Clinical experience with insulin detemir in patients with type 2 diabetes from the near East countries.

INTRODUCTION: This study aimed at determining the clinical safety and efficacy of insulin detemir (IDet) in combination with oral anti-diabetic drugs (OADs) in type 2 diabetes (T2D) patients from four Near East Countries (Israel, Jordan, Pakistan and Lebanon). METHODS: This prospective observational study included T2D patients previously on OADs and newly diagnosed patients initiating IDet with or without OADs, at the discretion of physicians. Safety objectives included evaluation of hypoglycemia and adverse drug reactions (ADRs) from baseline to Week 24. Efficacy outcomes included baseline to Week 24 changes in glucose control parameters (glycated hemoglobin [HbA1c], fasting plasma glucose [FPG] and post-breakfast post-prandial plasma glucose [PPPG]). Change in body weight during this period was also assessed. RESULTS: A total of 2,155 patients (mean ± SD: age 57.1 ± 11.0 years, BMI 29.4 ± 5.1 kg/m(2), average diabetes duration 9.2 ± 5.4 years) were included. IDet dose at baseline was 0.20 ± 0.09 U/kg titrated up to 0.34 ± 0.14 U/kg by Week 24. From baseline to Week 24, the total number of hypoglycemic episodes increased from 1.30 to 1.37 events/patient-year, while major hypoglycemic episodes decreased from 0.15 to 0.02 events/patient-year. A total of 9 ADRs were reported, of which one event was a serious ADR. Statistically significant improvements in glucose control were reported from baseline to Week 24 (HbA1c: 9.6 ± 1.6% vs. 7.6 ± 1.1%; FPG: 201.5 ± 59.5 mg/dL vs. 124.9 ± 31.6 mg/dL; PPPG: 264.2 ± 65.7 mg/dL vs. 167.2 ± 36.8 mg/dL; all p < 0.0001). Body weight did not change significantly after 24 weeks of IDet therapy. CONCLUSION: IDet therapy in combination with OADs improved glycemic control without increasing the risk of hypoglycemia or weight gain.

Effect of prenatal administration of therapeutic doses of topiramate on ossification of ribs and vertebrae in rat fetuses.

There are few studies that have addressed the effects of prenatal exposure of topiramate on ossification of the bones derived from the paraxial mesoderm. This study aimed to evaluate skeletal ossification of ribs and vertebrae in 20-day-old rat fetuses after maternal exposure to two therapeutic doses of topiramate. Three groups of Sprague-Dawley pregnant rats were used: control, topiramate 50 mg/kg/day and topiramate 100 mg/kg/day treated groups. Topiramate was administered by gavage from day 6-19 of gestation. Fetuses were collected on day 20 by caesarean section. Fetal bones were stained with alizarin red and ossification was assessed. Results showed significant delayed ossification of ribs and vertebrae in topiramate-exposed fetuses at both doses and the effects were not dose dependent. In all examined groups, there was a direct correlation between the fetal weight and the number of complete ossified vertebral centers. Also, there were significant increases in skeletal abnormalities, particularly in ribs in both treated groups when compared to the control group. In conclusion, therapeutic doses of topiramate should be taken cautiously during pregnancy as they lead to fetal growth restriction and increases abnormalities of axial skeleton in rat fetuses.

Undergraduate medical education in the Gulf Cooperation Council: a multi-countries study (Part 2).

