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   Table of Contents - Current issue
Coverpage
January-March 2022
Volume 15 | Issue 1
Page Nos. 1-54

Online since Saturday, March 26, 2022

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INVITED REVIEW  

Rheumatoid arthritis: A challenging inflammatory disease p. 1
Johannes Grisar
DOI:10.4103/hmj.hmj_22_22  
Introduction: Rheumatoid arthritis (RA) represents the most common inflammatory joint disease of the western world. The main clinical manifestations of this disease are swelling and tenderness of the joints, mainly in the fingers accompanied by morning stiffness. Several laboratory parameters, like surrogates of inflammation but also rheumatoid factor (RF) and antibodies against citrullinated peptide (anti-ccP) are helpful for diagnosis as well as imaging tools, mainy X-rays, ultrasound and magnetic resonance imaging (MRI). Methods: This review will focus on the clinical manifestations and the pathophysiology of RA and highlight the therapeutic options. Results: With regards to efficacious therapies methotrexate (MTX) still represents the anchor drug for initial treatment combined with short term glucocorticoids. If this therapy fails however, several therapeutic options like bDMARDs and Janus Kinase (JAK) inhibitors have emerged during the last decades.Following the well established treat to target principle, the goal of a successful therapy is either remission or, if this can not be reached, low disease activity according to composite scores. The disease activity should be controlled in regular intervals. Conclusions: RA is a frequent inflammatory joint disease. The goal of a sufficient therapy is to reach clinical remission and we nowadays have a broad armamentarium available to treat this disease sufficiently in a large population of patients.
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REVIEW ARTICLE Top

Acute coronary syndrome in COVID-19: Obstacles and management challenges p. 5
Anas Mohmoud Musa, Omar Yousef Al-Assaf, Nouha Azaza, Rahaf Wardeh, Reem Ahmad Awad
DOI:10.4103/hmj.hmj_32_21  
Introduction: Severe Acute Respiratory Syndrome Coronavirus has caused a pandemic in 2019 causing a significant increase in mortality. Varied cardiac manifestations have been reported and variety of management plan used in different parts of the world. Methodology: A review process using PubMed and Google scholars was conducted for articles reporting any cardiac disease in SARS-CoV-2 and SARS-CoV patients. Discussion: In this review, we focus the discussion on diagnosis and management of acute coronary syndrome and its association with COVID-19. In addition to ways improving patient care in such diseases.
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ORIGINAL ARTICLES Top

Knowledge of breast cancer and self-diagnostic skills amongst women in the United Arab Emirates Highly accessed article p. 11
Aysha Nasser Al Hosani, Nahla Eissa Al Mazrouei, Shalini Behl, Aisha Meskiri
DOI:10.4103/hmj.hmj_88_20  
Background: Globally, breast cancer remains one of the world's greatest public health problems and a leading cause of death. Breast malignancies are considered as the major sites for tumors diagnosed in the United Arab Emirates (UAE) and they pose a significant concern for the general public's well-being. Aim: To conduct a descriptive cross-sectional study to determine the knowledge of breast cancer and self-diagnostic skills amongst women in the UAE. Methodology: The study was conducted for 1 month, based on an online survey designed via Microsoft Forms. It composed of 20 closed multiple-choice questions, which helped to assess the participant's knowledge of breast cancer and self-diagnostic skills. A total of 584 female participants were included in the study, out of which 498 (85.3%) were Emirati while 86 (14.7%) were non-Emirati females. Results: Despite the government's effort in enhancing breast cancer awareness programs across the UAE, only 6% of the females had excellent knowledge about breast cancer, 35% good, 46% average and 13% demonstrated poor knowledge. While only 4% had excellent breast self-examination skills, 17% had good skills, 61% had average skills and 18% had poor skills. A more concerning point was the least concern that females had towards non-lump breast cancer symptoms. Results from the current study showed that UAE female residents have an average knowledge of breast cancer and poor breast cancer self-diagnostic skills. Conclusion: The UAE government must emphasize the importance of breast screening practices, which may positively enhance breast-screening responses and practices amongst women in the UAE.
