Intestinal lymphangiectasia in children: A favorable response to dietary modifications

Intestinal lymphangiectasia (IL) is a rare disease characterized by dilatation of intestinal lymphatics. It can be classified as primary or secondary according to the underlying etiology. The clinical presentations of IL are pitting edema, chylous ascites, pleural effusion, acute appendicitis, diarrhea, lymphocytopenia, malabsorption, and intestinal obstruction. The diagnosis is made by intestinal endoscopy and biopsies. Dietary modification is the mainstay in the management of IL with a variable response. Here we report 2 patients with IL in Bahrain who showed positive response to dietary modification.Intestinal lymphangiectasia (IL) is a rare1-4 benign disease characterized by focal or diffuse dilation of the mucosal, submucosal, and subserosal lymphatics.2,5 In addition to being an important cause of protein losing enteropathy (PLE),6 IL is frequently associated with extraintestinal lymphatic abnormalities.5 Depending on the underlying pathology IL can be classified as primary or secondary disease.1,2,4,5 Primary IL (PIL) probably represents a congenital disorder of mesenteric lymphatics.1,3 The IL can be secondary to diseases like constrictive pericarditis, lymphoma, sarcoidosis, and scleroderma.1 A secondary disorder should always be ruled out before labeling IL as primary, this is by testing for proteinuria, rheumatic, neoplastic, and parasitic infection.1,3 Recently, a functional form of PIL with typical endoscopic and pathological findings but without clinical symptoms has been reported.3 The clinical presentations of IL are pitting edema, chylous ascites, pleural effusion, acute appendicitis, diarrhea, lymphocytopenia, malabsorption, and intestinal obstruction.1,2,4 Palliative treatment with lifelong dietary modification is the most effective and widely prescribed therapy.6 Limiting the dietary fat intake reduces chyle flow and therefore, protein loss.1 Once protein level is within the normal range, recurrence of enteric protein loss can be prevented by total parenteral nutrition (TPN) and medium chain triglycerides (MCT).1 In cases of secondary IL, treating the underlying primary disorder may be curative.2 Although the therapeutic approach for this disorder have gained a lot of attention lately, few studies have considered the therapeutic effects, nutritional condition, and long-term results in PIL patients.4 Here, we report 2 patients with PIL who were diagnosed by endoscopy and biopsy, and showed positive response to dietary modifications. We present these particular cases to highlight the effect of dietary modifications on the clinical status of patients with IL.     

Prevalence and severity of plaque-induced gingivitis in a Saudi adult population

Objectives:

To evaluate the prevalence and severity of plaque-induced gingivitis among a Saudi adult population in Riyadh region.

Methods:

Three hundred and eighty-five eligible participants in this cross-sectional study were recruited from routine dental patients attending the oral diagnosis clinic at Al-Farabi College in Riyadh, Saudi Arabia from June 2013 to December 2013. A clinical examination was performed by 2 dentists to measure the gingival and plaque indices of Löe and Silness for each participant.

Results:

The prevalence of gingivitis was 100% among adult subjects aged between 18-40 years old. Moreover, the mean gingival index was 1.68±0.31, which indicates a moderate gingival inflammation. In fact, males showed more severe signs of gingival inflammation compared with females (p=0.001). In addition, the mean plaque index was 0.875±0.49, which indicates a good plaque status of the participants. Interestingly, the age was not related either to the gingival inflammation (p=0.13), or to the amount of plaque accumulation (p=0.17). However, males were more affected than females (p=0.005).

Conclusion:

The results of this study show that plaque accumulation is strongly associated with high prevalence of moderate to severe gingivitis among Saudi subjects.Plaque-induced gingivitis is the most common form of periodontal disease,1 which is considered to be the second most common oral disease after dental caries, affecting more than 75% of the population worldwide.2,3 In 2000, the United States Surgeon General released a report calling interest to the ‘‘silent epidemic’’ of dental and oral diseases, mainly dental caries and periodontal diseases suffered by millions of people throughout the US.4 The prevalence of periodontal diseases varies in different studies and different countries as a result of variations in study populations, age of participants, and the procedure of defining and diagnosing this type of disease. In general, gingivitis begins in early childhood, and becomes more prevalent and severe with age.5,6 Epidemiological studies revealed that plaque-induced gingivitis is prevalent among all ages of dentate individuals.7-9 Plaque-induced gingivitis is characterized by the presence of inflammation confined to gingiva without extension into other tooth-supporting structures.10-12 Persistence of this type of inflammation is correlated with the presence of microbial dental plaque. As long as this microbial biofilm is present adjacent to the gingival tissues, the inflammation will not resolve.13 However, it has been shown to be reversible after removing these causative factors.14 The clinical features that can be used as characteristic of gingivitis could be one of the following signs: erythematic and sponginess; changes in contour; bleeding upon stimulation; and presence of calculus, or plaque without clinical attachment loss, or radiographic evidence of crestal bone loss.15 Clinically, the severity and signs of gingival inflammation can be expressed by means of gingival index (GI) of Löe and Silness.16 According to this index, gingival inflammation can be classified as mild, moderate, or severe. However, the presence of these signs of inflammation is considered the initial stage for the more severe and irreversible form of periodontal diseases.17-19 A patient''s susceptibility to develop this type of disease also is highly variable and depends on the host response towards periodontal pathogens,17-19 which may be influenced by both acquired and genetic factors that can modify this susceptibility to infection.12,20 Prevention of dental plaque accumulation and early treatment of gingivitis reduces the risks associated with the development of a more severe, and destructive form of periodontal diseases.11,21 It is well known and documented that gingivitis develops after 10-21 days of accumulation of dental plaque,22 necessitating a daily effort to prevent plaque accumulation. Several studies revealed a significant correlation between reducing the incidence of gingivitis and regular plaque control measures.23-25 The aim of this study was to evaluate the prevalence and severity of plaque-induced gingivitis among a Saudi adult population in Riyadh region.     

X-ray repair cross-complementing protein 1 and 3 polymorphisms and susceptibility of breast cancer in a Jordanian population

Objectives:

To elucidate the contribution of x-ray repair cross-complementing (XRCC) protein 1 399Gln, XRCC3 241M, and XRCC3-5’-UTR polymorphisms to the susceptibility of breast cancer (BC) in a Jordanian population.

Methods:

Forty-six formalin fixed paraffin embedded tissue samples from BC diagnosed female patients, and 31 samples from the control group were subjected to DNA sequencing. Samples were collected between September 2013 and December 2014.

Results:

The XRCC1 Arg399Gln genotype did not exhibit any significant correlation with the susceptibility of BC (odds ratio [OR]=1.45, 95% confidence interval [CI]: 0.60-3.51) (p=0.47). Likewise, XRCC3 M241T genotype did not show significant correlation with BC (OR=2.02, 95% CI: 0.50-8.21) (p=0.40). However, distribution of XRCC3-5’UTR (rs1799794 A/G) genotype showed a significant difference between the patient and control group (OR=0.73, 95% CI: 0.06-8.46) (p=0.02).

Conclusion:

The XRCC3-5’UTR (rs1799794) G allele frequency was higher in cancer patients while XRCC1 (rs25487) and XRCC3 (rs861539) did not show any significant correlation with susceptibility of BC in the selected Jordanian population. Contribution of other environmental factors should be studied in future works, as well as the response of cancer therapy.Breast cancer (BC) incidence in Jordan has been estimated at 1,237 cases in 2012, with a prevalence of 4,260 cases over 5 years, and mortality rate up to 426 cases.1 Genetic predisposition contributes to less than 10% of BC cases, which raises a demand for further research into new genetic markers of BC risks.2 Fewer than 5% of BC cases have been found to be mutated at breast cancer 1 (BRCA1) early onset and BRCA2 genes, and approximately 40% of familial BC families have been identified for genetic predisposition.3 Unfortunately, mammalian cells are habitually exposed to genotoxic agents, such as ionizing radiation that can lead to DNA damage. Many double strand break,4 and single strand break (SSB) repairing proteins have been identified including DNA repair protein homolog, or RAD tecombinase, or x-ray repair cross-complementing (XRCC)s family proteins.5 Deficiency in repairing system might contribute to cancer development due to the loss of genetic integrity and genome instability.6 Mutation in DNA repair proteins is very rare.7 Therefore, many studies have been conducted to evaluate the role of allelic polymorphisms in DNA repair genes involved in cancers development.8,9 Genetic polymorphisms in DNA repair genes XRCC1, and XRCC3 have been screened to find an association with the risk of BC.10-12 Studies have demonstrated an association between XRCC1 and XRCC3 polymorphisms, and certain cancers subsuming colorectal cancer,13 lung cancer,14 pancreatic cancer,15 head and neck cancer,16 gastric cancer,17 esophageal cancer,18 melanoma skin cancer,19 oral squamous cell carcinomas,20 lung cancer risk,21 bladder cancer,22 and BC.23 Furthermore, a meta-analysis study supported the contribution of XRCC1 Arg399Gln polymorphism in susceptibility of BC in the American population.24 On the other hand, no relationship has been found between XRCC1 and XRCC3 polymorphisms and the risk of BC,25 lung cancer,26 bladder cancer,27 prostate cancer,28 lung cancer risk,29 cutaneous malignant melanoma,30 furthermore, it may decrease the risk for myeloblastic leukemia31 and non-melanoma skin cancer.32 Alcoholism, abortion, and non-breast feeding have been associated with increased risk of BC with contribution of XRCC1 399Gln and XRCC3 T241M polymorphisms.11 Moreover, family history,12 age group,33 polycyclic aromatic hydrocarbon-DNA adducts, fruit and vegetable and antioxidant intake, and non-smokers have been suggested to be associated with the risk of BC in interaction with XRCC1 or XRCC3 polymorphisms.34 The aim of the current study was to elucidate the contribution of XRCC1 399Gln, XRCC3 241M and XRCC3-5’-UTR polymorphisms in the susceptibility of BC in the Jordanian population. This study is intended to establish a reference point for future single nucleotide polymorphism (SNP) studies in the Jordanian population, which may contribute to the development of a national cancer database.     

The preparedness of private dental offices and polyclinics for medical emergencies: A survey in Western Saudi Arabia

Objectives:

To assess preparedness for medical emergencies in private dental offices in Jeddah, Kingdom of Saudi Arabia (KSA).