BACKGROUND: The Gulf Cooperation Council (GCC) countries have witnessed over the last 40 years a rapid and major social, cultural, and economic transformation. The development of medical education in the region is relatively new, dating from the late 1960s. An important goal among the medical colleges in the region is to graduate national physicians who can populate the healthcare service of each country. AIM: The aim of this study is to provide understanding of undergraduate medical education in each of the six GCC countries and the challenges that each face. METHODS: This is a descriptive cross-sectional study. Fourteen senior medical faculty were requested to submit information about undergraduate medical education in their own countries, focusing on its historical background, student selection, curriculum, faculty, and challenges. RESULTS: The information provided was about 27 medical colleges: 16 from the Kingdom of Saudi Arabia (KSA), five from the United Arab Emirates, two from the Kingdom of Bahrain, two from Sultanate of Oman, one from Kuwait and one from the State of Qatar. It was found that older colleges are reviewing their curriculum while new colleges are developing their programs following current trends in medical education particularly problem-based learning and integrated curricula. The programs as described 'on paper' look good but what needs to be evaluated is the curriculum 'in action'. Faculty development in medical education is taking place in most of the region's medical colleges. CONCLUSION: The challenges reported were mainly related to shortages of faculty, availability of clinical training facilities, and the need to more integration with the National Health Care services. Attention to quality, standards, and accreditation is considered essential by all colleges.

Undergraduate medical education in the Gulf Cooperation Council: a multi-countries study (Part 1).

BACKGROUND: The Gulf Cooperation Council (GCC) countries have witnessed over the last 40 years a rapid and major social, cultural, and economic transformation. The development of medical education in the region is relatively new, dating from the late 1960s. An important goal among the medical colleges in the region is to graduate national physicians who can populate the healthcare service of each country. AIM: The aim of this study is to provide understanding of undergraduate medical education in each of the six GCC countries and the challenges that each face. METHODS: This is a descriptive cross-sectional study. Fourteen senior medical faculty were requested to submit information about undergraduate medical education in their own countries, focusing on its historical background, student selection, curriculum, faculty, and challenges. RESULTS: The information provided was about 27 medical colleges: 16 from the Kingdom of Saudi Arabia (KSA), five from the United Arab Emirates (UAE), two from the Kingdom of Bahrain, two from Sultanate of Oman, one from Kuwait, and one from the State of Qatar. It was found that older colleges are reviewing their curriculum while new colleges are developing their programs following current trends in medical education, particularly problem-based learning and integrated curricula. The programs as described 'on paper' look good but what needs to be evaluated is the curriculum 'in action'. Faculty development in medical education is taking place in most of the region's medical colleges. CONCLUSION: The challenges reported were mainly related to shortages of faculty, availability of clinical training facilities and the need to more integration with the National Health Care services. Attention to quality, standards, and accreditation is considered essential by all colleges.

Incidence and ossification of sesamoid bones in the hands and feet: a radiographic study in an Arab population.

The incidence and ossification of sesamoid bones in the hands and feet were studied in 922 radiographs (400 hands and 522 feet) in an Arab population from Bahrain, 5-83 years of age and consisting of 549 adults (393 men and 156 women) and 373 children (286 boys and 97 girls). All radiographs of the hand and foot in the adult population showed two sesamoid bones in the thumb metacarpophalangeal (MCP) joint and in the hallucal metatarsophalangeal (MTP) joint, respectively. Only 2.3% and 1.5% of hands showed sesamoids at the MCP joints of the middle and ring fingers respectively compared to a reported incidence of 7.1% for each digit in Caucasians. The incidence of sesamoids in the MTP joints of third and fourth toes (0.6% each) and inferior to the hallucal interphalangeal joint (3.1%) is probably the lowest reported so far in the literature. In the hands, ossification commenced first in the thumb sesamoids, at the age of 10 years in females and 11 years in males and was completed by the age of 13 and 14 years, respectively. In the feet, ossification began first in the hallucal sesamoids at the age of 8 years in females and 9 years in males and was completed by the age of 10 years in both sexes. The incidence and ossification of sesamoids in the hands and feet in the Arab population from Bahrain seem to differ considerably from reports in other populations. The clinical significance of our findings is discussed.

The membranous layer of superficial fascia: evidence for its widespread distribution in the body.

