The future of transcranial magnetic stimulation in neuroscience and neurology in the Middle East.

OBJECTIVE: Transcranial magnetic stimulation (TMS) is a noninvasive technique for brain stimulation often used as a diagnostic and therapeutic therapy in neuroscience and psychiatry for different diseases including epilepsy, stroke, multiple sclerosis, and treatment-resistant major depressive disorders, such as autism and schizophrenia. MATERIALS AND METHODS: Recent studies have shown the enhanced benefits of using TMS for its potential to provoke changes in the physiological processing of the human brain. RESULTS: In the current review article, emphasis will be placed on both the applications of TMS as well as the different types of TMS used to benefit subjects with epilepsy, stroke, and multiple sclerosis. Furthermore, we aim at discussing the potential of using TMS for the treatment of neurological diseases. CONCLUSIONS: By paying special consideration to a Middle Eastern context, we aimed at illustrating the possibilities that TMS could bring for clinicians and patients in this nationally prioritized research field.

Mutations in codons 12 and 13 of K-ras exon 2 in colorectal tumors of Saudi Arabian patients: frequency, clincopathological associations, and clinical outcomes.

Mutations in codons 12/13 of K-ras exon 2 are associated with reduced benefit from anti-epidermal growth factor receptor antibody treatment for metastatic colorectal cancer (CRC). Here, we evaluated the frequency of K-ras mutations and their relationship with clinicopathological features and treatment outcomes in Saudi Arabian patients with CRC. The genetic status of K-ras was determined in 300 patients diagnosed with CRC. Clinical information was collected retrospectively. K-ras was wild-type in 58% and mutated in 42% of the tumors. Most mutations were at codon 12 (89%) and were associated with metastasis [odds ratio (OR) = 1.38 (95%CI = 1.14-1.67] and occurrence of >40 µg/L carcinoembryonic antigen (CEA) [OR = 1.33 (1.1-1.74)] during diagnosis. Patients in stages I-III of the disease with wild-type K-ras tumors had a median relapse free survival (RFS) of 29 months in contrast to 22 months for those with the mutated K-ras tumor (P = 0.0357). In multivariate analysis, only the stage of the disease significantly predicted RFS (P = 0.001). Patients in stage IV of CRC with the wild-type K-ras tumor did not reach the median overall survival (OS), whereas patients with the mutated K-ras tumor survived for 23.5 months (P = 0.044). CEA level >40 µg/L (P = 0.004) and status of K-ras (P = 0.044) were independent predictors of OS. This is the largest study investigating K-ras mutations in patients with CRC in the Middle East. Mutations were associated with advanced stage of CRC, higher serum CEA, shorter RFS and OS.

Taurine ameliorates 5-flourouracil-induced intestinal mucositis, hepatorenal and reproductive organ damage in Wistar rats: A biochemical and histological study.

5-Fluorouracil is one of the most commonly used anticancer drugs for the treatment of various types of cancer but has potential adverse effects such as intestinal mucositis, renal, hepatic, and reproductive organ toxicity. Attention has been given to approaches to reduce the side effects and improve the therapeutic effectiveness of chemotherapeutic drugs. In this study, we have investigated the protective effect of taurine (Tau) on 5-fluorouracil (5-FU) induced adverse effects in Wistar rats. Animals were divided into four groups with six animals (n = 6) in each group. Group I received vehicle only and served as control group. Groups II, III, and IV animals were given oral gavage of 5-FU at 50 mg/kg body weight for 4 days. Tau was given to the animals of groups III and IV 30 min prior to 5-FU administration. We observed marked elevation in the myeloperoxidase (MPO) activity after 5-FU administration, which was reversed by Tau pretreatment. Histological observation of liver, kidney, intestine, testis, and prostate revealed that 5-FU administration resulted in anomalies like distortion of normal cellular architecture, infiltration of inflammatory cells, and loss of cellular integrity. These histopathological changes were markedly suppressed by Tau treatment. In conclusion, biochemical and histological findings of this study suggest that Tau has strong preventive potential against complications of anticancer drug 5-FU and hence Tau may play an important role in combinational chemotherapy to enhance the therapeutic efficacy of anticancer drugs.