Methods:

In this cross-sectional study, a survey was distributed to 70 dental offices and polyclinics in Jeddah, Saudi Arabia between October 2013 and January 2014. The questionnaire gathered information on the prevention of medical emergencies, the preparedness of the office personnel, and availability of emergency drugs and equipment.

Results:

For prevention, 92% (n=65) of the offices reported that they obtain a thorough medical history prior to treatment; however, only 11% (n=8) obtain vital signs for each visit. Using a preparedness percent score (0 to 100), the mean level of preparedness of the office personnel in all surveyed dental offices was 55.2±20. The availability of emergency drugs was 35±35, and equipment was 19±22.

Conclusion:

We found a deficiency in personnel training, availability of drugs, and emergency equipment in the surveyed dental clinics. More stringent rules and regulations for emergency preparedness must be reinforced to avoid disasters in these clinics.Although uncommon, medical emergencies can occur at anytime in the dental office, possibly posing a direct threat to the patient’s life, and hindering the delivery of dental care.1,2 The prevalence, and severity of medical emergencies has been reported in various dental settings (academic or private) in many countries.3-5 In one 10-year survey study in Great Britain, an emergency event was reported, on average occurring with an average frequency of between one in 3.6-4.5 practice years.6 In a study published in 2009, Wilson et al7 found that the most prevalent medical emergency reported by dentists over a 12 month period was syncope (1.9 cases per year), followed by angina and hypoglycemia (0.17 per year), and epileptic fit (0.13 cases per year).7 Preparedness for acute medical emergencies in the dental office begins with a team approach by the dentist and staff members who have up-to date certification in basic life support (BLS) for health care providers. It also includes dentist and personnel training through mock drills and continuing education courses, a medical emergency protocol, availability of an emergency drug kit, and proper emergency equipment.8,9 The preparedness of dental offices was addressed through questionnaires for studies from different countries where a general consensus was reached for the need for continuous training and more stringent guidelines for medical emergencies.7,10 In the Kingdom of Saudi Arabia (KSA), there is a reported high prevalence of diabetes, obesity, and hypertension,11-13 all of which may contribute to a higher occurrence of medical emergencies in the dental office. A current literature search using the Medline and PubMed databases (from 1990-2014), revealed that there is a scarcity of published data on the prevalence, types, or severity of medical emergency events in government dental clinics, dental schools, or private dental practice. Additionally, no data could be found assessing the preparedness of private dental offices for medical emergencies in KSA. The Ministry of Health (MOH) in KSA oversees the licensing and operation of private dental clinics and polyclinics. It does not mandate that private dental offices have a specific emergency protocol, emergency drugs, or equipment. The objective of our study was to assess the preparedness and training of the office personnel, and availability of emergency drugs, and emergency equipment in a sample of private dental practices and polyclinics in Jeddah, KSA.     

Comparing dental students’ perceptions of their educational environment in Northwestern Saudi Arabia

Objectives:

To compare the perceptions of dental students over a 5-year period.

Methods:

This cohort study was carried at Taibah University, College of Dentistry, Al-Madinah Al-Munawwarah, Saudi Arabia between 2009 and 2014. Data was obtained using the Dundee Ready Education Environment Measure (DREEM), which consists of 50 items, 4 of these were irrelevant to this cohort and were excluded. All students registered in 2009 were included and followed up in 2014. Their responses were compared using the paired student’s t-test.

Results:

Thirty-four students completed the questionnaire in 2009, and 30 of them participated in 2014 (12% drop out rate). The mean domain and total scores decreased over time. The mean scores for 6 items decreased significantly, while 4 of them had a significant increase. The lowest mean score in 2009 regarding support for stressed students increased (p=0.004) in 2014. However, the highest mean score in 2009 related to having a good social life, reduced (p=0.007) in 2014. This could be an indication of the high workload and its impact on their social lives.

Conclusion:

Student’s perceptions were relatively low at the beginning, and remained low throughout the study. There were no significant changes in mean domain, and total scores and although scores of some items improved, most decreased over the study period.Students’ perceptions, regarding medical teaching institutions, have often been used as an assessment tool to evaluate them.1 These perceptions are based on many factors including social, economic, cultural, and past experiences.2 Students who attend these educational institutions came from various backgrounds and cultures and as a result; their perceptions vary in their assessment of the institute. However, studies have shown a positive association between the students’ perceptions, the educational environment, and the academic success of students.2,3 Tools have been developed to evaluate the perception of students and one of them, the Dundee Ready Education Environment Measure (DREEM) has proven to be valid and reliable.4-6 It has successfully been used in Malaysia,4 Saudi Arabia,5,6 and India,7 and translated into 8 languages including Arabic,6 Swedish,8 and Greek.9 A systematic review of studies using the DREEM, concluded that it is a useful tool in assessing the perceptions of students.10 It provides a quantifiable standardized tool for comparisons between teaching institutions, and is useful in identifying problematic areas that staff members may not be aware of.1,10 The Taibah University College of Dentistry (TUCoD) is located in Al-Madinah Al-Munawarrah, Saudi Arabia and was established in 2007. One of the goals of the TUCoD is to provide the best educational and environmental facility that would ensure students graduate with the highest standards. To achieve this, it is essential to monitor and evaluate the students’ perceptions on a regular basis. This would alert staff to problem areas, and help rectify them. The first intake of dental students started their preparatory year in 2008 and the first group of dentists graduated in 2014. The dental degree offered at TUCoD, similar to other Saudi Arabian dental colleges, extends over 7 years; a preparatory year followed by 5 years of dental training, and one year of internship. This study included the first group of dental students and dental graduates. Although many studies have used the DREEM, most of them were cross-sectional in design.4-10 There were 2 prospective studies, and both were carried out over a one-year period.11,12 The current prospective cohort study followed the same group of dental students from their first and second year (2009) to their fifth and internship years (2014). It extended over 5-years, and compared the perceptions of these students over time. The aims were to compare the student’s perceptions of TUCoD from 2009-2014.     

Prevalence and risks of habitual snoring and obstructive sleep apnea symptoms in adult dental patients

Objectives:

To determine the prevalence of habitual snoring and risk of obstructive sleep apnea (OSA) among dental patients and investigate factors associated with high-risk OSA.

Methods:

This cross-sectional study was performed at the Department of Preventive Dental Sciences, College of Dentistry, University of Dammam, Kingdom of Saudi Arabia, between October and December 2014. A total of 200 consecutive female and male dental patients were included in this study. Subjective and objective assessments were carried out. Habitual snoring and risk of OSA were assessed using the Arabic version of the Berlin questionnaire. Two trained investigators carried out the objective measurements of anthropometric data, blood pressure, oxygen saturation, pulse rate, and clinical examination of upper-airway, and dental occlusion.

Results:

Habitual snoring was present in 18.2% of the females and 81.8% of the males (p<0.05). Breathing pauses during sleep of more than once a week occurred in 9% (n=17) of the sample. Of the males, 78.3% were at high risk of OSA compared with 21.7% of the females. Multivariate analysis for risk of OSA revealed that obese patients were almost 10 times more likely to report OSA symptoms than their non-obese counterparts (odds ratio: 9.9, 95% confidence intervals: 4.4-22.1). Tongue indentations, tonsil size, and a high Epworth Sleepiness Scale score were also independent risks of OSA.

Conclusion:

Tongue indentations and tonsil grades III and IV were significantly associated with risk of OSA. This validates the important role of dentists in the recognition of the signs and symptoms of OSA.Obstructive sleep apnea (OSA) is a repetitive complete or partial obstruction of the upper airway during sleep.1 It is characterized by snoring, hypoxia, hypercapnia, and arousals from sleep.2 Obstructive sleep apnea is found in 24% of male and 9% of female adults.3 Data from the Canadian Community Health Survey4 showed that approximately 26% of adult Canadians were at high risk of developing OSA. Two studies5,6 in Saudi Arabian population reported a 39% prevalence of OSA in females and 33.3% in males. Obstructive sleep apnea can cause tiredness, anxiety, depression, and is associated with diminished motor and cognitive functions, and reduced quality of life.7 The individuals with OSA have 2-10 times increased risk of motor vehicle accidents than those without OSA.8 Untreated OSA has been linked to systemic complications such as coronary artery disease,9 heart failure,2 impaired glucose tolerance, insulin resistance, and dyslipidemia10 among other conditions. Unfortunately, most of the OSA cases (85%) remain undiagnosed,11 partly due to lack of information to patients and health professionals as well as the high costs of diagnostic tests. Several factors contribute to the development of OSA, which includes obesity, older age,12 male gender, menopause, hereditary, smoking, alcohol, craniofacial abnormalities,13 and periodontal disease.14 Orofacial anatomical abnormalities such as mandibular micrognathia or retrognathia, large tongue, hypertrophy of palatine tonsils, enlarged uvula, and deep palatal arch are craniofacial risks for developing OSA.15 Habitual snoring is one of the symptoms of sleep disordered breathing. A population based longitudinal study found that 13% of adults developed habitual snoring over 14 years. The factors associated with habitual snoring include male gender, obesity, smoking, and asthma.16 In addition, snoring is strongly associated with increased all-cause mortality.17 Dentists play a major role in the recognition of the signs and symptoms and the overall management of OSA.18 No data exist on the epidemiology or risks of OSA symptoms among dental patients in Saudi Arabia. This study aims to determine the prevalence of habitual snoring and OSA risk in adult dental patients and investigate the factors associated with high risk of OSA.     