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Trauma team training: A key to success p. 19
Amer Hashim Al Ani, Zeinab Kamal Riad, Heba Magdi Ahmed, Hesham Aboughosiba, Nizam Abuhussein, Hassan Abdulhakim, Nijamudeen Kabeer, Mumtaz Ibrahim, Anmar Atasi, Viqar Banday, Malik Makki, Ahmed Tamer, Nasreen Qassem
DOI:10.4103/hmj.hmj_40_21  
Background: Worldwide, trauma constitutes 10% of all causes of death. In the United Arab Emirates, trauma is the second leading cause of death for both national and expatriate populations, accounting for over 20% of all fatalities. Trauma affects all age groups, especially adolescents and young adults. Most trauma cases are preventable. Morbidity and mortality can be decreased after trauma by adopting a systematic approach towards trauma victims. Simulation-based training is beneficial in that it allows us to amplify a variety of real-life situations without compromising patient safety. Objectives: This study aims to assess the impact of trauma team training (TTT) on the performance of the trauma team and the time spent by the patient in the emergency department. Methods: In Sheikh Khalifa Medical City of Ajman, the TTT program was started early in 2016 for all members of the trauma team including (trauma team leaders, hand on surgeons, emergency room physicians, airway nurses, IV access nurses, documenting nurses and circulatory nurses) in addition to personnel recruited during trauma management like (anaesthetists, orthopaedic surgeons, blood bank physicians, radiology technicians, intensive care unit nurses, theatre nurses, laboratory and blood bank technicians, etc.). The 1-day training program, concentrated on the discipline of each member of the trauma team during simulated patient treatment, and his role in the team. Assessment of the impact of TTT on the performance of the trauma team was done by interrogating the participants in this training. The time spent to resuscitate the patient in the emergency department was measured before and after the training of the trauma team personnel. Results: After the TTT was employed, the results showed that there was a decrease by approximately 75% in the meantime of performance from 220.8 min to 54.48 min. This was in accordance to the patient's stay in the ER which decreased significantly from 9 to 827 min pre-training to 14–206 min post-training. Conclusion: Training reinforces the already learned skills, corrects and minimise mistakes. Implementation of TTT is of utmost importance to be adapted in every trauma centre to achieve optimal performance and benefit to the patient.
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Are we late in treating with growth hormone short small for gestational age children? Experience of a tertiary care centre p. 23
Shamma AlZaabi, Dana Anchassi, Dorra Alij, Asma Alij, Kiran Choudhry, Hassib Narchi, Noura Al Hassani
DOI:10.4103/hmj.hmj_33_21  
Background: Short small for gestational age (SGA) children not showing a catch-up growth by 2–4 years of age is an indication for growth hormone (GH) therapy. Objective: The objective of this study was to evaluate at what age short SGA patients present to our paediatric endocrine clinic and start on GH therapy. In addition, we aim to assess their GH response during the 1st year of therapy. Materials and Methods: This retrospective observational study included 108 'SGA' children with 'short stature' who were managed in the paediatric endocrine clinic at Tawam Hospital within 5 years. Patients' electronic medical records were reviewed and their data were retrieved. Results: The median (interquartile range) age at the time of presentation was 6.8 years (3.3, 10.0), with a statistically significant difference between the non-syndromic and syndromic patients, 7.3 (5.2, 10.7) versus 3.2 (1.8, 5.9) years, respectively, whereas the median age at the time of starting GH treatment was 10.7 years (8.1, 13.6), with 47.4% treated at 5–10 years of age and 42.1% at >10 years of age. The mean (±standard deviation) delta height z-score for all treated patients was 0.58 ± 0.40 at 1 year. There was a significant difference in both the mean height at pre and post 1 year of starting GH treatment between the non-syndromic and syndromic groups (P < 0.0001 and 0.003, respectively). Conclusion: The majority of our short SGA patients presented late and were subsequently treated with GH later than the international consensus or guideline recommendations. There is a need for increased awareness to refer these children earlier for a better outcome.
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Study of general health and haematological status of automobile garage workers exposed to toxicants: Comparison with office workers p. 29
Sudhir Prabhu Haladi, Faizan Kalekhan, Paul Simon, Manjeshwar Shrinath Baliga
DOI:10.4103/hmj.hmj_53_21  
Background: Automobile Garage Workers are exposed to a range of toxicants and depending on the level and duration of exposure various health effects are observed. The current study was undertaken to understand the haematological status and general health among garage workers when compared with occupationally nonexposed participants in Mangalore, India. Objectives: In this study, an attempt is made at understanding the general health and haematological status of garage workers by comparing them with age-matched controls (office workers) from the same area. Materials and Methods: This was a purposive, comparative cross-sectional study, and a camp-based approach was done with willing volunteers. The socio-demographic details were collected in a structured questionnaire, while a detailed clinical examination was carried out by senior clinicians and blood collected was analysed for haematological parameters. Knowledge of occupational safety and health insurance was also collected from the garage workers. The data were subjected to frequency and percentage and analysed using X2 and t-test, P < 0.05 was considered statistically significant. Results: In this study, most of the garage workers (58.6%) were involved in mechanical work and 91.3% of them did not use any kind of protective measures. Joint pain (13.04%) was the most common ailment, whereas in the office workers, back pain was common (6.52%). In the garage workers, awareness of health-related problems due to their occupation was less. In addition, none of the garage workers had any kind of employees' state insurance benefits. When compared with the controls, there was a significant difference in haematological parameters and eosinophilia was more in garage workers. Conclusions: The results of the study indicate that garage workers have occupation-related health issues and that appropriate and effective safety measures need to be taken by the workers to prevent possible chemical exposure during routine tasks.