A discrete membranous layer, "stratum membranosum", in human subcutaneous tissue is classically described as confined to the lower anterior abdominal wall and perineum and referred to as Scarpa's and Colles' fasciae, respectively. Evidence for its existence elsewhere in the body is scanty and therefore the present study was undertaken. Dissection of six embalmed adult cadavers, along with ultrasound imaging on four living subjects, were carried out to determine the existence, topography, and thickness of the membranous layer of superficial fascia in different regions of the body. In all six cadavers, a continuous layer of fibrous membrane in the superficial fascia was found consistently in all the dissected regions of the body and was also confirmed by ultrasonography. The arrangement and thickness of this membranous layer varied according to body region, body surface, and gender. It was thicker in the lower than in the upper extremity, on the posterior than anterior aspect of the body, and in females than in males. The mean thickness of the membranous layer ranged from 39 to 189 mum, being thickest in the leg and thinnest over the dorsum of the hand. The membranous layer was observed to have two or even three components in regions such as the breast, back, thigh, and arm and was seen to split, forming special compartments around subcutaneous major veins of upper and lower extremities, with fibrous septa extending to attach to the vessel wall. Functionally, the membranous superficial fascia may play a role in the integrity of the skin and support for subcutaneous structures particularly veins, by ensuring their patency. Understanding the topographic anatomy of this fascial layer may help explain body-contour deformities and provide the anatomic basis for surgical correction.

The hamate facet of the lunate: a radiographic study in an Arab population from Bahrain.

Based on the presence of a facet for the hamate two types of lunate bone have been described in the wrist; type I is without a facet for the hamate while type II bears a facet on the medial surface for articulation with the proximal pole of the hamate. Compared to type I lunates, type II lunates have been shown to have different kinematics, are more prone to clinically relevant degenerative changes in the hamato-lunate joint and may cause ulnar-sided wrist pain. The incidence of type II lunates seems to vary in different populations. Postero-anterior (PA) view of plain radiographs of the hand was studied in Arab subjects from Bahrain (n=381; 307 males and 74 females) to determine the incidence of type I and type II lunates. The mean age of the subjects was 31.1 years, the range being 18-80 years. In the population studied, only 148 (38.8%) of the 381 wrists showed type II lunate; 121 (31.7%) were found in males and 27 (7.1%) in females. There was no significant difference in the mean age of subjects with type I or type II lunates (P=0.16). There was no correlation between side and gender with the presence or absence of a hamate facet on the lunate. The incidence of type II lunate was much lower than reports in the literature of populations from the Western world, which could be attributed to a genetic variation in the Arab population in Bahrain. These data indicate that osteoarthritis of the hamate or lunate is less likely to be a cause of ulnar-sided wrist pain in Bahraini Arabs.

Penile measurements in normal adult Jordanians and in patients with erectile dysfunction.

The purpose of this work was to determine penile size in adult normal (group one, 271) and impotent (group two, 109) Jordanian patients. Heights of the patients, the flaccid and fully stretched penile lengths were measured in centimeters in both groups. Midshaft circumference in the flaccid state was recorded in group one. Penile length in the fully erect penis was measured in group two. In group one mean midshaft circumference was 8.98+/-1.4, mean flaccid length was mean 9.3+/-1.9, and mean stretched length was 13.5+/-2.3. In group two, mean flaccid length was 7.7+/-1.3, and mean stretched length was 11.6+/-1.4. The mean of fully erect penile length after trimex injection was 11.8+/-1.5. In group 1 there was no correlation between height and flaccid length or stretched length, but there was a significant correlation between height and midpoint circumference, flaccid and stretched lengths, and between stretched lengths and midpoint circumference. In group 2 there was no correlation between height and flaccid, stretched, or fully erect lengths. On the other hand, there was a significant correlation between the flaccid, stretched and fully erect lengths. Comparing group 1 and group 2, the patients in group 1 were slightly older than in group 2 (P=0.035), but there was no significant difference in their height. However, there was a significant difference regarding the mean flaccid length 9.3 vs 7.7 (P=0.001), and the mean stretched length 13.5 vs 11.6 (P=0.000). We divided both groups into those who are less than 40 y of age, and over 40 y old. There was no statistical difference in the stretched and flaccid lengths between the younger and older individuals in each group. However, when we compared the stretched and flaccid lengths in those of less than 40 y old in group 1 and 2, a significant difference was noticed. Similarly, a significant difference in the stretched and flaccid lengths in those patients over 40 y of age was also present.