Kimura disease: No age or ethnicity limit

Kimura disease is a chronic inflammatory disease that mainly manifests as a lump in the cervical region. Although the underlying pathophysiology is not clear yet, the diagnosis can be established based on specific histopathological characteristics. The first case of this disease was described in China, as well as the majority of subsequent cases that were also described in the Far East countries made Kimura disease traditionally a disease of adult patients of Asian descent. This report describes the occurrence of Kimura disease in pediatric non-Asian patient with a similar clinicopathologic presentation.Although Kimura disease can be grouped under inflammatory disease of chronic nature, the underlying cause is still to be investigated. The disease usually present with enlarged, but painless cervical lymph node or subcutaneous masses in the cervical region.1,2 Clinical and histological characteristics of Kimura disease (primary allergic reaction or an alteration of immune regulation) help to differentiate it from angiolymphoid hyperplasia with eosinophilia (an arteriovenous malformation with secondary inflammation mostly involving dermal or subcutaneousparts), which were previously thought to be the same disease.1,2 Most cases have been reported in adult patients from the Far East of Asia.1,2 Elevation of inflammatory mediators that are usually elevated in autoimmune disorders made hypersensitivity a possible underlying pathophysiological mechanism of this disease.1,2 Patients usually present with non-tender mass in the cervical region with elevated eosinophils count and high levels of serum immunoglobulin type E (IgE).2 Unfortunately, there are no specific radiological characteristics of that disease.2 The only way to diagnose Kimura disease is through its histopathologic features, which necessitate a surgical biopsy.1,2 Treatment usually start with medical therapy and if that fail or show no spontaneous resolution then surgical excision would be the choice at that point with radiotherapy reserved for selected cases.1,2 The main objective of presenting this case report is to emphasize that Kimura disease can involve pediatric Saudi patients in contrast to what was historically described as a disease of adult Asian only. Secondary, it is to support what had been reported of occurrence of the disease in non-Asian patient with a similar clinicopathologic presentation of the Asian patients.2,3     

A cross-sectional study of anxiety and marital quality among women with breast cancer at a university clinic in western Saudi Arabia

Objectives:

To examine relationship between the quality of marital relationship and anxiety among women with breast cancer (BC) in the Kingdom of Saudi Arabia (KSA).

Methods:

This cross-sectional study recruited a consecutive series of 49 married women with BC seen in the Al-Amoudi Breast Cancer Center of Excellence at King Abdulaziz University, Jeddah, KSA in early 2013. Participants completed the Hospital Anxiety and Depression Scale, Spouse Perception Scale, and Quality of Marriage Index forms, and answered questions on demographic and cancer characteristics.

Results:

Anxiety symptoms indicating “possible” anxiety disorder were present in 10.4% and “probable” anxiety disorder in 14.6% (25% total). No significant relationship was found between the quality of marital relationship and anxiety symptoms (B=-0.04, standard error=0.05, t=-0.81, p=0.42). Anxiety was primarily driven by low education, poor socioeconomic status, and young age.

Conclusion:

Anxiety symptoms are prevalent among married women with BC seen in a university-based clinic in the KSA. Further research is needed to determine whether a diagnosis of BC adversely affects marital relationship, and whether this is the cause for anxiety in these women.Breast cancer (BC) is the most common cause of cancer death in women worldwide,1 and the Kingdom of Saudi Arabia (KSA) is no exception.2 Breast cancer has become a particular problem in Arab countries due to its late stage at presentation and its increased occurrence among young women.3 Both during and after treatment, even if the cancer goes into remission, concerns regarding recurrence, effect on the marital relationship, and frequent medical visits for monitoring, often result in high levels of anxiety (including post-traumatic stress-like symptoms).4-8 Anxiety and other mood symptoms are not benign in women with BC, as they are associated with increased mortality and cancer recurrence.9,10Studies in Western countries (United States, Canada, England, Australia, and Germany) indicate a prevalence of significant anxiety ranging from 4-45% in BC patients, depending on anxiety measure, cutoff score, geographical region, and time since diagnosis11-14 (compared with 15-37% of cancer patients in general with anxiety during the first year after diagnosis).15 The most commonly used measure of anxiety symptoms in BC patients is the Hospital Anxiety and Depression Scale (HADS), which assesses for “possible” and “probable” anxiety disorder (with a sensitivity and specificity of approximately 80%).12,16,17 Using this measure, the prevalence of “probable” anxiety disorder in BC patients ranges from 2-23% and “possible” anxiety disorder is present in an additional 19-22% (21-45% combined).11,13,18 Although factors that increase risk of anxiety in women with BC are poorly understood, a few studies largely from Western countries report more symptoms in younger persons and Caucasians, immigrants, those with lower education, later disease stage, and lower social support.8,11,13,19 In one of the few studies from an Eastern country,20 anxiety levels among BC patients from Bangkok, Thailand, were significantly higher among those with poor problem solving skills, more pain and fatigue, and poorer family functioning. Although research is limited almost entirely to the US and other Western countries, studies indicate that support from a spouse (especially emotional support) improves the adjustment of women to BC,21-25 and may even impact survival.26 Not all studies, however, report that having a marital partner buffers against the stress of BC.27,28 The demands of caregiving, the effects of BC and its treatments on sexual relationship, and coping with psychological changes in a BC patient can all lead to lower well-being in a spouse, and decrease his ability to provide support.24 Our exhaustive review of the literature uncovered several studies that have examined the prevalence of emotional reactions to BC in the Middle East, finding that 19-73% of women had significant anxiety symptoms.22,29-34 In those studies, anxiety was associated with poorer physical functioning, the presence of metastatic disease, higher education, lower social support, duration of marriage, and spouse’s level of anxiety. With regard to KSA, there has been a significant increase in the incidence of BC, which occurs at a younger age than in Western countries.35 A recent review of research on coping with BC, however, revealed not a single study from KSA.36 Our review identified only 2 studies37,38 that examined the prevalence or correlates of anxiety in Saudi cancer patients (none specifically in BC), and only one study39 that examined attitudes of Saudi males toward BC. The first study examined anxiety in 30 hospitalized patients with cancer (9 with BC) at the King Khalid National Guard Hospital in Jeddah, KSA.37 Researchers found that anxiety symptoms assessed by the Hamilton Anxiety Scale were significantly higher in cancer patients compared with 39 patients with a range of chronic illnesses; 3 patients with cancer (10%) had a clinical diagnosis of generalized anxiety disorder based on Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria. The second study examined non-pain symptoms in 124 cancer patients (27% with BC) at King Faisal Specialist Hospital in Riyadh, KSA.38 The most frequently reported non-pain symptoms were fatigue (80%), loss of appetite (72%), dry mouth (69%), and anxiety (61%). Finally, researchers examined attitudes toward BC among males accompanying female patients to outpatient clinics at King Abdulaziz Hospital in Jeddah, KSA. When men were asked what they would do if their wives were diagnosed with BC, 9.4% said they would leave their wives.39Given the current knowledge gap on this subject in KSA, we decided to: 1) determine the prevalence of anxiety symptoms in married women seen in an urban-based university outpatient clinic in Jeddah; 2) identify the correlates of anxiety symptoms (especially marital quality [MQ]); and 3) determine whether the relationship between MQ and anxiety differed between Saudi nationals and immigrants. We hypothesized that anxiety symptoms would be prevalent, that higher MQ would be strongly and inversely related to anxiety symptoms, and that this relationship would be particularly strong in women who were Saudi nationals (where cultural factors might have the most influence).     

Sublingual varices in relation to smoking,cardiovascular diseases,denture wearing,and consuming vitamin rich foods

Objectives:

To identify potential risk factors such as smoking, cardiovascular diseases (CVD), denture wearing, and consuming vitamin rich foods, and its relation to the development of sublingual varices (SLV).

Methods:

This cross-sectional observational study was conducted on patients who attended the Department of Dentistry at The University of Jordan Hospital, Amman, Jordan between February and May 2013. Clinical examinations and inspections of 391 patients (203 males and 188 females), 13-74 years of age were conducted to determine the presence of SLV. Sublingual varices were classified into 2 categories: grade 0 (few or none visible), and grade one (moderate or severe). Frequency distributions of both SLV and risk factors were obtained. Multiple logistic regression analysis and Chi-square test were used to analyze the influence of individual risk factors on the incidence of SLV.

Results:

There were 88 subjects (22.5%) who had SLV. In the multivariate logistic regression model, SLV were significantly associated with age (odds ratio [OR]: 2.27, p=0.008) with highest occurrences in the eighth decade of life, gender (OR: 2.74, p=0.001), smoking (OR: 2.93, p=0.002), denture wearing (OR: 2.03, p=0.044), and CVD (OR: 4.01, p=0.00).

Conclusion:

The presence of SLV could be indicative of some potential risk factors including old age, female gender, and denture wearing, and may alert the dental clinician to recognize underlying systemic conditions, particularly CVD.Sublingual varices (SLV) are dilated tortuous veins that may be seen along the ventral surface of the tongue or floor of mouth, and tend to become more prominent with age. However, in a young population, such vascular lesions could be part of Fabry, or Osler syndrome.1 Sublingual varices may be noticed by patients, or more commonly by dentists. They are often confused with the main veins running from the tip of the tongue backwards, and should be differentiated from primary malignant melanomas of the tongue base.1 Several explanations have been suggested concerning the pathogenesis of SLV; it is known that the ageing process, including changes in the connective tissues and venous walls is associated with an increase in the incidence of varices.2-4 Kaplan and Moskona5 reported that varicosities increased from 11.1-41.1% between ages 50-99 years. Few studies in the literature1,2-4,6-10 investigated the relation between SLV and some potential risk factors, such as cardiovascular diseases (CVD), smoking, denture wearing, and consuming foods rich in vitamins, such as vegetables. Furthermore, portal hypertension,6 and varicose veins of the leg2 have been claimed to have a possible connection and association with SLV. Differences in the incidence of SLV between males and females has been the subject of a recent survey.1 The relation between SLV and CVD remains controversial; whereas some studies found no relation,4,6 other older studies reported an association.2,3 A recent study1 of 281 consecutive adults aged 40-92 years demonstrated a strong association between CVD and SLV. Similarly, controversy regarding the relation between SLV and smoking still exists, and there is one study published in the English literature investigating the relation between SLV and smoking.1 Smoking was established as a predisposing factor for CVD, particularly hypertension.11 Hedström and Bergh1 found that SLV was significantly associated with smoking. However, Kroeger et al12 reported a preventive effect of smoking on the development of varicose veins of the leg. Ettinger and Manderson,2 in their study of SLV found a relation between sublingual veins and varicose veins of the leg. Sublingual varices were also ascribed to vitamin C deficiency in older age groups. A study of 22 elderly vegetarians aged 57-75 years found a much lower incidence of sublingual petechiae and varicosities than generally reported in an older population.7 However, the literature did not support a link between SLV and diabetes,13 or denture wear.8-10 In Jordan, a recent study showed that more than 48% of adult males were current smokers.14 In addition, more than 60% of patients who attended the United Nations Relief and Works Agency (UNRWA) primary health care clinics in Jordan were diagnosed with hypertension.15 Hence, it is expected that SLV could be a common finding among a Jordanian population. Therefore, the aim of this study was to assess the influence of potential risk factors including CVD, smoking, denture wearing, and consuming vitamin rich foods on the incidence of SLV among the young, middle aged, and elderly population.     