A case of recurrent metastatic ameloblastoma and hypercalcaemia successfully treated with carboplatin and paclitaxel: long survival and prolonged stable disease.

We describe a case of recurrent metastatic malignant ameloblastoma to the lungs with hypercalcaemia in a 47-year-old man. The first lung metastasis was resected nine years after the initial primary, and the tumour recurred with extensive pulmonary metastases 21 years after the primary tumour was resected. This case presented with malignancy-associated hypercalcaemia, likely due to paraneoplastic syndrome, which is exceedingly unusual in association with malignant ameloblastoma. He was successfully treated with carboplatin/paclitaxel and showed the longest survival and stable disease, from the diagnosis of recurrent metastasis, recorded as a case report. This regimen is reasonably well tolerated and can be repeated safely.

Nefrectomía parcial en tumores sobre 4 Cms: evolución posperatorio resultados oncológicos y complicaciones / Partial nephrectomy for tumors over 4 cms: postoperatory evolution oncological results and complications

La nefrectomía parcial (NP) es el tratamiento de elección para tumores renales malignos menores de 4 cm, ya que ha demostrado resultados oncológicos equivalentes y una sobrevida global superior a la nefrectomía radical. Esto se explica debido a la capacidad de la NP de preservar la función renal y prevenir los efectos deletéreos asociados a la disfunción renal. Existe una cantidad creciente de estudios que indican que esta ventaja seria también extensible a tumores estadio T1b (4-7 cm). Este trabajo, evalúa los resultados oncológicos de la NP en tumores mayores de 4 cms y las complicaciones con un score validado y reproducible. Material y métodos: Se identificó, de manera retrospectiva, a un total de 214 pacientes sometidos a nefrectomía parcial entre los años 2002 al 2009. De éstos, 39 presentaban tumor mayor de 4 cms. Se excluyeron aquellos pacientes que presentaban metástasis al momento del diagnóstico, los con seguimiento menor a 6 meses y/o, tumores no esporádicos. Se analizaron las variables categóricas y continuas con los test Chi cuadrado y Mann-Whitney, respectivamente. Se utilizó el análisis de Kaplan-Meier para calcular la sobrevida global y cáncer especifica. Se clasificaron las complicaciones según score de Clavien. Resultados: Se identificaron 45 tumores en 39 pacientes. La edad media fue de 61 años (110, 7). El tamaño promedio tumoral fue de 5, 7cms. En 7 pacientes la indicación de nefrectomía fue absoluta (riñón solitario o contralateral atrófico), mientras que fue electiva en 32 (82 por ciento). El estudio anátomo-patológico demostró 87,1 por ciento (34) de tumores malignos y 12, 9 por ciento (5), benignos. Luego de un seguimiento promedio de 35, 9 meses (media de 34 meses), la sobrevida fue de 92,3 por ciento, sin detectarse muertes a causa del tumor renal...

The role of nephron-sparing surgery (NSS) is well established for T1 a renal lesions (<4 cm). Renal tumor control achieved by NSS is equivalent to one achieved by Radical Nephrectomy (RN) in appropriate/y selected patients, offering the benefits of decreased renal insufficiency rate when compared to RN. Recent data for renal tumors > 4 cms have suggested that it might be possible to expand the indication of NSS, with comparable oncological and clinical outcomes. However, NSS for tumors > 4 cms has been associated with a slight/y higher rate of complications. Objectives: To evaluate the oncological and clinical outcomes of NSS for renal tumor > 4 cms and to assess the complications based in a graded, va/idated and reproducible score (Clavien grade ). Material and methods: After the approval of the institutional ethic board, we retrospectively identified 214 patients who underrnt NSS for renal tumors. Thirty nine patients had tumors over 4 cms. The study period was from 2002 to 2009. Patients with metastasis at the time of diagnosis, follow-up less than 6 months or with non-sporadic tumors were excluded from the study Continues and categorical variable were assessed with Mann- Whitney U test and chis-quare test, respectively. Kaplan-Meier analysis was used to calculate the overall survival and cancer specific survival rate. The assessment of the complication was done using the Clavien score. RESULTS Forty five tumors were identified ¡n 39 patients. The median age was 61 year r 10. 7. Median tumor size was 5. 7cms. The surgical indication was imperative in 7 patients (solitary kidney or contralateral atrophic kidney) and elective in 32 (82 percent). The final pathology report showed that 32 (87,1 percent) and 5 (12,9 percent) tumors were malignant and benign, respectively After a mean folIow- up of 35.9 months (median 34 months), the over all survival rate was 92,3 percent while none had died from renal tumors...