Integrating applied anatomy in surgical clerkship in a problem-based learning curriculum.

Little attention has been given to structured teaching of applied anatomy to senior medical students in problem-based learning (PBL) medical schools. A course named "Anatomical Principles in Surgical Practice" was introduced at the Arabian Gulf University (AGU) in 2001 for fifth- and sixth-year medical students during their surgical clerkship rotation. The course aims to emphasize, update and integrate applied anatomical concepts that are essential for surgical practice. The course consists of 15 interactive sessions held weekly to ensure topics coincide with the surgical problem-solving sessions. A questionnaire was administered to students completing their surgical rotations (n = 131) seeking their perceptions about the new course during the academic years 2001, 2002 and 2003. To measure learning outcome, 70 students were also given pre- and post-tests. Positive responses were given by 85.2% of the students for course arrangement, by 92.0% for course content, by 88.3% for clinical correlation, by 95.2% for level of teaching and by 87.2% for overall judgment. The students' mean scores in the post-test (71.7%+/-11.7) was significantly higher than their mean scores in the pre-test (42.3%+/-12.6, p < 0.001). Students liked the course and reported feeling more confident in correlating anatomy with surgery during their rotations. By extending anatomical teaching into the clerkship phase, a link between basic medical and clinical sciences has been established that further enhances vertical integration within a PBL curriculum in a spiral fashion.

Thymic proliferative response during different physiological states: a comparative study.

OBJECTIVE: To study the thymic proliferative response during different physiological states to distinguish those changes due to alterations in steroid hormone secretion from those resulting from the presence of spermatozoa and/or early conceptual products in the female reproductive tract. METHOD: Using mature female rats of an inbred AO(RT1(u)) strain, observations on the thymus were made at 24 hour intervals during the oestrous cycle, early pseudopregnancy and early syngeneic pregnancy. Each daily group contained a minimum of 6 animals. RESULTS: During the oestrous cycle, a significant mid-cycle increase of thymocyte proliferation occurred during dioestrus which peaked on day 2, and as a repetitive response may be a preparation for a coital challenge. This response may be oestrogen-dependent since oestrogen levels begin to increase during early dioestrus. The induction of pseudopregnancy generates a comparable but delayed increase in thymic proliferative activity. Since thymocyte proliferation and oestrogen secretion both peak on day 3 of pseudopregnancy, such a response may indeed also be oestrogen-dependent. After syngeneic mating, there was a significant depression in thymic proliferative activity on day 3 followed by a significant increase on day 5 compared with the same days of pseudopregnancy. CONCLUSION: This initial depression of proliferative activity may be induced by the immunosuppressive action of seminal plasma, to safeguard the preimplantation conceptus while the day 5 increase in cellular proliferation suggests a response to implantation.

Brachial plexus palsy and spinal subarachnoid pneumatosis following trauma.

The case of a 33-year-old male involved in a road traffic accident, resulting in brachial plexus palsy associated with subarachnoid pneumatosis, is described. A knowledge of the regional anatomy at the root of the neck is used to explain the patient's neurological signs and the mechanism of entry of air into the subarachnoid space.

Attitudes and reactions of Arab medical students to the dissecting room.