Management of rhino-orbital mucormycosis

Mucormycosis is an uncommon acute invasive fungal infection that affects immunocompromised patients. It progresses rapidly and has poor prognosis if diagnosed late. Early detection, control of the underlying condition with aggressive surgical debridement, administration of systemic and local antifungal therapies, hyperbaric oxygen as adjunctive treatment improves prognosis and survivability.Mucormycosis also known as zygomycosis and phycomycosis is an uncommon, opportunistic, aggressive fatal fungal infection caused by fungi of the order Mucorales, frequently among immunocompromised patients. This fungal infection begins from the sinonasal mucosa after inhalation of fungal spores; the aggressive and rapid progression of the disease may lead to orbital and brain involvement.1-4 In the past, the mortality rate of the rhino-cerebral type was 88%, but recently the survival rate of rhino-cerebral mucormycosis averages 21-73% depending on the circumstances.1 Mucormycosis is classified according to anatomical site into rhino-cerebral, which is the most common, central nervous system, pulmonary, cutaneous, disseminated, and miscellaneous.1,2,4-6 The rhino-orbito-cerebral is the most common form of mucormycosis.3 The most common predisposing factor is uncontrolled diabetes mellitus (DM), especially when the patient has a history of ketoacidosis, these species thrive best in a glucose rich and acidic environment.3,4,6,7 Immunosuppressive drugs such as steroids, neutropenia, acquired immune deficiency syndrome, dialysis patients on deferoxamine, malnutrition, hematologic malignancy, and organ transplant patients are also at risk of affection by the fungi.1,4-7 This case report describes a case of rhino-orbital mucormycosis affecting a diabetic female with good prognosis and satisfactory healing. Our objective in presenting this particular case is to emphasize that early diagnosis and proper management leads to good prognosis and high survivability.     

Pemphigus and pregnancy: Analysis and summary of case reports over 49 years

Pemphigus is a group of immune-mediated bullous disorders, which often cause fragile blisters and extensive lesions of the skin or mucous membranes, such as in the mouth. This disease could be life-threatening in some cases. During pregnancy, its condition will become more complicated due to the change in the mother’s hormone level and the effect of drug therapy on both the mother and her fetus. Thus, it will be more difficult to identify the clinical manifestations and to establish the treatment plan. In this article, we present a comprehensive review of pemphigus and pregnancy by analyzing 47 cases of pemphigus reported between 1966 and 2014, with diagnosis before or during pregnancy. The aim of this study is to make a comprehensive review of pemphigus and pregnancy, provide organized and reliable information for obstetricians, dermatologists, physicians, and oral medicine specialists.Pemphigus is characterized by widely distributed bullae and erosions on the skin and mucosa membranes. There are mainly 3 types of pemphigus: Pemphigus vulgaris (PV), Pemphigus foliaceus (PF), and other variants of pemphigus.1,2 The pathogenesis of pemphigus is associated with autoantibodies directed against transmembrane glycoproteins of desmosomes, which causes steric hindrance to homophilic adhesion of desmogleins, and results in the formation of Dsg1-depleted desmosomes in PF and Dsg3-depleted desmosomes in PV.3,4 Pemphigus usually affects the elderly, and genetics play an important role in predisposition.5,6 Pemphigus could involve one or more mucosae, while PV often shows extensive lesions of the oral mucosa.7,8 When it occurs in pregnancy, the condition becomes more complex.9 Early diagnosis and individually adjusted therapy are needed to avoid any risk for mother or child.10 The purpose of this article is to make a comprehensive review of the pemphigus and pregnancy, and provide organized and reliable information for clinicians.

Basic demographics

The existing reseasrch is mainly focused on case reports and retrospective studies. References were retrieved by an electronic search strategy “(pemphigus [MeSH Terms]) AND pregnancy [MeSH Terms] Filters: Case Reports” on PubMed, and a total of 62 cases were reviewed. Of the 62 cases, 14 were excluded based on abstract, which indicated discussion about gestational pemphigoid, and 7 were excluded because they were non-English. Finally, we included 41 relevant case reports according to their titles and abstracts. These 41 case reports between 1966 and 2014 involved 47 women identified with pemphigus before (n=21 cases) or during pregnancy (n=26 cases). These cases of pemphigus and pregnancy have been reported in different populations, Asia, Europe, and North America, with more than in Africa, South America, and Oceania (Figure 1). A recent study from the United Kingdom has suggested an incidence of PV of 0.68 cases per 100,000 persons per year. The incidence varies in different areas, being more common in the Near and Middle East than in Western Europe and North America.11-14Open in a separate windowFigure 1Regional distribution of 47 cases of pemphigus and pregnancy between 1966 and 2014.We analyzed the characteristics of 21 patients with pemphigus diagnosed before pregnancy. Among them, 71.4% were diagnosed as PV, 19% as PF, 4.8% as Pemphigus vegetans, while the remaining was indefinite. The age of onset of pemphigus was generally 20-42 years old (mean age 27.35±5.73), with a mean interval of 3.16±2.11 years between disease onset and pregnancy. The pemphigus course was characterized by exacerbation (61.9%), improvement (9.5%), and remaining stable (28.6%) during the pregnancy. The newborn status is meaningful for our conclusion. The incidence of neonatal pemphigus was as high as 57.1% (including 38.1% of PV and 19% of PF). In contrast, the percentage of healthy neonates was only 33.3%, which may be considered to be publication bias (15-31

Table 1

Characteristics of 21 patients with pemphigus diagnosed between 1966 and 2013.Open in a separate windowIt seems to be quite a rare phenomenon that pregnancy as a triggering factor of PV seems to be quite a rare phenomenon.13 4,14,19,32-52

Table 2

Characteristics of 26 patients with pemphigus diagnosed during pregnancy between 1966 and 2013.Open in a separate window

Effects on the mother

If a pregnant woman becomes sick (such as pemphigus), she is more likely to suffer from disorders of the neuroendocrine system and immune system due to the state of high pressure.53 According to the current study, the mother’s condition may exacerbate, enter into remission, or remain stable during the pregnancy.54 The disease is aggravated most likely during the first, second trimester, and postpartum, then is relived during the third trimester.15 This may be due to the increased level of endogenous corticosteroid hormone chorion and subsequent immunosuppression.40,55 Although some literature reports the postpartum flare of pemphigus due to the rapid drop of corticosteroid hormones levels, the postpartum status in our study was optimistic, only 2 cases (9.5%) of pemphigus diagnosed before pregnancy and 8 cases (30.8%) of pemphigus diagnosed during pregnancy exacerbated after delivery.19,56 However, some patients with pemphigus during pregnancy may not show any obvious changes, especially those patients in remission.9,15

Effects on the mode of delivery

Goldberg et al32 and Fainaru et al14 indicated that the trauma of vaginal delivery can result in extension and deterioration of the wound. In a cesarean section, patients who receive long-term steroid therapy will increase the risk, and the disease itself, and corticosteroid therapy may complicate wound healing. Therefore, delivery by cesarean section is the absence of additional benefits. Except for obstetric contraindications, vaginal delivery is recommended. Although it is a potential risk that local blisters may result in passive transfer of antibodies to the fetus through the breast milk, breastfeeding is not contraindicated.

Effects on the pregnancy outcome

Pregnancy outcome includes live birth, stillbirth, spontaneous abortion, and induced abortion.57 Pemphigus vulgaris in pregnancy may result in abortion, fetal growth retardation, intrauterine death, premature delivery, and in approximately 30% neonatal PV of the newborns.58 In this article, we will discuss the 3 most common outcomes of pemphigus in pregnancy: normal fetal outcome, neonatal pemphigus, and stillbirth.

Normal fetal outcome

Most of the patients with pemphigus can give birth to a normal full-term, healthy newborn through vaginal delivery or cesarean section, depending on the collaborative efforts of the dermatologist and obstetrician.56 In our study, although there were only 7 (33.3%) healthy neonates from the cases with pemphigus diagnosis before pregnancy, we considered it likely to be an underestimate due to the less frequent reports of successful deliveries than that of neonatal adverse outcomes.

Neonatal pemphigus

Neonatal pemphigus is a rarely reported transitory autoimmune blistering disease. It is clinically characterized by transient flaccid blisters and erosions on the skin and rarely on the mucous membranes.17 The disease can be self-healing at 2-3 weeks without special treatment, and does not have long-term clinical significance. No new vesicles or bullae appears in the newborn after birth. Neonatal PV has never been reported to persist beyond the neonatal period and progress to adult disease.17,34,35,39 Neonatal pemphigus is mainly due to the transplacental transmission of antibodies, and only a very small amount of immunoglobulin G (IgG) is synthesized by the neonate itself.36,59 Pemphigus IgG is found both in the fetal circulation and fixed to the fetal epidermis in a characteristic intercellular distribution, while IgA, IgM, IgE, and IgD generally do not participate in the passive transport.60 Contrary to PV, PF in pregnant women rarely leads to neonatal skin lesions.61 The absence of skin disease in the newborns may be due to low transfer of IgG4 autoantibodies through the placenta, and the “immunosorbent” effect of the placenta to contain desmosomes and desmogleins.62-65 This is because to the distribution and cross-compensation of the pemphigus antigens desmoglein 3 and 1 in neonatal and adult skin or mucosa are different.60

Stillbirth

In the literature, the rate of stillbirth in pemphigus during pregnancy was reported to range from 1.4-27%.18,33,56,66 In contrast to the high percentage of some previous observations, pregnancy ended in stillbirth in only one case (4.8%) of pemphigus diagnosed before pregnancy and 2 cases (7.7%) of pemphigus diagnosed during pregnancy in our study. The occurrence of stillbirth emphasizes the management problems encountered when a pemphigus patient becomes pregnant.56,66No relevance has been indicated between maternal treatment regimen and fetal outcome.38,67 Instead of particular medications, adverse pregnancy outcomes seem to be correlated more closely to poor maternal disease control, higher maternal serum, and umbilical cord blood antibody titers.38