Comparison of oral midazolam with combination of oral midazolam and nitrous oxide inhalation in relation to safety of dental sedation in young children.

The objective of the study was to compare the safety of 0.6 mg/kg oral midazolam sedation alone with a combination of 0.6 mg/kg oral midazolam and nitrous oxide-oxygen sedation during dental treatment of young children. The study had a crossover design where every patient received two different sedation regimens i.e. oral midazolam 0.6 mg/kg alone and oral midazolam 0.6 mg/kg with nitrous oxide-oxygen inhalation during two dental treatment visits. Thirty children (17 males and 13 females) were selected for the study with mean age of 55.07 (+/- 9.29) months. Safety of the two regimens was evaluated by monitoring hemodynamic parameters (heart rate, blood pressure & oxygen saturation) and through observing the child for 24 hours post-sedation for any side effects such as nausea and vomiting. Very few changes in hemodynamics were noted from baseline during both the visits. However, the mean oxygen saturation level with oral midazolam and nitrous oxide-oxygen was significantly (p < 0.05) higher than oral midazolam alone. Postoperative side effects were very few and mainly remained limited to post-sedation drowsiness. It can be concluded that oral midazolam (0.6 mg/kg) alone and oral midazolam (0.6 mg/kg) plus nitrous oxide (30%-50%) sedation are both safe while providing dental treatment to children with behavior problems.

A new technique of flexor profundus repair in the distal part of zone I: inclusion of the palmar plate.

Flexor profundus lacerations in the distal part of zone I are usually treated by tendon reinsertion into bone. We present a modified technique in which three 'figure of eight' sutures include the palmar plate in the distal purchase. Inclusion of the palmar plate significantly strengthens the tensile strength of the repair and this was confirmed biomechanically in an experimental study. In a prospective clinical study, 15 patients with clean-cut complete lacerations of the profundus tendon in the distal part of zone I underwent the modified repair technique of three separate 'figure of eight' sutures with the palmar plate included in the suture distally and 7 mm suture purchase proximally, with postoperative immediate active motion that ensured full active extension of the interphalangeal joints. There were no ruptures or infections. At final follow-up 12-25 weeks after surgery, the mean range of motion at the distal, proximal, and combined interphalangeal joints was 66 degrees, 100 degrees and 166 degrees respectively. All patients achieved an excellent or good outcome.

Obstetric brachial plexus palsy in newborn babies of diabetic and non-diabetic mothers.

Compared to non-diabetic mothers, diabetic mothers are known to deliver larger babies who are at higher risk for shoulder dystocia and obstetric brachial plexus palsy. The intrapartum forces applied during delivery of larger babies are expected to be higher. Hence, the chances of these babies for good spontaneous recovery are expected to be lower; and this is a generally believed hypothesis. The objective of this retrospective study was to compare obstetric brachial plexus palsy in newborn babies of diabetic and non-diabetic mothers. There were a total of 655 cases of obstetric palsy: 253 cases with diabetic mothers and 402 with non-diabetic mothers. The former were more likely to develop total palsy while the latter were more likely to develop extended Erb's palsy. Newborn babies of diabetic mothers had significantly larger birth weights than those of non-diabetic mothers regardless of the type of palsy. The rate of good spontaneous recovery of the motor power of the limb in the two groups was not significantly different except in total palsy cases for shoulder external rotation and elbow flexion where the recovery was significantly better in the diabetic group. It was concluded that the generally believed hypothesis is not correct if one compares the outcome in the diabetic and non-diabetic groups for each type of palsy.

