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Abdulrazak Abyad MD, MPH, MBA, AGSF, AFCHSE


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EDITORIAL September 2023

In this issue we have a number of paper of high relevance to the practicing physician and a number of challenging case report.

Alhudaithi et al., did a Cross-Sectional Population Study Knowledge and Awareness of the Public toward Pediatric Eye Health and Diseases in Aseer region, Saudi Arabia. Pediatric ophthalmic conditions are a common and a serious public health problem, as they can not only impact the child's ability to learn, have a normal social life, and get a better quality of life, but they can also lead to complete blindness or visual impairment. Early intervention is necessary for childhood eye diseases since they can result in ongoing issues. The underlying causes of blindness in children differ significantly from region to region, depending on some factors, including socioeconomic development and access to primary healthcare services and facilities. However, it is estimated that there are over 19 million people globally with visual impairments and that there are roughly 1.4 million cases of blindness. As a result, the purpose of this study is to assess the parents' and caregivers' awareness in Aseer, Saudi Arabia, about various common pediatric ophthalmic diseases, including strabismus, amblyopia, refractive errors, and congenital glaucoma. By identifying the gap in knowledge and awareness, this could help create targeted educational and awareness programs geared toward the parents and the public of Aseer, Saudi Arabia, which could help prevent or reduce the prevalence of pediatric ophthalmic conditions, and boost the children's eye health.

Al Jabir1 et al., followed a quantitative cross-sectional design at Khamis Mushayt Maternity and Children's Hospital (KMMCH) to explore parents' perspectives regarding why parents (caregivers) prefer to escort their less urgent, or non-urgent sick children to the emergency departments (EDs) instead of using other more appropriate healthcare services. The age of 18.3% of parents was <30 years, while 28.5% were 30-39 years old. More than half of the parents' visits were non-urgent, while 43.25% were less-urgent, 55.3% of patients visited the ED before due to similar complaints, while 46% visited a primary health care center before their ED visits. The main reasons for visiting the ED instead of the primary healthcare centers (PHCCs) were to save time (49.3%) and to get an earlier appointment (48%). Patients' triage levels differed significantly according to parents' age groups (p<0.001), nationality (p=0.022), educational level (p=0.022), ED visits for similar complaints (p<0.001), and previously visiting the PHCC for the current health problem (p=0.002). Triage levels also differed significantly according to some reasons for choosing to go to the ED instead of the PHCC, especially to get an earlier appointment (p=0.044), preferring the healthcare services provided by the ED (p=0.005), having a nearby ED (p=0.001), or being at the hospital at that time (p=0.002). The authors concluded that there is a clear relationship between inappropriate ED visits and certain associated factors, indicating that prevention would be best targeted to certain categories, such as Saudi, younger, and educated parents. The main reasons for inappropriate ED visits are to save time and to avoid getting a late appointment.

Alsufyani et al., did a systematic review and meta-analysis to compare the perioperative results of RARN and LRN in the treatment of RCC. The meta-analysis revealed no statistically significant demographic differences between the two surgical techniques. There were no significant differences between RARN and LRN in terms of predicted blood loss, length of hospital stay, conversion rate, or transfusion rate. The meta-analysis of complications revealed no significant differences between the two surgical methods for intraoperative or postoperative problems. The authors concluded that this comprehensive review and meta-analysis suggests that RARN and LRN had comparable perioperative results when used to treat RCC. Although RARN may give prospective benefits in the form of enhanced visibility and dexterity, the clinical significance of these benefits remains unknown. Further high-quality studies with long-term follow-up are required to further comprehend the possible advantages and disadvantages of RARN against LRN in the treatment of RCC.

El Mahdy, et al., tried to estimate the prevalence of violence against female students at Jazan University, Saudi Arabia, and identify their knowledge and response towards emotional and physical domestic violence. Domestic violence against females is one of the most important social problems negatively affecting health psychologically and physically. It is a descriptive cross-sectional, observational type of epidemiologic study conducted on 450 female students at 3 Faculties, female sections, Jazan University, for eight weeks. The data is collected using an Arabic questionnaire containing 35 questions and analyzed by SPSS Program. 25.6% of the female students in the studied sample are exposed to domestic violence at some point. The emotional type is the most prevalent (18.3%), followed by the physical type (16.9%). The authors concluded that domestic violence against females is prevalent in the Jazan community, with various socio-demographic and economic determinants influencing its occurrence. The most prevalent type is emotional domestic violence. Art faculties show the highest rating of domestic violence, health faculties, and the least scientific faculties. They recommended effort to Increase community awareness about domestic violence. Religious leaders sustain the greatest responsibility to increase awareness according to the rules of the Islamic religion.

Dr Ali & Chaudhary, presented a rare presentation of Aortic Aneurysm which was a diagnostic challenge. This case report highlights a rare presentation of abdominal aortic aneurysm, which posed a diagnostic challenge due to its atypical clinical manifestations. The patient initially presented with vague symptoms of renal colic and underwent a comprehensive evaluation, including imaging studies to establish the diagnosis. Through a multidisciplinary approach and careful analysis of the diagnostic findings, a rare form of aortic aneurysm was identified. This case emphasizes the importance of considering unusual presentations of aortic aneurysms and the need for thorough investigation to ensure accurate diagnosis and appropriate management.

