scholar, Medline, Pub Med, EMBASE, Web of Science, and Science Direct. Data also obtained from WHO and PA reports, and the published peer-reviewed articles of 2019-nCoV. The review focuses on the strategies, guidelines, therapeutics, challenges, and different approaches used in the treatment and management of the disease in Palestine and globally. Conclusion: The Palestinian Ministry of Health (MoH) strategies to end the COVID-19 pandemic were; slow and stop transmission; provide optimized care for patients; and minimize the impact of the epidemic on health systems, social services, and economic activity. Thus, proper management, right actions, and effective treatment of the disease should be considered to achieve these strategies. The biggest problem for PA to control and stop the outbreak of the disease is the different challenges which include; the Israeli military and economic control, uncontrol the borders, shortage of medical and financial resources, crowded cities and refugee camps, poverty, food insecurity, and the financial crisis. To date, there are no specific vaccines or medicines for COVID-19; and treatments are under investigation through clinical trials. However, an array of drugs approved for other indications, as well as multiple investigational agents, are being studied for the treatment of COVID-19; in several hundred clinical trials around the World. Treatment is essentially supportive and symptomatic.
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Burn management during the COVID-19 pandemic: Recommendations and considerations p. 163
Amjad Soltany, Ali Ramez Hasan, Farah Mohanna
DOI:10.4103/ajm.ajm_153_20  
Coronavirus disease-2019 (COVID-19) is a respiratory disease, caused by a novel coronavirus (SARS-COV-2). This disease has been raising international public health concerns since its recent outbreak in December 2019. As the virus is easily transmitted by respiratory droplets, all hospital departments needed to change their practices in an attempt to control the spread of this virus. Burn units and clinics are particularly affected by this pandemic because of the larger risk of contamination for both patients and caregivers. Furthermore, cross-clinical aspects especially pain management and complications such as coagulopathy might be caused by both extensive burns and COVID-19 infections, which makes the management of these patients particularly challenging. That’s why we covered both main aspects in this review. In addition, we present briefly a synthesis of guidelines from several entities to help manage the health crisis and provide optimal care for all burn patients during this pandemic.
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Pathophysiology of diabetes: An overview p. 174
Mujeeb Z Banday, Aga S Sameer, Saniya Nissar
DOI:10.4103/ajm.ajm_53_20  
Diabetes mellitus is a chronic heterogeneous metabolic disorder with complex pathogenesis. It is characterized by elevated blood glucose levels or hyperglycemia, which results from abnormalities in either insulin secretion or insulin action or both. Hyperglycemia manifests in various forms with a varied presentation and results in carbohydrate, fat, and protein metabolic dysfunctions. Long-term hyperglycemia often leads to various microvascular and macrovascular diabetic complications, which are mainly responsible for diabetes-associated morbidity and mortality. Hyperglycemia serves as the primary biomarker for the diagnosis of diabetes as well. In this review, we would be focusing on the classification of diabetes and its pathophysiology including that of its various types.
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ORIGINAL ARTICLES Top

A systematic review of contemporary evidence on SARS-CoV-2 and HIV coinfection: What does it look like up to date? p. 189
Mohammad Abrar Shareef, Hafss M Bashaiwth, Abdullah O AlAkbari, Marwan S Bahamran, Maryam O AlAmodi, Salem H Albaiti, Meryam A Ali, Abdulaziz M Eshaq, Khaled Alkattan, Abdulhadi A Alamodi
DOI:10.4103/ajm.ajm_175_20  
Background: Preexisting alteration of the immune system by factors including older age, cardiovascular diseases, morbid obesity, diabetes, and chronic obstructive pulmonary disease (COPD) have detrimental effects on SARS-CoV-2 patients. Literature regarding SARS-CoV-2/human immunodeficiency virus (HIV) is still developing. Materials and Methods: We reviewed the existing literature pertaining to SARS-CoV-2/HIV coinfection systematically. Research records’ characteristics and patients’ clinical data were collected. Results: Seven research records were included, of which three were case series and four were case reports, reporting a total of 16 cases. There was one case of death, whereas (15/16) patients were discharged home. Majority of patients developed consistent clinical presentation of SARS-CoV-2. All patients had initial positive RT-PCR results, and four cases had HIV-related lymphopenia. Conclusion: Although the current literature is still growing to increase our understanding of SARS-CoV-2/HIV coinfection, people living with HIV should adhere to the guidelines of healthy behavior and practice during this pandemic.