A questionnaire on the emotional and psychological reactions of Arab medical students to the dissecting room (DR) was distributed to 272 students in four successive pre-clinical and clinical years in the same academic year (1993-1994) at Sultan Qaboos University (SQU) Medical College; 205 students responded. Varying degrees of fear on first entering the DR was reported by 46%. The most frequent reactions were recurring visual images of cadavers (total 38%) and temporary loss of appetite (total 22.5%). Students' reactions were most commonly elicited by the smell of the DR (total 91%) and by fear of infection (total 62%). The most frequent method of coping with such fears was by rationalization (total 65%). Significant gender differences (P < 0.05) were found concerning all aspects of the DR experience. Female students showed higher levels of fear, reported stronger physical and behavioral reactions, were more disturbed by certain stimuli in the DR, and used certain coping methods more frequently than their male peers. The need for appropriate psychological preparation of students before studying human cadaveric anatomy is discussed.

Effect of blood substitute, recombinant hemoglobin, on in vivo hematopoietic recovery from AZT toxicity.

We determined the in vivo ability of infused human recombinant hemoglobin 1.1 (hr-Hb) and erythropoietin to rescue the hematopoietic activity from the suppressive effects of AZT in normal and in a murine model of AIDS (MAIDS) mice. Mice were fed with AZT for 8 weeks with or without treatment in the last 4 weeks by administering various concentrations of hr-Hb and/or erythropoietin (Epo). Blood parameters, body weight (BW) and erythroid burst-forming units (BFU-E) for all mice were determined. AZT-treated normal and MAIDS mice showed a significant decrease in hematocrit (64 and 78.1%), hemoglobin (27.2 and 45.5%), BW (17.5 and 35.5%), number of white (66.9 and 42.1%) and red blood cells (65.5 and 38%), and the number of BFU-E (73 and 59%), whereas the AZT-treated normal and MAIDS mice that received hr-Hb (5 mg/kg BW/day) and/or Epo (2 U/mouse/day) showed significant alleviation of AZT cytotoxicity. This was evident by the recovery in all blood indices examined, the number of BFU-E and the BW of mice treated. BFU-E recovery in MAIDS (97%) was greater than that in normal mice (63%) as compared to their controls. hr-Hb produced a similar response as the combination, however recovery was slightly better with the latter in some hematological parameters. Higher concentrations of hr-Hb (10-15 mg) did not result in a more significant increase in most blood indices. Our results indicate that infusion with hr-Hb can alleviate AZT toxicity in normal and in immunodeficient mice, and that hr-Hb may be clinically useful in preventing severe bone marrow depression brought about by various drugs or agents such as AZT.

Studies on haemolymph nodes. IV. Comparison of the route of entry of carbon particles into parathymic nodes after intravenous and intraperitoneal injection.

Haemolymph nodes are found in certain mammals including man. In the rat they are located near the kidneys, spleen and thymus. A distinctive feature is that their sinuses contain numerous erythrocytes. For renal and splenic haemolymph nodes, the erythrocytes appear to be extrinsic in origin, entering the node via its afferent lymphatics (Hogg et al. 1982; Abbas et al. 1983). In the present study we investigated the drainage of carbon particles injected intraperitoneally or intravenously into the parathymic haemolymph nodes. Carbon particles injected intraperitoneally reached the nodes rapidly, within minutes and in large quantities, via the afferent lymphatics draining principally from the diaphragmatic peritoneum. Carbon particles injected intravenously entered the nodes much more slowly, reaching a maximum after 5-7 d, and in much smaller amounts, although the pattern of distribution was similar, spreading from the subcapsular sinus into the intermediate and medullary sinuses. No carbon particles were found crossing the walls of high endothelial venules. Carbon particles injected intravenously reach the parathymic nodes from peripheral lymph via the afferent lymphatics. Whilst accepting that there are significant biological differences between carbon particles and erythrocytes it seem possible that erythrocytes, like injected carbon particles, may enter the nodes by a similar route.

The role of the diaphragm in lymphatic absorption from the peritoneal cavity.