Treatment options

Almost all types of pemphigus patients experience severe worsening of the disease after delivery if there is a lack of treatment during pregnancy (n=66). Treatment is often required to control both maternal diseases and fetal outcomes.68 The current study suggested that standard therapy gives priority to systemic glucocorticoids, alone or in combination with other immunosuppressive agents such as immunosuppressant, intravenous immunoglobulin (IVIg) or plasmapheresis.15,32,69 If the disease worsens during the first trimester, a medical termination of pregnancy may be considered, and if it happens during the second and third trimester, application of corticosteroids is a safe treatment.20 The treatment of pemphigus patients diagnosed during pregnancy is similar to the treatment before pregnancy.38

Glucocorticoids

The use of systemic steroids is considered safe in pregnancy, and glucocorticoid remains the first-line agent for treatment with low dosages when patients are mildly ill.70 Some corticosteroids such as prednisone (FDA pregnancy category B), featured with a fast action and high pharmacological effect, can be safely used as immunosuppressive drugs during pregnancy as they do not readily cross the placenta. Prednisone is the safest drug compared with other less used glucocorticoids such as dexamethasone and betamethasone.71,72 The dose of prednisone/prednisolone should be reduced to the lowest effective dose, and standardized doses are still experimental.15,19,32,56

Immunosuppressants

Immunosuppression of steroid-sparing agents are needed when pemphigus has to be controlled by larger doses of medications. Azathioprine is the most widely used steroid-sparing agent for pemphigus.73,74 Cyclosporine is believed to be less effective in the treatment of pemphigus, but it is the safest corticosteroid-sparing agent in pregnancy.38,69 Mycophenolatemofetil, cyclophosphamide, and methotrexate are strongly discouraged or even contraindicated in pregnancy.38,72

Intravenous immunoglobulin

There is moderate evidence suggestive of an effective and safe effect of IVIg as an auxiliary therapy in pregnancy patients with pemphigus.75-77 Therefore, when pregnancy is associated with significant medical problems or disease states, clinicians may need to consider using IVIg early.78

Plasmapheresis

Plasmapheresis is a useful alternative immunosuppressive therapy in pregnancy, which can be used as adjuvant therapy, combined with systemic corticosteroids, reducing the dosage of glucocorticoid treatment.21In conclusion, the patients may suffer from pemphigus before or during pregnancy. The condition of pemphigus and pregnancy can interact with each other and make the treatment and prognosis of these diseases more complicated, presenting challenges for the clinician. Pregnancy may precipitate or aggravate pemphigus, and new born babies of such patients may have a normal outcome or neonatal pemphigus, or, rarely, a stillbirth. Current treatment of pemphigus coexisting with pregnancy priorities systemic glucocorticoids, alone or in combination with other immunosuppressive agents such as immunosuppressants, IVIg or plasmapheresis. The number of reported cases of pemphigus in pregnancy is too small to predict the change of conditions for an individual patient. In summary, pemphigus and pregnancy is still an indistinct area that needs collaborative work by obstetricians, dermatologists, neonatologists, endocrinologists, and oral medicine specialists, to establish a mechanism of multi-disciplinary treatment.     

Pattern of drugs use and association with anti-mutated citrullinated vimentin antibody in rheumatoid arthritis

Objectives:

To demonstrate the pattern of disease-modifying antirheumatic drugs (DMARDs) use in Saudi and non-Saudi rheumatoid arthritis (RA) patients, and to evaluate the association of DMARDs use with anti-mutated citrullinated vimentin (anti-MCV) positivity and other factors.

Methods:

Retrospectively, for a period of 7 years (2007-2014), we studied 205 RA patients, at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia. All patients used DMARDs. Pattern of use for all 6 DMARDs was almost the same among Saudis and non-Saudis with no significant difference (p>0.05) for each DMARD; MTX was the most commonly used DMARD (71-76%).

Results:

There was no association between anti-MCV positivity and different DMARDs use. Methotrexate was used 76 times as combination, scoring the highest in this respect. There was a significant correlation (p<0.05) between Plaquenil with Methotrexate and with Sulfasalazine; Leflunomide with anti-TNF and with Prednisolone; age with Methotrexate and with Plaquenil; anti-MCV positivity with Prednisolone. Saudi/non-Saudi status showed no correlation with all factors or drugs. There was no significant association between DMARDs and comorbidity.

Conclusion:

Similar to worldwide results, MTX was the most commonly used DMARD; with the addition of anti-TNF to increase the effect, and folic acid to minimize the side effects. In this cohort, the pattern of use for all DMARDs was similar among Saudis and non-Saudis; treatment depended neither on anti-MCV positivity nor on the presence of comorbid conditions. A study of the association of DMARDs with disease activity is recommended.The effective treatment of rheumatoid arthritis (RA) can be achieved by disease-modifying antirheumatic drugs (DMARDs) that decrease joint damage with improvement of symptoms and functional abilities.1 The DMARDs have been classified into synthetic (sDMARDs) and biological.2 The sDMARDs are traditional drugs; such as methotrexate (MTX), sulfasalazine, leflunomide, and hydroxychloroquine (Plaquenil).2 The sDMARDs also include synthetic glucocorticoids (such as Prednisolone).3 If an sDMARDs is not effective after a trial of 3 months,4 they are usually combined with a biological DMARD, such as tumor necrosis factor alpha (TNF-α) blockers.1 To achieve disease remission in approximately 50 of people and improved overall outcomes, the DMARDs should be started very early in the disease.5 The frequently used DMARDs include MTX (the most commonly used one), Plaquenil (hydroxychloroquine), Azulfidine (sulfasalazine), and Arava (leflunomide), either as monotherapy, or in combination.1 Methotrexate is the most commonly used DMARD wordwide,6,7 and is the first line of treatment;8-10 even according to the treatment guidelines from the American College of Rheumatology (2012),11 and the European League Against Rheumatism (2010).12 Methotrexate is usually combined with folic acid (a vitamin),13 in order to reduce its adverse effects including nausea, vomiting or abdominal pain (gastrointestinal), hematologic, pulmonary, and hepatic.10 Methotrexate is teratogenic, thus, pregnancy should be avoided.8,10 Prednisolone (a synthetic glucocorticoids) can be used in the short term, while waiting for slow-onset drugs to take effect,1 and also as an injections into individual joints.1 Although its long-term use reduces joint damage, it also results in osteoporosis and susceptibility to infections, and thus is not recommended.1 A better effect can be achieved by combining MTX with anti-TNF than with MTX monotherapy.14 The response rate is better when switching from MTX monotherapy to MTX plus anti-TNF than combined DMARDs to MTX plus anti-TNF.14 In this study, our aim was to determine the pattern of disease modifying antirheumatic drugs use, and their association with anti-mutated citrullinated vimentin antibody (anti-MCV) in rheumatoid arthritis patients.     

The desire to utilize postmastectomy breast reconstruction in Saudi Arabian women: Predictors and barriers

Objectives:

To study factors that influence the desire to utilize breast reconstruction after mastectomy, and to investigate the barriers to reconstruction among women in Saudi Arabia.

Methods:

We conducted a cross-sectional study at 2 surgical centers in Jeddah, Saudi Arabia. A self-administered questionnaire was distributed to all breast cancer patients attending the surgery clinics for follow-up after mastectomy between January and March 2013. Ninety-one patients met the study inclusion criteria. The first part of the questionnaire covered the demographic and socioeconomic information regarding factors that might influence the desire to utilize breast reconstruction including possible barriers. Multivariate logistic regression was used to determine the significant predictors of the desire to undergo reconstruction.

Results:

Overall, 16.5% of patients underwent breast reconstruction after mastectomy. Young age and high educational attainment were significantly associated with an increased desire to undergo reconstruction. The main barriers to reconstruction were the lack of adequate information on the procedure (63%), concerns on the complications of the procedure (68%), and concerns on the reconstruction interfering with the detection of recurrence (54%).

Conclusion:

Age and educational level were significant predictors of the desire to utilize breast reconstruction. Furthermore, modifiable barriers included the lack of knowledge and misconceptions on the procedure. Addressing these issues may increase the rate of breast reconstruction in Saudi Arabia.Surgical resection (mastectomy) is considered the primary treatment for breast cancer. In the past decade, changing attitudes toward breast reconstruction among both patients and providers have led to an increasing number of women seeking breast reconstruction after mastectomy.1 In 2009, there were approximately 86,000 breast reconstruction procedures performed in the United States.2 There has been a significant rise in immediate reconstruction rates, attributable to a notable increase in implant use.3 Many types of breast reconstruction are available including silicone and silane implants, tissue expanders, and pedicle and free musculocutaneous flaps.4,5 Although these reconstruction options have been proven to be oncologically safe,5 and many women still refuse breast reconstruction.6 The choice to proceed with breast reconstruction after mastectomy is difficult, and is affected by many factors. Most breast reconstruction procedures are performed in women younger than 60 years of age.7 The decision to proceed with reconstruction can be influenced by patient factors, physician factors, cancer related factors, and insurance status.7-10 Patient factors include patient age, socioeconomic status, race, site of mastectomy, and patient preference.1 Of these factors, age >50 years is the most common negative predictor of breast reconstruction after mastectomy.8,9,11-13 According to the Saudi Cancer Registry,14 breast cancer has been the most common cancer among Saudi females over the past 12 years. In a recent study, Ibrahim et al15 estimated that the burden of breast cancer in Saudi Arabia will increase by approximately 350% by 2025. In a previously published study, almost half of the general surgeons surveyed reported that they had treated patients who refused breast reconstruction despite its availability.4 Previous studies on the factors influencing postmastectomy breast reconstruction in the Middle East were conducted in Egypt13,14 and we are not aware of any similar studies conducted in Saudi Arabia or the Gulf Region. The objectives of this exploratory study were to study the demographic and socioeconomic factors influencing the desire to utilize postmastectomy breast reconstruction and to evaluate the barriers to postmastectomy breast reconstruction among women in Saudi Arabia.     