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Aspirin dosage for the prevention of graft occlusion in people undergoing coronary surgery: A systematic review and meta-analysis p. 198
Fares Alahdab, Ruba Zuhri Yafi, Abdelkader Chaar, Ali Alrstom, Muayad Alzuabi, Omar Alhalabi, Somar Hasan, Mahmoud Mallak, Mohamad Luay Jazayerli, Qusay Haydour, Mohamad Alkhouli, Wedad Alfarkh, Mohammad Hassan Murad
DOI:10.4103/ajm.ajm_17_20  
Background: Aspirin is almost always used after coronary artery bypass graft (CABG) surgery; however, it is unclear what optimal dose should be prescribed. In this systematic review, we evaluated the effects of high versus low-dose aspirin in patients after CABG. Methods: A comprehensive database search was conducted in several databases from date of inception until February 2018. There were no language restrictions. We included studies that compared different doses of aspirin in patients that had undergone CABG surgery. We included studies that evaluated patient-important outcomes (mortality, cardiovascular events, and gastrointestinal bleeding); and if not reported, we collected data on the surrogate outcome thromboxane B2 (TXB2). We collected relevant data and performed a meta-analysis. Results: We identified 5903 references, and after two levels of screening by two independent reviewers, we included three randomized controlled trials in the meta-analysis with a total number of 122 participants. Mean age of trial participants was 65.63 years, and 88.68% were male. We planned to analyze all possible clinical outcomes, including mortality, recurrence, and hospitalization. However, no clinical outcomes are reported by the literature. The surrogate biochemical outcome of serum TXB2 was the only outcome reported by the eligible studies. High-dose aspirin (162–325 mg once daily) achieved better suppression of TXB2 than low-dose aspirin (75–100 mg once daily) (mean difference [MD], 2.00ng/mL, 95% confidence interval [CI]: 0.72–3.32; participants = 122; studies = 3; I2 = 0%). Conclusions: We found no clinical trials addressing any of the clinical outcomes of interest. High-dose aspirin was superior to low-dose aspirin in suppressing platelet function, a surrogate outcome. Trials evaluating clinical and patient-important outcomes are needed to better inform medical practice and fill this gap in clinical knowledge.
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Suggested modifications in oncology/hematology inpatient service in Saudi Arabia during coronavirus disease-2019 (COVID-19) pandemic p. 208
Shereef Elsamany, Fayza Hassanin, Amal Al-Abdulwahab, Emad Tashkandi
DOI:10.4103/ajm.ajm_166_20  
Background: Management of cancer patients in the current era of coronavirus disease-2019 (COVID-19) pandemic poses significant challenges on health-care systems. However, it is mandatory to keep the required level of care of cancer patients while taking the necessary precautions to maintain the safety of both patients and health-care professionals (HCPs). The present survey explores suggested modifications of inpatient oncology/hematology care during the COVID-19 pandemic. Materials and Methods: A web-based questionnaire using SurveyMonkey was distributed to HCPs taking care of inpatient hematology/oncology service including oncologists, hematologists, and inpatient nurses in Saudi Arabia. The 25 items selected for the survey focused on five domains including characteristics of HCPs, COVID-19 infection risk among admitted patients, possible modifications related to physicians/nursing practice, and suggested infection control measures. Clinical sensibility assessment was conducted to evaluate the comprehensiveness, clarity, and face validity of our instrument on a scale of 1–5. The percentages of HCP responses to the suggested modifications in the survey were assessed in descriptive statistics to summarize data and report views of participants. Results: Of 215 HCPs, 195 responded and completed the survey. Of the respondents, 30.4% were medical oncologists, whereas hematologists and nurses constituted 6.7% and 62.9% of the participants, respectively. The majority of respondents (87.6%) work in governmental hospitals. The majority of participants (82%) have diagnosed patients with COVID-19 in their hospitals and modifications in inpatient practice during the COVID-19 pandemic were supported by 95% of respondents. The supported modifications by participants include enhanced use of oral medications (83.5%), phone calls to admitted stable patients by physicians, instead of physical interview (77%), decreasing frequency of vital signs assessment in stable patients (91%), decreasing the duration of stay in patients rooms (89%), using peripheral instead of central lines (76%), using video-based educational materials to patients through hospital TV network (91%), testing for COVID -19 before scheduled radiology imaging and procedures (74%), and performing routine nasopharyngeal swabs for HCPs (67%). Conclusion: Several modifications in inpatient oncology/hematology practice were supported by the survey participants. These suggestions need to be discussed on local basis considering local infrastructure, available resources, and level of required care.