Obstetric brachial plexus palsy: a comparison of affected infants delivered vaginally by breech or cephalic presentation.

In this retrospective study we compared obstetric brachial plexus palsy (OBPP) in two non-operated groups of newborn babies delivered vaginally by breech or cephalic presentation. There were 35 cases of OBPP in the breech group and 663 cases in the cephalic group. The former group was more likely to develop upper Erb's palsy while the latter group was more likely to develop total palsy. The breech group also had a significantly lower mean birth weight, a significantly higher percentage of bilateral OBPP palsies and concurrent phrenic nerve palsy. Spontaneous recovery of shoulder abduction and elbow flexion in newborn babies with upper Erb's palsy was significantly worse in the breech compared with the cephalic group. It was concluded that OBPP following vaginal breech delivery has several unique demographic features and breech babies with upper Erb's palsy have a worse prognosis for spontaneous recovery than those in the cephalic group.

Association of reproductive factors with the incidence of breast cancer in Gulf Cooperation Council countries.

This article presents the incidence of female breast cancer in the Gulf Cooperation Council (GCC) countries and reviews the data in relation to established reproductive factors. Overall 4480 female breast cancer cases were diagnosed during 1998-2002 among GCC country nationals. Breast cancer was the most common malignancy in all GCC countries, ranging from 16.1% of female cancers in Oman to 35.4% in Bahrain. The age-standardized incidence rate per 100,000 was highest in Bahrain (46.4), followed by Kuwait (44.3), Qatar (35.5), United Arab Emirates (19.2), Oman (14.4) and Saudi Arabia (12.9). These rates are low compared with most industrialized countries.

Narakas classification of obstetric brachial plexus palsy revisited.

Narakas classified babies with obstetric palsy into four groups: upper Erb's, extended Erb's, total palsy, and total palsy with a Horner. Over the last 15 years, it was noted at our obstetric palsy clinic that good spontaneous recovery in newborns with extended Erb's palsy (C5, C6, C7 injury) was more likely if they recovered active wrist extension against gravity before 2 months of age. A hypothesis was made that newborns with extended Erb's palsy (Narakas Group II) may be subclassified into two groups according to this 'early recovery of wrist extension.' In a retrospective study of 581 cases with strict inclusion criteria, the hypothesis was found to be true: patients with extended Erb's and 'early recovery of wrist extension' have significantly higher percentages of good spontaneous recovery of limb function than those with extended Erb's and 'no early recovery of wrist extension' (P<0.0001 by chi-squared test).

Comparison of oral midazolam with a combination of oral midazolam and nitrous oxide-oxygen inhalation in the effectiveness of dental sedation for young children.

AIM: To compare the effectiveness of 0.6 mg/kg oral midazolam sedation alone and a combination of 0.6 mg/kg oral midazolam plus nitrous oxide-oxygen inhalation sedation, in controlling the behavior of uncooperative children during dental treatment. STUDY DESIGN: The study had a crossover design where the same patient received two different sedation regimens, that is, oral midazolam 0.6 mg/kg and oral midazolam 0.6 mg/kg with nitrous oxide-oxygen inhalation during two dental treatment visits. MATERIALS AND METHODS: Thirty children (17 males and 13 females) were randomly selected for the study, with a mean age of 55.07 (+/- 9.29) months, ranging from 48 - 72 months. A scoring system suggested by Houpt et al. (1985) was utilized for assessment of the children's behavior. RESULTS: There was no significant (p > 0.05) difference in the overall behavior assessment between the two sedation regimens, that is, oral midazolam alone and oral midazolam plus nitrous oxide-oxygen. However, the combination of midazolam and nitrous oxide-oxygen showed significantly (p < 0.05) superior results as compared to midazolam alone, in terms of controlling movement and crying during local anesthesia administration and restorative procedures. CONCLUSION: Compared to oral midazolam alone, a combination of oral midazolam and nitrous oxide inhalation sedation appears to provide more comfort to pediatric dental patients and operators during critical stages of dental treatment.