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Reactive bone marrow plasmacytosis: A common denominator with diverse etiology p. 33
Sajida Batool, Sunayana Misra, Vijay Kumar, Arvind Ahuja, Sadhna Marwah, Garima Baweja, Sanjay Kumar
DOI:10.4103/hmj.hmj_52_21  
Background and Aims: Reactive plasmacytosis (RP) is characterised by the diffuse distribution of mature polyclonal plasma cells in the bone marrow (BM) and it is known to occur in various disorders. These need to be differentiated from the clonal plasma cell dyscrasias (PCD). We aim to study the morphological features of RP and to help differentiate them better from PCD. Materials and Methods: We analysed 1409 consecutive BM aspirates for the percentage of plasma cells along with the associated clinical findings. The study group included cases with BM RP and the polyclonality being supported by serum protein electrophoresis or by kappa/lambda immunohistochemistry on BM biopsy. The clinical records, haemogram and BM aspiration findings were retrieved and reviewed in all cases. Morphological features of RP cases were analysed in detail. Further, these cases were compared with 10 confirmed cases of PCD in an attempt to distinguish between the two on morphology. Results: A total of 210 BM aspirates showed increased plasma cells (>3.5%). Clonality could be proven in 135 cases, of which 98 cases were polyclonal and 37 were PCD. Majority of RP cases were >40 years with male predominance. The plasma cell concentration in RP ranged from 4% to 25%. The associated diseases included infections followed by autoimmune diseases. On the morphology, RP unveiled scattered, non-aggregated mature plasma cells while in PCDs, there was a mixture of both immature and mature forms including plasmablasts with frequent clustering. Conclusion: A number of diseases show increased percentage of plasma cells in BM raising suspicion of PCD. It may be difficult to distinguish reactive from neoplastic conditions as there is an overlap both in cell counts and morphology. Assessment of subtle morphological features along with associated clinical and laboratory findings are cardinal for making a correct diagnosis.
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Effect of vaginal scrubbing on post-C-section infection p. 39
Seema-Gul Salman, Maria Rafiq
DOI:10.4103/hmj.hmj_5_22  
Aims: The aim was to study the effect of vaginal scrubbing on post-C-section infection. Settings and Design: This was a randomised controlled trial. Subjects and Methods: This study was carried out from January 2019 to January 2021 on 434 patients who were divided into two groups: Group 0 which received abdominal and vulval scrubbing with povidone-iodine and Group 1 which also received vaginal scrubbing. Patients were monitored for any infection from the time of C-section to 30-day post-operative. Results: The mean ages of patients in Groups 0 and 1 were 27.15 ± 8.11 and 28.27 ± 8.14 years, respectively. Pyrexia was noted in 45 (10.4%) patients of Group 0 and 22 (5.1%) patients of the second group, respectively, with P = 0.01. Surgical site infection was noted in 22 (5.1%) patients of Group 0 and 21 (4.8%) patients of Group 1, P = 0.8. Endometritis occurred in 27 (6.2%) patients of Group 0 and 12 (2.8%) patients of Group 1; P = 0.01. Conclusions: Vaginal scrubbing reduces post-C-section infection.