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Physician’ attitudes to growth hormone replacement therapy in adults following pituitary surgery: Results of an online survey p. 215
Aishah Ekhzaimy, Salem A Beshyah, Khaled M Al Dahmani, Mussa H AlMalki
DOI:10.4103/ajm.ajm_46_20  
Objective: The aim of this study was to evaluate physician attitudes and practices in the management of adult growth hormone deficiency (GHD) following pituitary surgery. Materials and Methods: An online questionnaire survey was sent to a sample group of physicians. Results: A total of 131 respondents provided usable responses. More than three quarters were senior physicians, with most practicing in tertiary care centers (73%). Four-fifths of the respondents see at least 1 to 5 patients with GHD following pituitary surgery per year. Seventy-four percent acknowledge the benefit in principle of growth hormone replacement therapy (GHRT) for patients with GHD after pituitary surgery. Most respondents (84%) would only consider GHRT for symptomatic patients. However, 16% stated that patients with GHD after pituitary surgery generally suffer from the side effects of GHRT. Forty-four percent said that the serum insulin-like growth factor-1 (IGF-1) level is the best screening test for assessing GHD after pituitary surgery but 57% of the respondents would use IGF-I levels, and 29% the insulin tolerance test (ITT), in patients with a documented deficiency in three pituitary axes. The main barriers to long-term GHRT use were that it requires injections (67%), and is costly with limited supply (61%). Other reasons not to use GHRT include an absence of GHD symptoms and apparent GHT ineffectiveness (44%), physician lack of familiarity with the medication (40%), and lack of adherence to available guidelines (38%). Conclusion: This survey addressed physician attitudes and practices in recognizing and treating GHD in adult’s post-pituitary surgery. Regional guidelines must be developed to help address/tackle these issues and assist physicians in understanding and treating this condition.
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Pediatric visceral leishmaniasis in Tartous, Syria Highly accessed article p. 223
Ali Othman Hamwi, Ali Abdallatif Mohammad, Sara Othman Hamwi, Razan Abdallatif Mohammad, Kayss Younis Shahin
DOI:10.4103/ajm.ajm_168_20  
Background: Visceral leishmaniasis (VL) type in Syria is Lashmania infantum, a fatal incapacitating disease, which is mostly seen in infants. Subjects and Methods: Hospital records of 19 children with VL were retrospectively reviewed. The period of the study was from June 2016 to July 2019. Results: The median age of the patients was 45.5 months. None was coinfected with human immunodeficiency virus or known to be immunocompromised. Pallor and anemia were observed in all cases, fever in 13 (68.42%), splenomegaly in 18 (94.7%), hepatomegaly in 11 (57.9%), thrombocytopenia in 15 (78.95%), and leukopenia in nine (47.4%). A bone marrow aspirate was obtained and Leishmania amastigotes were detected in all patients. All patients were initially treated with meglumine antimonate; one child did not respond and was treated with lipid formulations of amphotericin B. Conclusions: Presentation of VL in the pediatric age group is characterized by pallor, fever, splenomegaly, and hepatomegaly. Hematological and biochemical indices are typical with cytopenias. In all cases, microscopic examination provided a positive diagnosis. Despite recent reports on decreased responses to antimonial drugs of patients with Mediterranean VL, meglumine antimonate treatment appears to be still highly effective in Syria.
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R-IDARAM treatment in central nervous system lymphomas: A single-center experience and review of the literature p. 227
Senem Maral, Murat Albayrak, Cigdem Pala, Abdulkerim Yıldız, Hacer B Ozturk, Osman Sahin
DOI:10.4103/ajm.ajm_59_19  
Introduction: Central nervous system lymphomas (CNSLs) require effective treatment strategies due to aggressive nature of disease. Despite therapeutic approaches having improved in the last decades, there is no standard treatment for these patients. As a CNSL targeted-therapy IDARAM protocol was developed, the outcomes were reported with a few studies. We observed the R-IDARAM protocol in our CNSL cases, and we discuss the effectiveness, tolerability, and toxicity with a review of the literature in this article. Subjects and Methods: We retrospectively analyzed response rates, progression-free survival, adverse events, and long-term side effects in patients who were treated by modified R-IDARAM as standard clinical care of CNSL in our hematology department. Results: Response was achieved in five of nine patients. Three patients (two primary CNSL and one secondary CNSL) are still being followed up without disease progression with a median duration of follow-up of 79 months (88, 79, and 17 months, respectively). Manageable hematological side effects including thrombocytopenia and neutropenia were experienced by all patients. Conclusion: R-IDARAM protocol may be an option with high early response rates and manageable toxicity. Hematological side effects are the main problem, and long-term neurological toxicity is not common. Eligible patients must continue with autologous stem cell transplantation due to poor long-term survival outcomes.