Nasopharyngeal carcinoma in Saudi Arabia: clinical presentation and diagnostic delay

Nasopharyngeal carcinoma is commonly advanced at diagnosis. In this study we evaluated the clinical presentation, diagnostic delay and factors affecting delay in nasopharyngeal carcinoma. Data were collected prospectively for 307 newly diagnosed patients, including detailed demographic data, disease history, health care consultations and referral process. Diagnostic delay was classified as patient, professional and overall. Neck lump and nasal obstruction were the commonest presenting symptoms. There was a significant association between delay time of >/= 3 months and advanced stage. Patient's age and otological symptoms were associated with increased overall delay time. Advanced clinical stage at diagnosis was associated with paitents' sociodemographic characteristics

Association of reproductive factors with the incidence of breast cancer in Gulf Cooperation Council countries

This article presents the incidence of female breast cancer in the Gulf Cooperation Council [GCC] countries and reviews the data in relation to established reproductive factors. Overall 4480 female breast cancer cases were diagnosed during 1998-2002 among GCC country nationals. Breast cancer was the most common malignancy in all GCC countries, ranging from 16.1% of female cancers in Oman to 35.4% in Bahrain. The age-standardized incidence rate per 100 000 was highest in Bahrain [46.4], followed by Kuwait [44.3], Qatar [35.5], United Arab Emirates [19.2], Oman [14.4] and Saudi Arabia [12.9]. These rates are low compared with most industrialized countries

Epidemiology of thyroid cancer: a review with special reference to Gulf Cooperation Council (GCC) states.

A wide variation in incidence of thyroid cancer according to age, sex, ethnicity and geographic region was observed. In general, it occurs more frequently in women than men and a substantially higher rate was observed particularly during fertile period of women compared with men of the same age. Papillary carcinoma is the most prevalent histological type, irrespective of gender and conditions like iodine level. Over the years the incidence of thyroid cancer, especially papillary type, increases around the world. Ionizing radiation, in particular radiotherapy to head and neck region was the most established risk factor for thyroid cancer. Goiter, miscarriage or abortion (particularly in the first pregnancy) may also predispose to thyroid cancer risk. Cigarette smoking and use of contraceptives may be modifier of thyroid cancer risk. In all the GCC states thyroid cancer is the second most common cancer except in Babrain and Kuwait (where it stands third). During the five year peribd (1998-2002) 549 male and 1898 female thyroid caneers were diagnosed in all the GCC states. Papillary carcinoma is the predominant histological type followed by follicular carcinoma in both genders. Among females, Qatar has the highest incidence with an age standardized incidence rate of 13.5 per 100,000 followed by Kuwait (7.7), Bahrain (7.6), Emirates (6.0), Oman (5.9), and Saudi Arabia (5.0). There were at least 2.6 female thyroid cancer cases (in Kuwait) for each male thyroid cancer case and this goes up to 6.6 in Babrain. Incidence of thyroid cancer in the GCC states is closer or higher than that of some of the developed countries.

Living related liver transplantation in 13 cases of progressive familial intrahepatic cholestasis.

Progressive familial intrahepatic cholestasis (PFIC) is a heterogenous group of disorders with various etiologies. Recent molecular and genetic studies have categorized the spectrum of types. Liver transplantation is a curative modality of treatment in this disease. We report our experience with 13 patients with PFIC who underwent living related liver transplantation. The follow-up periods ranged from 12 to 50 months. Two children died at 1 and 2 years posttransplantation, leading to a decrease in survival rate from 100% in the first year to 84.6%.

Risk factors associated with sexual dysfunction after transurethral resection of the prostate.