Lymphatics in the diaphragm form a specialised system draining fluid from the peritoneal cavity and returning it to the vascular system. Fluid enters subperitoneal lymphatic lacunae, between muscle fibres of the diaphragm, the lacunae being separated from the peritoneal cavity by a barrier comprising, successively, lymphatic endothelium, a layer of collagenous fibres, a thin fenestrated layer of elastic tissue, and the peritoneal mesothelium. To reach the lacunae, peritoneal fluid passes through stomata located between cuboidal mesothelial cells of the lacunar roof. Whilst the distribution of mesothelial stomata and subjacent lymphatic lacunae varies in different species, stomata appear to be exclusive to the diaphragm and may serve as the main drainage channels for absorption from the peritoneal cavity. Clinically, they may provide escape for tumour cells, pathogens and toxins from the peritoneal cavity. They could provide access for blood transfusions, for intraperitoneal chemotherapy to treat malignancies, and for peritoneal dialysis in treating chronic renal failure. From the lacunae, fluid traverses the diaphragm via intrinsic lymphatics to reach collecting lymphatics beneath the diaphragmatic pleura. Both intrinsic and collecting lymphatics contain valves. The collecting lymphatics drain principally into retrosternal (parasternal) lymphatic trunks that carry lymph to the great veins after it filters through mediastinal lymph nodes.

Assessment of basic medical sciences in an integrated systems-based curriculum.

Basic medical sciences at Sultan Qaboos University (SQU) are taught in a systems-based curriculum. During the development of the courses different formats have been used for the written examinations and also different types of questions. This paper compares students' performance in relation to examination format and to types of questions used. The formats were non-coordinated (NCAs), each discipline having a separate paper; coordinated (CAs), questions from various disciplines being given in the same paper but with separate sections for each discipline; and integrated assessments (IAs), questions being grouped under structure, function, and problem-based integrated long essays. The types of questions used were multiple choice (MCQs), short essays (SEQs), and structured integrated long essays (SILEQs). Students performed better in SEQs than in MCQs. Our analyses also show that SILEQs measure skills similar to those of MCQs and SEQs combined. Students performed best in NCAs. In CAs, students concentrated on those disciplines carrying most weight in the final grade. Currently we use IAs consisting of two parts: part I, comprising MCQs and SEQs, and part II, comprising SILEQs. To date, students are performing better in part II than in part I. We suggest that it is prudent to use different types of questions to measure students' knowledge and skills when IAs are used for systems-based courses.

Hemopoietic recovery from AZT toxicity with recombinant hemoglobin in a murine model of AIDS.

We studied the toxic effects of azidothymidine (AZT) on the hemopoietic colony growth (CFU-E, BFU-E and CFU-GM) of bone marrow in a murine model of AIDS (MAIDS). A sparing effect by recombinant hemoglobin (r-Hb) on AZT suppression of MAIDS bone marrow was found when 10 microM of r-Hb was included in bone marrow cultures. The AZT toxicity dose response curve showed that at a concentration of 0.1 microM, AZT inhibited CFU-E by 66%, BFU-E by 55% and CFU-GM by 67%. The addition of r-Hb (10 microM) to AZT-treated cultures stimulated CFU-E, BFU-E and CFU-GM by 89, 125 and 160%, respectively, as compared with AZT-treated (control). The addition of r-Hb to non AZT-treated cultures showed further stimulation of CFU-E, BFU-E and CFU-GM to 100, 160 and 187% of the control, respectively. These results indicate that exogenous r-Hb reverses AZT-induced hemopoietic toxicity and may prove to be useful in ameliorating AZT toxicity in immunosuppressive diseases.

Bilateral extensor medii digiti: a rare anatomical variation.

A supernumerary extensor muscle to the middle finger was found to be present bilaterally in a male cadaver. It originated from the distal end of the ulna and its tendon inserted into the proximal phalanx of the middle finger. The bilateral presence and manner of insertion appear to be unique from a review of the literature. Morphological variability and clinical significance are reviewed. Such variations may be clinically significant during hand surgery, especially tendon transfer procedures.