Dr Chaudhary & Ali did a narrative review elucidates association between metformin therapy in T2DM and cobalamin (Vit. B12) deficiency. According to various studies, diabetic patients receiving metformin medication had a higher risk of Vit. B12 (vitamin B12) deficiency than those T2DM patients not receiving metformin therapy, ranging from 14% to 22.4% in those taking metformin and from 6% to 10% in those not taking metformin. Odds ratios for Vit. B12 deficiency associated with using metformin ranged from 2.2 to 2.7, indicating a moderate to high risk. The management of Vit. B12 deficiency in T2DM involves a combination of accurate diagnosis, appropriate supplementation strategies, patient education, and interdisciplinary collaboration. Consensus and guidelines recommend routine monitoring of serum vitamin B12 levels, high-dose oral supplementation, intramuscular injections for severe deficiency, and consideration of alternative routes of administration, along with lifestyle modifications.

Dr. Alkhier, reviewed the clinical significance of thyroid antibodies in non- thyroid diseases. Epidemiological studies showed that the population has a high immune disease prevalence, and thyroid immune diseases are among the top autoimmune disorders seen in clinical practice. Investigators noticed an association between Some non-thyroidal conditions with thyroid autoantibodies, and some of the outcomes of these non-thyroid diseases may be affected by the presence of these thyroid antibodies. A systematic literature review was done using selection criteria with the help of search questions. Multiple search engines were searched for eligible articles. Eighteen (18) articles fulfilled the inclusion and exclusion criteria; 44.4% were analytical cross-section studies,5% were prospective studies, 5.5% were meta-analysis studies,5.5% were case-control studies, and 16.7% were retrospective studies. The authors concluded that Thyroid autoantibodies are not exclusively markers of thyroid autoimmune diseases but can also be markers and indicators of non-thyroidal illnesses. Their presence could be either a favourable prognostic indicator, as with breast carcinoma cases or unfavorable prognostic, as with abortion. Further studies are recommended to explore more association.

Helvaci, et al., looked at Autosplenectomy in sickle cell diseases. Patients with red blood cells (RBCs) transfusions of less than 50 units in their lives were put into the first and 50 units or higher were put into the second groups. There were 224 patients in the first and 92 patients in the second groups. Mean ages were similar in them (28.9 vs 30.0 years, respectively, p>0.05). The male ratio was higher in the second group (45.5% vs 64.1%, p<0.001). In contrast to the lower prevalence of autosplenectomy (56.2% vs 45.6%, p<0.05), painful crises per year, digital clubbing, chronic obstructive pulmonary disease (COPD), leg ulcers, stroke, chronic renal disease (CRD), and coronary heart disease (CHD) were all higher in the second group (p<0.05 for all). The authors concluded that the sickled or just hardened RBCs-induced capillary endothelial damage initiates at birth, and terminates with multiorgan failures even at childhood. Although RBCs suspensions and corticosteroids in acute, and aspirin with an anti-inflammatory dose plus low-dose warfarin plus hydroxyurea both in acute and chronic phases decrease severity, survivals are still shortened in both genders, dramatically. In contrast to the lower prevalence of autosplenectomy, painful crises per year, digital clubbing, COPD, leg ulcers, stroke, CRD, and CHD were higher in the second group. So there may be an inverse relationship between prevalence of autosplenectomy and severity of SCDs, and spleen may act as a chronic inflammatory focus as a filter of blood for these abnormally hardened RBCs.

Alfarhan et al., did a systemic review to explore the effectiveness of commonly used dosing for mannitol (MN) compared with hypertonic saline solution (HSS) in children with elevated intracranial pressure (ICP) due to diabetic ketoacidosis (DKA), head trauma, or acute central nervous system (CNS) infections. A structured literature review was carried out using the component of the PICO framework. The literature search was conducted in Medline, Ovid, Embase, Google Scholar, and PubMed. A total of 169 articles were identified through the searches, while 8 articles met the inclusion criteria. The characteristics and results of included studies were discussed, regarding the study design, sample size, and outcome. The authors concluded that Osmotic agents, such as HSS and MN are commonly used in the management of high ICP. HSS (3% or 7.5%) has superior therapeutic effects over MN (20%) in lowering increased ICP in children with cerebral edema.

Alshahrani report a case of Crohn's disease that presented with a clinical picture mimicking a strangulated incisional hernia. A 33-year-old Saudi male patient presented to the Emergency Department (ED) with vomiting, pain, and swelling at the right iliac fossa after lifting heavyweight objects two days earlier. The patient had a past history of appendectomy through a transverse incision nine years earlier. Clinically, the patient was vitally stable. He had tenderness at the right iliac fossa, and rebound tenderness. A tender swelling (6 x 8 cm) was observed underneath the previous scar. It was firm, not expansile on cough, and not reducible, with no redness or skin changes. The laboratory report showed normal results for complete blood count, apart from slight leukocytosis. Blood electrolyte levels, renal and liver function tests were normal. Plain CT abdomen showed a defect in the transversus abdominis muscle with the presence of swelling beneath the oblique muscles associated with air, which were connected to the bowel. The preliminary diagnosis was a "strangulated incisional hernia". After laparotomy, the swelling showed pus within the external oblique aponeurosis, with a fistula tract connected to the ileum. After abdominal exploration, the inflammation was observed to be limited to the ileum and cecum with no other abnormality noted. Ileocecoctomy was done with side-to-side anastomosis between the ileum and ascending colon. The resected part was sent for histopathology, which confirmed the characteristics of Crohn's disease. The diagnosis of Crohn's disease remains challenging. Its management is multi-disciplinary. Surgical management is dependent on disease location and severity. It seems that early surgery is gradually going to play a more important role in the multidisciplinary management of Crohn's disease, rather than being a last-resort therapy.

Dr Abdulrazak Abyad
Chief Editor
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