BACKGROUND: The effect of transurethral resection of prostate (TURP) for benign prostatic hyperplasia (BPH) on sexual function continues to be a controversial issue. The aim of this study was to evaluate sexual functions in Saudi patients suffering from BPH before and after TURP. PATIENTS AND METHODS: The influence of TURP on libido, erection and ejaculation was prospectively studied in 179 patients undergoing TURP for BPH. The risk factors studied for erectile dysfunction (ED) were old age, polygamy, comorbidities, late presentation, intraoperative bleeding, intraoperative capsular perforation and bacteriuria. Patients reporting ED underwent intracavernosal injection (ICI) of 20-40 AA(1/4)g of prostaglandin E1 (PGE1) before and/or after surgery. RESULTS: Before surgery, ED was present in 33/179 patients (18%) and was significantly associated with old age and comorbidities but not with polygamy or late presentation. In the patients with normal erection before surgery, dry ejaculation, ED and diminished libido developed after TURP in 71/134 (53%), 20/137 (15%), and 22/137 (16%), respectively. Postoperative ED was significantly associated with diminished libido (P=0.001), but not with postoperative dry ejaculation. The only significant risk factor associated with ED following TURP was capsular perforation. The response to ICI before and after TURP was comparable. CONCLUSION: ED associated with TURP is most likely of neurogenic origin due to capsular perforation, or of psychogenic nature as suggested by the significant association with diminished libido.

High glycemic index foods, overeating, and obesity.

OBJECTIVE: The prevalence of obesity has increased dramatically in recent years. However, the role of dietary composition in body weight regulation remains unclear. The purpose of this work was to investigate the acute effects of dietary glycemic index (GI) on energy metabolism and voluntary food intake in obese subjects. METHODS: Twelve obese teenage boys were evaluated on three separate occasions using a crossover study protocol. During each evaluation, subjects consumed identical test meals at breakfast and lunch that had a low, medium, or high GI. The high- and medium-GI meals were designed to have similar macronutrient composition, fiber content, and palatability, and all meals for each subject had equal energy content. After breakfast, plasma and serum concentrations of metabolic fuels and hormones were measured. Ad libitum food intake was determined in the 5-hour period after lunch. RESULTS: Voluntary energy intake after the high-GI meal (5.8 megajoule [mJ]) was 53% greater than after the medium-GI meal (3.8 mJ), and 81% greater than after the low-GI meal (3.2 mJ). In addition, compared with the low-GI meal, the high-GI meal resulted in higher serum insulin levels, lower plasma glucagon levels, lower postabsorptive plasma glucose and serum fatty acids levels, and elevation in plasma epinephrine. The area under the glycemic response curve for each test meal accounted for 53% of the variance in food intake within subjects. CONCLUSIONS: The rapid absorption of glucose after consumption of high-GI meals induces a sequence of hormonal and metabolic changes that promote excessive food intake in obese subjects. Additional studies are needed to examine the relationship between dietary GI and long-term body weight regulation.

Mesenteric panniculitis of the sigmoid colon.

Full text is available as a scanned copy of the original print version.

An outbreak of food poisoning associated with restaurant-made mayonnaise in Abha, Saudi Arabia.

In May 1996, an outbreak of gastroenteritis occurred among customers who bought dinner from a restaurant that specialised in fried chicken in Abha city, south-west Saudi Arabia. The median incubation period was 10 hours (range: 3 to 27 hours). Of the 10 food items served, only mayonnaise (RR 2.52; 95% CI 1.71-3.73) and minced garlic (RR 1.20; 95% CI 1.02-1.41) were associated with cases. Salmonella enterica was isolated from 124 (84%) of the 159 persons with symptoms of food poisoning, and 91 (73%) were serogroup Enteritidis, phage type B 14. Mayonnaise was prepared in the restaurant using a regular blender. Minced garlic was prepared with the same blender immediately after making the mayonnaise. Unsafe storage of the mayonnaise at room temperature for a median of 6 hours could have resulted in overgrowth of bacteria and a high infective dose of bacteria per serving.