A call-to-action from the feedM.E. Middle East study group: Use of a screen-intervene-supervene strategy to address malnutrition in healthcare

Up to 50% of hospitalized patients worldwide are malnourished or at risk of malnutrition. Guidelines recommend nutritional screening of all patients on hospital admission. Results from studies of hospitalized patients show that screening, with follow-up nutritional assessment and care when indicated, can improve patients’ clinical outcomes and reduce healthcare costs. Despite compelling evidence, attention to nutritional care remains suboptimal in clinical settings worldwide. The feedM.E. Global Study Group developed a simple, stepwise Nutrition Care Pathway to facilitate best-practice nutrition care. This pathway guides clinicians to screen patients’ nutritional status on hospital admission or at initiation of care; intervene promptly with nutrition care when needed; and supervene or follow-up routinely with adjustment and reinforcement of nutrition care plans. The feedM.E. Middle East Study Group seeks to extend this program to our region. We advise clinicians to adopt and adapt the Nutrition Care Pathway, bringing quality nutrition care to everyday practice.Up to 50% of hospitalized patients are reported to be at risk of malnutrition or actually malnourished.1,2 Clinical studies in healthcare settings worldwide have shown that disease-related malnutrition is exceedingly common,3-7 especially in older patients.8,9 The prevalence of disease-related malnutrition-nutritional inadequacy with an inflammatory component10 is similarly high in hospitals of both emerging and industrialized nations. This prevalence remains as high now as it was a decade ago in almost every country.11-14 Patients with poor nutritional status are susceptible to disease progression and complications, and their recovery from illness or injury is often prolonged.1,15,16 A key barrier to best-practice nutrition care is limited hospital resources; clinicians report that too little time and not enough money constrain staff training on how to recognize and treat malnutrition.17,18While educational training and nutrition interventions have financial costs, so do the consequences of malnutrition. Disease-related malnutrition increases costs of care due to higher rates of complications (infections, pressure ulcers, falls) longer hospital stays, and more frequent readmissions.19-28 By contrast, clinical study results show that attention to nutrition care during hospitalization can improve patients’ health outcomes and cut healthcare costs.29-39 Nutrition planning and follow-up nutrition care can also provide both health and financial paybacks, whether the patient is living in the community, preparing for surgery, or ready to be discharged from the hospital.40-43 Yet disease-related malnutrition continues to be overlooked and under-treated.Despite compelling evidence of benefits from nutrition care29,30,32,34-38 and clearly-stated nutrition care guidelines,43-46 nutrition interventions for people with disease-related malnutrition still fall far short of best-practice.3,4,47 To address this shortfall, clinicians worldwide have issued a “call-to-action” for increased recognition of nutrition’s role in improving patient outcomes.42,48-50 To take action, clinical nutrition experts from Asia, Europe, the Middle East, and North and South America formed the feedM.E. (Medical Education) Global Study Group and put together a working program to increase awareness and improve nutrition care around the world.1 The global feedM.E initiative introduced the mantra “screen, intervene, and supervene” to cue the steps of a straightforward Nutrition Care Pathway.1 To support the feedM.E. global educational initiative, we formed a feedM.E. Middle East Study Group, which includes nutrition leaders from Egypt, Saudi Arabia, Turkey, and the United Arab Emirates (Open in a separate windowIn our current article, we the members of the feedM.E. Middle East Study Group emphasize the screen-intervene-supervene strategy for nutrition care, which is further defined for incorporation into practice as a Nutrition Care Pathway. For Middle East healthcare, we advise that this pathway can be adapted to meet cultural differences in different Middle East countries, and can be followed for patients in the community, in the hospital, and after discharge to home or to long-term care centers.

Malnutrition in the Middle East

Countries of the Middle East region are highly diverse in ecology (green valleys and dry yellow deserts), political structures (republics, monarchies), government stability or instability (conflicts, civil wars, unrest), and economic status (world’s richest and poorest countries). This diversity creates marked differences in the health and nutritional status of people in regional populations.51 In some cases, rapid urbanization and social development have occurred in the absence of economic growth.51 For adults in the Middle East and worldwide, malnutrition is often related to sickness, which includes people with limited physical or mental function. Disease-related malnutrition occurs in people of all ages and circumstances but is notably common in older people.9 Disease-related malnutrition is evident at hospital admission, during hospitalization, and in the periods before admission and after discharge. With all these influences, the prevalence of disease-related malnutrition varies widely across the Middle East; from 6% to 58% of hospitalized patients are malnourished or at risk of malnutrition (52

Table 2

Reports of hospital- and community-based malnutrition prevalence in Middle East countries.Open in a separate window

Malnutrition predicts poor health outcomes

Poor nutrition is a predictor of poor outcomes, as shown by results of a large multicenter collaboration including hospitals in 3 countries of the Middle East (Lebanon, Egypt, and Libya) and 9 countries in Europe.53 This prospective study enrolled 5,051 patients; of these, 33% of patients were found to be ‘at risk’ of malnutrition (NRS 2002 score). The proportion of ‘at risk’ patients generally reflected the severity of the underlying illness or injury in the population studied. For patients in the Middle East, risk for malnutrition by hospital department was: internal medicine (11%), oncology (37%), surgery (55%), and intensive care (97%).53 Patients ‘at risk’ had significantly more complications, longer lengths of hospital stay, and higher rates of mortality.53 Further, of those who were discharged, fewer ‘at risk’ patients were discharged to home, and more were sent to nursing homes or to other hospital care sites, as compared with patients who were adequately nourished.53

Malnutrition is under-treated

Even when nutrition problems are identified, studies have found that such problems are not adequately treated. In one Middle Eastern study, 34 Turkish hospitals from 19 cities contributed data from 29,139 patients.54 On admission, 15% of patients were found to be at nutritional risk; risk was highest in intensive care unit patients (52%). Of those identified to be ‘at nutritional risk’ in this study, only around half received nutrition intervention.54 Studies carried out in Australian and European hospitals reported similar shortfalls in treating malnutrition or reaching nutritional targets.3,47

Nutrition care improves outcomes and lowers costs

Nutrition interventions, including food fortification or oral nutrition supplements (ONS), tube-fed enteral nutrition, and parenteral nutrition, are recognized to have significant clinical and economic benefits across patient groups and in different settings. Specifically, nutrition interventions were associated with fewer in-hospital complications,30 reduced pressure ulcer incidence,37 achievement of higher functional status in recovery,30 improved quality of life,34,55 and reduced risk of mortality,56 as shown by results of randomized and controlled trials and by meta-analyses. Nutrition interventions to prevent or treat disease-related malnutrition also show resource savings; reports have shown reduced length of hospital stay,57 fewer readmissions,38,55 and lowered hospital-related costs.35,36 Few studies have considered cost of hospital-based malnutrition in Middle East countries. However, a recent survey of neurologists from 8 tertiary centers in Turkey examined current practice related to treatment of patients recovering from strokes.58,59 The researchers determined that the overall one-year costs of care were higher for malnourished patients compared to those who were adequately-nourished ($5201 versus $3618; p=0.09). Of the total costs, oral nutrition supplements (ONS) costs were $868 in patients with malnutrition and $501 in patients without malnutrition, whereas all others costs were $4334 and $3117. Investment in ONS as treatment for malnutrition was thus supported as a way to decrease the cost of illness.

Malnutrition definition

For caregivers to provide best-practice nutrition care, it is important to be aware of the current definition of malnutrition. Malnutrition is now recognized as 3 clinical syndromes, which are characterized by underlying illness or injury and varying degrees of inflammation.10 These malnutrition syndromes are: 1) starvation-related malnutrition, namely, a form of malnutrition without inflammation; 2) chronic disease-related malnutrition, namely, nutritional inadequacy associated with chronic conditions that impose sustained inflammation of a mild-to-moderate degree; and 3) acute disease- or injury-related malnutrition, namely, undernutrition related to conditions that elicit marked inflammatory responses. Inflammation is a component of underlying disease in several chronic disease states, such as kidney disease and heart failure and thus increases the risk of malnutrition,60 even among patients who are overweight or obese.61 Most severe acute health crises such as severe infection, surgery, burn injury, or sepsis are associated with marked inflammation, which contributes to and intensifies risk for severe malnutrition.60 Adult undernutrition was further described as a condition characterized by 2 or more of 6 criteria: unintentional weight loss, inadequate energy intake, loss of muscle mass, loss of subcutaneous fat, fluid accumulation, and functional decline (for example, decreased hand-grip strength).62

The feedM.E. Nutrition Care Pathway

The feedM.E. Global Study Group recently introduced screen-intervene-supervene as a guide for delivering prompt and complete nutrition care (Appendix 1A).1 We members of the feedM.E. Middle East Study Group support this overall strategy, and we advise the use of the Nutrition Care Pathway to bring this strategy to everyday practice. To facilitate broad use of the Nutrition Care Pathway throughout the Middle East, we provide versions in Turkish and Arabic (Appendix 1 B and ​andCC). For complete uptake, specific aspects of nutrition care may need adjustments to meet country-to-country cultural differences to accommodate disparate lifestyles, food availability, and genetic factors, as was the case with a diabetes nutrition program.63,64

Nutrition Care Pathway: screen for malnutrition risk

Screening patients for malnutrition on admission to the hospital is now a standard of care. In the Middle East, we advise that routine nutrition screening is likewise appropriate in rehabilitation facilities, long-term care centers, and community healthcare settings. To determine nutritional risk, we advise screening with (1) the 2 Malnutrition Screening Tool (MST) questions65,66 and (2) a quick clinical decision on whether the patient’s illness or injury carries risk for malnutrition.10In the Middle East, as is the case elsewhere, admitting nurses are often the first contacts for patients, and we suggest that nurses conduct the initial screen for nutritional risk. If risk is found, we advise immediate intervention with nutrition advice, an increase in the quantity or protein density of food, and/or use of protein-containing oral nutrition supplements. With risk recognition, particularly when the patient is unable to take food orally, refer to a trained clinician (dietitian, nutrition specialist) for further assessment and specific treatment.