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Safety and efficacy of dual versus triple antithrombotic therapy in Patients with atrial fibrillation undergoing percutaneous coronary intervention: A meta-analysis p. 232
Abdelmoniem Moustafa, Mohammad Saud Khan, Abdalla Marei, Mohd Amer Alsamman, Muhammad Baig, Marwan Saad
DOI:10.4103/ajm.ajm_40_20  
Background: Patients with atrial fibrillation undergoing percutaneous coronary intervention have indications for oral anticoagulation and dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor. The concurrent use of all three agents, termed triple oral antithrombotic therapy (TAT), increases the risk of bleeding. A number of prospective trials showed that the omission of aspirin mitigates the risk of bleeding without affecting major adverse cardiovascular event (MACE). Materials and Methods: The databases of PubMed, Embase, and Cochrane Central databases were searched from inception to October 2019. Relevant randomized control trials comparing dual antithrombotic therapy (DAT) versus TAT were identified and a metanalysis was performed using random-effect model. The safety endpoints of interest were thrombolysis in myocardial infarction criteria (TIMI) major and minor bleeding, TIMI major bleeding, and intracranial bleeding. The efficacy endpoints of interest were MACE and individual components of MACE. Results: Six trials with 11,722 patients were included. For safety endpoint, DAT was associated with significantly lower incidence of TIMI major and minor bleeding [RR: 0.58, 95% CI 0.44–0.77, P = 0.0001], TIMI major bleeding [RR: 0.55, 95% CI 0.42–0.73, P < 0.0001] as well as intracranial bleeding [RR: 0.35, 95% CI 0.16–0.73, P = 0.006] compared with TAT. No significant difference was observed for MACE [RR: 0.96 (0.79–1.17) P = 0.71] or any of the individual components of MACE between the two groups. Conclusion: Omission of aspirin from TAT in patients with Atrial Fibrillation (AF) after percutaneous coronary intervention is associated with lower risk of bleeding without compromising the efficacy in terms of mortality and cardiovascular thrombotic events.
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High Ki67 proliferation index but not cell-of-origin subtypes is associated with shorter overall survival in diffuse large B-cell lymphoma p. 241
Feras Zaiem, Rada Jerbi, Omar Albanyan, Jordyn Puccio, Zyad Kafri, Jay Yang, Ali M Gabali
DOI:10.4103/ajm.ajm_81_20  
Background: CD10, BCL6, and MUM1 are commonly used immunohistochemical stains for classifying diffuse large B-cell lymphoma (DLBCL), which is useful in predicting outcome. Conflicting reports of the prognostic value of other markers such as BCL2, CD23, and Ki67 proliferation index have been reported. Our objective was to correlate these immunostains and Hans classification with response to therapy and overall survival. Materials and Methods: A retrospective study of patients diagnosed with DLBCL from 2008–2014 at a tertiary-care cancer hospital. The slides with the IHC stains were reviewed by two independent pathologists. The clinical outcomes––assessed independently––were response to therapy and overall survival. The treatment response evaluation was based on the new Lugano classification. Statistical analyses were conducted using the Fisher’s exact test and Kaplan–Meier survival curves. Significance was set at P < 0.05. Results: Forty-one patients were included in the study with a known Hans classification, available clinical data, and at least 5-year follow-up. CD10 immunostain was reported in all patients, whereas CD23 was the least reported in only four patients. No significant association was observed between CD10, BCL6, MUM1, BCL2, and both Response to therapy and overall survival. Owing to few cases reported CD23 immunostain, further analysis of association is not reported. High Ki67 proliferative index of >80% was statistically significantly associated with shorter overall survival and not statistically significant associated with no response to therapy. Hans classification subtypes were not predictive in regard to therapy response. Conclusion: High Ki67 expression (>80%) was associated with shorter overall survival in DLBCL. Hans classification subtypes were not predictive.
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CASE REPORT Top

Thyrotoxic periodic paralysis after urethral dilatation Highly accessed article p. 249
Moayyad Alziadat, Mourad Ismail
DOI:10.4103/ajm.ajm_54_20  
Thyrotoxic periodic paralysis (TPP) is a rare and serious manifestation of thyrotoxicosis that causes flaccid paralysis. In severe cases, it can be life-threatening due to respiratory failure and cardiac arrhythmias. TPP is due to increased sodium/potassium ATPase activity during thyrotoxic states, which is due to mutations encoding potassium channels. It is precipitated by situations that cause a surge in catecholamines, insulin, or both. It can be treated with potassium supplementation and nonselective beta blockers, and it can be prevented by establishing euthyroid state. With the increasing numbers of outpatient procedures performed nowadays and the stress related to these procedures, patients with TPP may develop paralysis after these procedures, so clinicians should be aware of this condition and the importance of identifying it in patients presenting with flaccid paralysis.
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