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CASE REPORTS Top

Behcets disease presenting as renal failure in a 5-year-old child from Bahrain: A case report and literature review of renal manifestations of Behcets disease p. 42
Deena Mohammed Almastoor, Hanin Abdulla Aljazaf, Latifa Khalifa Abdan, Reem Albinzayed
DOI:10.4103/hmj.hmj_30_21  
Background: Behcet's disease (BD) is a chronic vasculitis that results in multisystem involvement including cardiovascular, gastrointestinal, musculoskeletal, and nervous system. BD is more commonly found in adults. Children account only for 15%-20% of cases. Generally, the renal manifestations of BD are not predominant and less reported. Case Presentation: A 5-year-old boy presented with renal failure, and he was noted to have multiple oral ulcers, cutaneous lesions, and arthritis. In view of the multisystem involvement, BD was highly suspected, and the diagnosis was confirmed by a positive pathergy test and the presence of the HLA-B52 gene. The patient was commenced on peritoneal dialysis and anti-inflammatory medications. Conclusion: The diagnosis of BD in children is challenging and requires a high index of suspicion. Especially if the patient is presenting with renal symptoms. Early recognition of the disease is crucial to prevent irreversible complications such as end-organ damage including renal failure.
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Hepatoblastoma in an infant with cat eye syndrome p. 45
Shiva Shankar, Heba Qusai Hamid Al Saqban, Rola Al Zir, Abid Qazi, Alan Taylor
DOI:10.4103/hmj.hmj_44_21  
Introduction: Cat eye syndrome (CES) is a rare chromosomal disorder with highly variable clinical presentations involving multiple organs. The features mimic other syndromes such as CHARGE or VACTERL, and genetic testing is required to confirm the diagnosis. CES and malignancy were not reported until recently in a 3-year-old child. Case report: We report a case of CES with hepatoblastoma presenting in infancy, highlighting the need to be vigilant during the follow-up of these patients. Conclusion: Our case report has possibly identified an association of malignancy with CES in infancy. Further studies linking the association of malignancy with CES may highlight the need for careful monitoring, a high index of suspicion and a low threshold for an ultrasound scan and AFP to ensure timely diagnosis and treatment.
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Isolated tropical pyomyositis of first web space in a child p. 48
Ganesh Singh Dharmshaktu, Tariq Akhtar Ansari, Tanuja Pangtey
DOI:10.4103/hmj.hmj_48_21  
Introduction: Pyomyositis or tropical pyomyositis is a form of acute pyogenic infection affecting skeletal muscles. Despite being called tropical pyomyositis, these cases are frequently reported from both tropical and non-tropical regions. The most common causative organism is Staphylococcus aureus with anecdotal reports of a variety of muscles involved throughout the human body. The isolated and focal affliction of muscles is uncommon and more so in children. Case Report: We report a case of isolated pyomyositis involving inter-osseous muscles of the first web space of the left hand in a 5-year-old otherwise healthy male child. Conclusion: The good delineation of the lesion on magnetic resonance imaging was followed by aspiration of the abscess, leading to uneventful healing and good clinical outcome.
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Multiplanar imaging in a familial case of cleidocranial dysplasia and various orthodontic-surgical protocols approved for its treatment p. 50
Sajad Ahmad Buch, Renita Lorina Castelino, Subhas G Babu, Mudasir Rashid Baba
DOI:10.4103/hmj.hmj_61_21  
Introduction: Cleidocranial dysplasia (CCD) is a rare autosomal-dominant disorder that results in defective ossification. The gene responsible for pathogenesis has been mapped to the short arm of chromosome 6p21 core-binding factor alpha-1 or runt-related transcription factor-2. The condition being a complex congenital disorder with numerous skeletal and dental anomalies, its management depends considerably on the patient's ambitions, age, economic status and permanent dentition status, endodontic and periodontal health. Case Report: A 17-year-old female reported with complaint of misaligned teeth and desired orthodontic treatment. The patient had been diagnosed with CCD during childhood but, seemingly, with no previous management. Family wise patient's mother presented with features of CCD but no previous health records. A familial case report of CCD is presented with a brief explanation of various orthodontic-surgical methods carried out for its treatment Conclusion: CCD is a rare disorder, with no universally acknowledged treatment plan; hence, it is appropriate to involve a multidisciplinary team for its management.
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Non-steroidal anti-inflammatory drugs use in pachydermoperiostosis and gastrointestinal complications p. 53
Ismail Darwish, Omar Yousef Al-Assaf, Maram Al-Ashoor, Nabil Al-Baghdadi
DOI:10.4103/hmj.hmj_63_21  
Introduction: Pachydermperiostosis (PDP) is a rare multi-organ disease. In which non-steroidal anti-inflammatory drugs are used as the first line treatment. Case Report: A young male known to have PDP presented to our hospital with upper gastrointestinal bleeding. On endoscopy he was found to have multiple ulcers. Discussion: We discuss the possible association between the two diseases and possible approaches in such cases. Furthermore, our case suggests the need for a well-recognized screening program with routine upper GI endoscopies.
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