Nutrition Care Pathway: intervene with targeted nutrition

The intervention portion of the Nutrition Care Pathway includes assessment of nutritional status, diagnosis of malnutrition, and implementation of treatment. For nutrition assessment, the SGA is widely used for most adults,67 and the MNA is used for older persons;68 other tools are available.52 To facilitate malnutrition diagnosis and help standardize malnutrition care, experts from A.S.P.E.N. and the Academy of Nutrition and Dietetics (AND) defined specific criteria for malnutrition diagnosis.62 Guidelines support prompt intervention, namely, targeted nutrition therapy within 24 to 48 hours of admission.43-46 Implementation of treatment involves decisions on how much to feed, how and when to feed, and what to feed, as discussed in detail for the feedM.E. global initiative.1

Nutrition Care Pathway: supervene

The next step of the Nutrition Care Pathway is to supervene, or follow-up with continuing attention to meeting nutrition needs. Individuals receiving nutrition therapy should also be monitored regularly to ensure feeding tolerance and adequate supplies of energy with sufficient protein, vitamins, and minerals.69 For those patients who are initially well-nourished, rescreening should occur at regularly determined intervals, especially when clinical status changes.70 An effective nutrition plan considers multiple aspects of care.43 It requires that the patient have cognitive competence, social and functional abilities, and economic access to food; alternatively, some patients need a caregiver and other social support programs to meet their needs. The nutrition plan should be prepared for and discussed with the patient, modified as needed to meet personal and cultural preferences, and include ongoing measures/assessment of the patient’s nutritional status.To ensure best-practice nutrition care in the Middle East, we recommend continued efforts to prevent and treat malnutrition among patients who have been discharged from the hospital into long-term care centers or into the community. Such efforts include nutrition education for the patient or their caregivers and individualized dietary advice on the use of food enrichment and/or oral nutrition supplements. We also emphasize the importance of routine rescreening for malnutrition risk. We call on regional and local health authorities to endorse nutritional risk assessment as an integral part of routine medical care.In conclusion, attention to nutrition is fundamental to good clinical practice. As members of the feedM.E. Middle East Group on nutrition in healthcare, we call healthcare providers in our region to action. To do so, we recommend use of the Nutrition Care Pathway that includes 3 key steps: screen always, intervene promptly when needed, and supervene or follow-up routinely. Because of wide socioeconomic differences among Middle Eastern countries, we recognize that feedM.E. global strategies may need to be adapted to meet country-specific needs, and we propose testing pilot models for feedM.E. training in each country.     

Effects of occupational therapy on quality of life of patients with metastatic prostate cancer: A randomized controlled study

Objectives:

To evaluate the efficiency of occupational therapy relative to a home program in improving quality of life (QoL) among men who were treated for metastatic prostate cancer (MPC).

Methods:

Fifty-five men were assigned randomly to either the 12-week cognitive behavioral therapy based occupational therapy (OT-CBSM) intervention (treatment group) or a home program (control group) between March 2012 and August 2014 in the Department of Occupational Therapy, Faculty of Health Sciences, Hacettepe University, Ankara, Turkey. The Canadian Occupational Performance Measure (COPM) was used to measure the occupational performance and identify difficulties in daily living activities. The QoL and symptom status were measured by The European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire C30 and its Prostate Cancer Module. A 12-week OT-CBSM intervention including client-centered training of daily living activities, recreational group activities, and cognitive behavioral stress management intervention were applied.

Results:

The COPM performance and satisfaction scores, which indicate occupational participation and QoL increased statistically in the treatment group in relation to men who were included in the home-program (p≤0.05).

Conclusion:

A 12-week OT-CBSM intervention was effective in improving QoL in men treated for MPC, and these changes were associated significantly with occupational performance.Prostate cancer is one of the most frequent male malignancies in the world.1 The development of serum prostate-specific antigen (PSA) and advanced prostate cancer treatment modalities increased 10-year survival rates from ~60% to >70%.2 Prostate cancer can be occurred as a local disease or advanced metastatic disease. The standard of care for metastatic prostate cancer (MPC) is hormone (androgen blockade) therapy, which delays progression and relieves pain for an average of 18 months to 24 months.3,4 Nearly all patients who have hormone therapy eventually develop significant disease and treatment related morbidity including fatigue, decrease in bone density, bone pain, weight loss, gynecomastia, and hot flushes.3 Increased survival and subsequent functional, physical, and psychological needs produced a growing acceptance of understanding the rehabilitation needs to increase the occupational performance and quality of life (QoL) of the patients with MPC.5 Occupational therapy (OT), one of the core elements of oncologic rehabilitation, is in a unique position to contribute to the development and fulfillment of occupational performance and participation with the motto of ‘live life to its fullest’.6 The role of the occupational therapist in oncology is to facilitate and enable an individual to achieve maximum functional performance, both physically and psychologically, in everyday living skills regardless of his or her life expectancy.6 Occupational performance or participation in everyday occupations is vital for all humans as defined by the International Classification of Functioning, Disability and Health7 (ICF). Occupational performance has a positive influence on health, well-being, and the presence of cancer has been found to lead to participation in meaningful activities /occupations that are effected by the cancer and its treatments.8 Previous studies9-14 have ably identified OT interventions mostly in general oncology and palliative care. The literature on OT, specifically on patients with breast cancer, investigates management of pain, fatigue, nausea, metastatic patients intervention, stress reducing and management program, the value of engagement in meaningful activities, lymphedema, vocational rehabilitation, creative and therapeutic use of activity, cognitive therapy, and, changing life style with cognitive behavioral therapy.9-14 According to the literature, a survey on women with breast cancer provides a picture of the interventions employed by the occupational therapists and can help to create an OT service to regain the patients level of control and independence by maintaining or resuming engagement in purposeful occupations and meaningful activities; however, the effect of OT in patients’ QoL was not completely specified.15,16 Another interdisciplinary study recommended examination of the effectiveness of OT in patients’ functional needs and to promote evidence-based practice of OT in oncology.8,17Prostate cancer oriented rehabilitation interventions may be valuable in functioning, and activity participation in daily living activities and also in helping men to acknowledge, express, accept, and use a problem solving approach on the changes that occur as a result of treatment and to seek out adaptive solutions for enduring fatigue, bone pain, weight loss, gynecomastia, and hot flushes.18 Such interventions may lead to significant improvements in functional, cognitive, and emotional coping skills, use of social support, utilization of health care, and management of symptoms.5,18-21 Rehabilitation interventions were adapted to meet the needs of cancer patients including functional individualized support and group therapy interventions22 and stress management intervention23 approaches. The research shows that effective stress management components include relaxation training to lower arousal, disease information and management, an emotionally supportive environment in which participants can address fears and anxieties, behavioral and cognitive coping strategies, and social support.19,20 Participation in rehabilitation intervention provides a clear and robust benefit to cancer patients by relieving treatment-related symptoms, reducing the physiologic concomitants of stress, and improving mood. Previous study19 found that the benefits in coping with cancer may be quite significant in male participants.19 This is supported by the positive experiences that men report from their participation in rehabilitation programs. Although, collectively, these findings indicated that men treated for prostate cancer derive benefit from a rehabilitation experience, most studies did not include a randomized intervention design and did not study the occupational performance of the participants.15,23 Only a few studies20,21 have investigated the efficacy of structured stress-management interventions in improving QoL and the mechanisms associated with such improvements despite stressful and negative side effects associated with treatment with limited activity participation.The limited reports in the literature indicates that there is a lack of study on the effect of OT combined cognitive behavioral stress management skills in patients with MPC. In the current study, it was hypothesized that participants treated for MPC enrolled in the cognitive behavioral stress management based OT (OT-CBSM) would demonstrate greater improvements in occupational performance and QoL compared with a control group (CG) enrolled in the home-program. The objectives of this study were to identify the effect of OT-CBSM on occupational participation and QoL, and to explore the areas/activities of daily life that were the most commonly affected, and needed support in patients with MPC.     

The variations of peroneus digiti quinti muscle and its contribution to the extension of the fifth toe: A cadaveric study

Objectives:

To investigate the origin, prevalence, and possible effects of peroneus digiti quinti muscle (PDQ) on the fifth toe, to find out the variations of PDQ by determining the relationship between peroneus brevis muscle (PB) and PDQ, and to reveal its importance for the applications in foot and ankle surgery.

Methods:

This study was conducted at the Faculty of Medicine, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey between September 2013 and June 2014. The study was a prospective dissection of cadaveric lower limbs. Twenty-five amputated lower limbs were stored in the freezer at -15°C. The legs were dissected; prevalence and variations of peroneus digiti quinti were investigated.

Results:

Peroneus digiti quinti muscle was found in 8 (32%) of 25 dissected lower limbs. However, 2 different tendon extensions were found at 3 (37.5%) of 8, and 5 (62.5%) of them were determined to have a single tendon.

Conclusion:

The incidence, dimensions, length, and insertions of peroneus digiti quinti are important in the evaluation and treatment of functional loss of the fifth toe, lateral foot deformities, and tendon problems behind the lateral malleolus of the ankle.There are 2 peroneal muscles in the lateral compartment of the leg. Peroneus longus muscle (PL) is longer than the 2, passing behind the lateral malleolus (LM), and enters a groove under the cuboid bone and reaches its attachment at the base of first metatarsal bone. Peroneus brevis muscle (PB) is the shorter one, passing behind LM, and attaches the tuberosity of the fifth metatarsal bone.1,2 However, due to developmental factors, it is claimed that the variations, or rather accessory tendons of these muscles are quite common.3 Variationally, there may be various accessory tendons, the incidence of which changes from one population to another, such as peroneus tertius muscle (PT), and peroneus digiti quinti muscle (PDQ), and particularly peroneus quartus muscle (PQ).4-7 Generally, these muscles arise from peroneus brevis but their insertions exhibit variabilities.8 Peroneus quartus muscle inserts on the calcaneus and adjacent structures,9 PT inserts on the base of the fifth metatarsal bone10 and PDQ inserts on the fifth toe.3 The presence of PQ was reported to be approximately 22%,11-13 and PT to be approximately 10%.10 The prevalence of PDQ is so varied in the literature that it was reported by Reimann14 as 79.5%, and by Jadhav et al15 as 51%. Peroneus digiti quinti muscle extends as a small slip from the tendon of PB to the extensor aponeurosis,15,16 or proximal phalanx of the fifth toe.6 Peroneus digiti quinti muscle is innervated by superficial fibular nerve just like PB.17,18 Moreover, in some studies, it is stated that PDQ is innervated by the accessory deep peroneal nerve.18 Generally it is reported that PDQ, the diameter of which varies from 0.7 to 3 mm, does not have any kind of function since it has a really small muscle belly and a thin tendon.14 Generally, accessory muscles are asymptomatic, and they can lead different clinical symptoms related to vessels, nerves, and tendons.17,19 Peroneus digiti quinti muscle is also an asymptomatic accessory muscle, which means that it does not cause any pain, or neurological disorder.15 In a study carried out by Macalister,25 Yammine stated that in cases that PQ developed fully, PDQ arose from PQ, and reached the fifth proximal phalanx and contributed to the extension of the fifth toe.3 According to some other articles,6,15 PDQ is usually separated from PB, and there is insufficient information regarding its function. It has been only stated that PDQ partially pronates the fifth toe.20 Loss of function can be observed at muscle-tendon units of toes due to traumatic or non-traumatic reasons, and the muscle-tendon units can lose their primary functions. Tendon anomalies may confuse the clinicians during evaluation of their functions. In order to evaluate the function and anatomic structure of the foot, it is necessary to know the function, morphology of the muscles and tendons, as well as their anomalies. Peroneus digiti quinti muscle, when present, can be used as an accessory muscle and it can contribute to the extension of the fifth toe, since it ends on the dorsal aponeurosis of the fifth toe. Therefore, the aim of this study was to: 1) investigate the origin, prevalence, and possible effect of PDQ on the fifth toe, 2) to find out the variations of PDQ by determining the relationship between PB and PDQ, and 3) to reveal its importance for the applications in foot and ankle surgery.     

Recognition of oxidized albumin and thyroid antigens by psoriasis autoantibodies: A possible role of reactive-oxygen-species induced epitopes in chronic plaque psoriasis

Objectives:

To investigate the role of reactive-oxygen-species (ROS) induced epitopes on human-serum-albumin (HSA) and thyroid antigens in psoriasis autoimmunity.

Methods:

This study was performed in the College of Medicine, Qassim University, Buraidah, Saudi Arabia between May 2014 and February 2015. The study was designed to explore the role of ROS-induced epitopes in psoriasis autoimmunity. Singlet-oxygen (or ROS)-induced epitopes on protein (ROS-epitopes-albumin) was characterized by in-vitro and in-vivo. Thyroid antigens were prepared from rabbit thyroid, and thyroglobulin was isolated from thyroid extract. Immunocross-reactions of protein-A purified anti-ROS-epitopes-HSA-immunoglobulin G (IgGs) with thyroid antigen, thyroglobulin, and their oxidized forms were determined. Binding characteristics of autoantibodies in chronic plaque psoriasis patients (n=26) against ROS-epitopes-HSA and also with native and oxidized thyroid antigens were screened, and the results were compared with age-matched controls (n=22).

Results:

The anti-ROS-epitopes-HSA-IgGs showed cross-reactions with thyroid antigen, thyroglobulin and with their oxidized forms. High degree of specific binding by psoriasis IgGs to ROS-epitopes-HSA, ROS-thyroid antigen and ROS-thyroglobulin was observed. Immunoglobulin G from normal-human-controls showed negligible binding with all tested antigens. Moreover, sera from psoriasis patients had higher levels of carbonyl contents compared with control sera.

Conclusion:

Structural alterations in albumin, thyroid antigens by ROS, generate unique neo-epitopes that might be one of the factors for the induction of autoantibodies in psoriasis.Psoriasis, a chronic skin disorder is known to be the most prevalent autoimmune disorder in humans.1 It is characterized by hyperplasia of the epidermis, infiltration of leukocytes of dermis and epidermis as well as dilatation and proliferation of blood vessels, which are likely to be triggered by multiple factors such as drugs, physical and psychological stress, bacterial infections, or injury.2 Psoriasis appears in different clinical variants and the most frequently is the plaque psoriasis (also known as psoriasis vulgaris), presents with scaly red plaques on common areas, such as on scalp, the back, dorsal skin of the elbows, and ventral skin of knees.3 Although, the role of immunologic and environmental factors in the pathogenesis of plaques psoriasis has been proposed, but the precise etiology of disease remains poorly understood.1,3 It is well documented that oxidative stress is one of the major factors involved in the pathogenesis of psoriasis4-6 and now it has been well established that excess generation of reactive oxygen species (ROS) by the immune system play a vital role in the development of psoriasis.7 Cellular events such as cell proliferation, apoptosis, cell differentiation, and immune response are influenced by ROS, and these events are altered in psoriasis patients.4-7 Although the exact pathogenesis of psoriasis is unknown, but the occurrence of autoimmune reactions has been assumed,8-10 the presence of autoantibodies and various underlying immunologic abnormalities in the affected sites of these patients have also been reported.8,11-15 The autoimmune etiology has been also proposed on the basis of its association with various autoimmune diseases,8,10 but the precise mechanism of generation of autoantibodies in psoriasis remains unclear.Thyroid disorders have a high prevalence in medical practice; they are associated with a wide range of diseases with which they may or may not share etiological factors. One of the organs which best show this wide range of clinical signs of thyroid dysfunctions is the skin.16-18 Thyroid abnormalities are well documented in psoriasis patients, thyroid gland causes an increase of epidermal growth factor levels, which has an important role in keratinocytes proliferation in psoriasis.19-21 In addition, a high prevalence of thyroid associated autoimmunity has also been reported in patients with psoriasis.20 Moreover, elevated ROS levels are often seen to be associated with thyroid dysfunctions, and now it is proposed that the thyroid hormones influence the ROS steady-state environment in the cell.22-24 The most common idea is the hyperthyroidism, which enhances the ROS production that perturbs the ROS steady-state environment to facilitate the cellular damage or damage to the cellular components as also reported in psoriasis patients.22,25 Therefore, it is assumed that in psoriasis, cells or cellular components are continuously exposed to oxidative stress, so that alterations in conformation and function of these cellular components may occur, which may results in modification of their biological properties. In view of these, this study was aimed to investigate the role of ROS-induced epitopes on albumin and thyroid antigens in psoriasis autoimmunity. To test this, ROS-modified epitopes were generated on albumin and antibodies against ROS-modified-albumin (anti-ROS-modified-epitopes antibodies) were experimentally generated. Cross-reactions of affinity purified anti-ROS-modified-epitopes immunoglobulin Gs (IgGs) with native- and ROS- modified thyroid antigen, thyroglobulin or human DNA were determined. Our data showed that anti-ROS-modified-epitopes-IgGs showed immunospecificity with thyroid antigen, thyroglobulin and with their oxidized forms. Importantly, the antigen(s) binding characteristics of naturally occurring chronic plaque psoriasis antibodies to ROS-modified epitopes, thyroid antigen, ROS-modified thyroid antigen, thyroglobulin, ROS-modified thyroglobulin, human DNA, and ROS-modified human DNA were determined.     

Gingival biotype in relation to incisors’ inclination and position

Objectives:

To study the association between gingival biotypes and inclination and position of the maxillary and mandibular incisors.

Methods:

This cross-sectional study included 142 consecutive orthodontic patients (64 males and 78 females) who were seeking orthodontic treatment at the Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia from February 2013 to January 2014. Gingival biotype was assessed independently for the maxillary and mandibular central incisors using the transparency of periodontal probe method. Maxillary and mandibular incisors’ inclination and position were measured using cephalometric analysis.

Results:

The mean age was 23.56 (±2.55) years. The prevalence of thin gingival biotype was 43% for the maxillary and 52.1% for the mandibular incisors. Females were 4 times more likely to have thin gingiva for the maxillary incisors and 5 times more likely for the mandibular incisors. A significant association was found between mandibular incisor inclination and position and thin gingival biotype, while there was no association between the maxillary incisor inclination and position and gingival biotypes.

Conclusion:

Mandibular incisor proclination and protrusion is associated with thin gingival biotype while no association is found in the maxilla. The evaluation of the gingival biotype is essential during diagnosis and treatment planning for potential orthodontic patients.The inclination and position of incisor teeth is an important factor when planning orthodontic tooth movement. In recent years, there have been several investigations regarding the limits to the degree of incisor proclination in the dental arch.1-4 The effect of proclination may consequently lead to gingival recession. Gingival recession can be generalized or localized, affecting one tooth surface or more, and might lead to an esthetic impairment.5,6 Several factors were suggested to play a role in the development of gingival recession. The main known etiologic factors, among others, are periodontal diseases, and mechanical trauma.7 Periodontal health is a prerequisite prior to starting any orthodontic tooth movement. The role of orthodontic tooth movement in the development of gingival recession is still a debatable subject.8-10 Even though some found an increase in gingival recession in adolescents and adults, 3,4,9 others did not find that gingival recession was induced by orthodontic fixed appliance therapy.1,11 The inconsistencies between these studies could be attributed to the fact that the etiology of gingival recession is complex. Several factors were suggested to modulate the incidence of gingival recessions following orthodontic therapy, for example: the total orthodontic tooth movement, the quality of oral hygiene, and the gingival biotype.1-3,12 The evaluation of the gingival biotype is essential, especially prior to orthodontic tooth movement because it defines the soft and hard tissues surrounding teeth. Gingival biotype can be classified as thin or thick.13 The thin gingival biotype is characterized by delicate soft tissue with a minimal amount of attachment that is susceptible to trauma and inflammation while the thick gingival biotype is characterized by dense, fibrotic soft tissue with a large amount of attachment. Thick gingivae are generally suggested as the model of periodontal health.14 Reduction in gingival thickness is considered a predisposing factor to marginal tissue recession during orthodontic treatment, and proper clinical assessment of gingival biotype will insure accurate decision-making during planned incisor inclination. This is supported by one study where they observed an increase in the risk of gingival recession after orthodontic treatment when the thickness of free gingival margin is less than 0.5mm especially when it comes to incisor proclination.3 The prevalence of different gingival biotypes varies depending on the studied population. In a Saudi sample, the prevalence of thin gingival biotype was 25% among males and 64% in females.15 The association between dental malocclusion and the prevalence of gingival biotype has been previously studied and no significant association was demonstrated.15 However, the relationship between the maxillary or mandibular incisors inclination and position and gingival biotypes has not been previously studied. This study therefore aimed to evaluate the association between gingival biotypes and the inclination and position of the maxillary and mandibular incisors. A secondary aim was to study the relationship between gingival biotypes and space analysis in the anterior segment of both arches.