Cerebral venous sinus thrombosis Hosam M Al-Jehani Saudi Journal of Medicine and Medical Sciences 2019 7(3):135-136 The diagnosis and management of cerebral venous sinus thrombosis (CVST) is challenging. It involves a multidisciplinary, integrated approach including emergency physicians, neurologists, hematologists and neurosurgeons. Each discipline has a role in the management of CVTS patients. Astute observation is necessary to suspect sinus thrombosis owing to multifactorial, gender-related specific causes. The “malingering” filter is often incorrectly imposed for these patients, most of who are young females with repeated episode of headache. Despite the clarity of CVST guidelines and treatment protocols, there is a diagnostic delay in the earliest phases in many CVST patients. By the time a correct diagnosis is made, the condition would have deteriorated, which likely affects the prognosis. In addition, the acute phase of this disorder is unpredictable and has a high mortality rate. Favorable prognosis is possible through a rapid diagnosis and prompt initiation of the treatment.[1] Repeated visits to the emergency room should lower the threshold of suspected CVST in patients with its risk factors. This could be improved by refinement of our triaging systems to alert the physicians and increase their clinical awareness about such predisposing factors and conditions. The initial imaging assessments of these patients are important. It should be noted that there is a paucity in the literature addressing stratification of the venous thrombosis and its effect on the clinical course and management strategies.[2] Involvement of cortical veins as well as superficial and deep venous systems results in diverse and nonspecific clinical presentations.[3] This imposes the need for different treatment modalities that should be considered in the upcoming standard guidelines and treatment protocols. Another aspect of imaging that has clinical implications is perfusion imaging, which can be used as an inference gauge to the degree of tissue edema and gradation of tissue vulnerability.[4] The mainstay of management for CVST is anticoagulants. Choosing the right anticoagulant for optimal duration is important for better prognosis. Patients with CVST are candidates for interventional therapy and surgical hemispheric decompression.[5],[6] The key to the success of these escalation therapies is that they should be implemented before major deterioration in a patient's level of consciousness, which usually reflects serious brainstem compromise. If the brainstem is indeed compromised, the escalation of therapy might border on futility. This cannot be overemphasized in CVST complicating traumatic brain trauma injury. For traumatic brain injury patients labeled with refractory intracranial hypertension, decompressive craniectomy can be offered. However, if the cause of the refractoriness is CVST, decompressive surgery and interventional therapy would result in significant improvements in the course of these patients.[7]     References   1. Saposnik G, Barinagarrementeria F, Brown RD Jr., Bushnell CD, Cucchiara B, Cushman M, et al. Diagnosis and management of cerebral venous thrombosis: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011;42:1158-92.        2. Coutinho JM, Gerritsma JJ, Zuurbier SM, Stam J. Isolated cortical vein thrombosis: Systematic review of case reports and case series. Stroke 2014;45:1836-8.        3. Luo Y, Tian X, Wang X. Diagnosis and treatment of cerebral venous thrombosis: A review. Front Aging Neurosci 2018;10:2.        4. Mokin M, Ciambella CC, Masud MW, Levy EI, Snyder KV, Siddiqui AH, et al. Whole-brain computed tomographic perfusion imaging in acute cerebral venous sinus thrombosis. Interv Neurol 2016;4:104-12.        5. Yang X, Wu F, Liu Y, Duan J, Meng R, Chen J, et al. Predictors of successful endovascular treatment in severe cerebral venous sinus thrombosis. Ann Clin Transl Neurol 2019;6:755-61.        6. Ferro JM, Bousser MG, Canhão P, Coutinho JM, Crassard I, Dentali F, et al. European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis – Endorsed by the European Academy of Neurology. Eur Stroke J 2017;2:195-221.        7. Chen KW, Lin YH, Lee CW. Acute posttraumatic cerebral venous sinus thrombosis-induced malignant increased intracranial pressure treated with endovascular dural sinus thrombectomy and stenting: A case report. World Neurosurg 2019. pii: S1878-8750(19)31379-8.

Clinical aspects, diagnosis and management of cerebral vein and dural sinus thrombosis: A literature review Abdulla Al-Sulaiman Saudi Journal of Medicine and Medical Sciences 2019 7(3):137-145 Cerebral vein and dural sinus thrombosis (CVST) is an uncommon cause of stroke, but its delayed diagnosis carries significant morbidity and mortality. Several studies have reported higher incidence of CVST than that previously reported. The clinical presentation of CVST varies and can be atypical. Advancement in neuroimaging modalities has made it possible to make an early diagnosis and initiate management with a wide range of therapeutic options, including direct oral anticoagulants and endovascular treatment. This narrative review summarizes the epidemiology, clinical aspects, diagnosis and management of CVST.

Demographic and clinicopathological patterns of colorectal cancer at the National Cancer Institute, Sudan Husam S Khougali, Ahmed A Albashir, Hatoun N Daffaalla, Mohammed Salih Saudi Journal of Medicine and Medical Sciences 2019 7(3):146-150 Background: Colorectal cancer is a common type of cancer worldwide, including in Sudan. However, few studies have assessed its demographic, clinical and pathological patterns in the Sudanese population. Objective: To assess the demographic, clinical and pathological patterns in patients with colorectal cancer at National Cancer Institute, University of Gezira, Sudan. Methods: This retrospective, cross-sectional study analyzed the data of all colorectal cancer patients who presented to National Cancer Institute, University of Gezira, between January 2016 and December 2017. National Cancer Institute, University of Gezira, is one of the two National Cancer Institutes in Sudan and receives patients from across Sudan. The demographic, clinical and pathological information were extracted from the patients' files. Results: A total of 163 colorectal cancer patients who presented to National Cancer Institute during the study period and met the inclusion criteria were included in this study. Most patients were aged >40–69 years (58.8%), were male (53.4%) and from Central Sudan (65.6%). About 44% of the patients were diagnosed 6–12 months from the disease onset and 26.8% after >12 months. Change in bowel habits (51.5%), rectal bleeding (42.3%) and abdominal pain (32.5%) were the most common clinical presentations. About 58% of the patients did not undergo per rectal examination during their initial presentation. Rectum was the most common site of tumor (58.9%), and the majority of patients had Grade I adenocarcinoma (50.3%). Duke's Class B (38%) and Class C (31%) were the most common stages of the patients' tumor, and signet ring carcinoma was found in 4.9% of the patients. Conclusion: This study found that in Sudan, colorectal cancer patients most commonly present late after the onset of symptoms, with an advanced stage and aggressive pattern as well as the proportion of younger patients is high. Further, per rectal examination is often not performed during the initial presentation.

Effect of sterilization on cyclic fatigue resistance of Proflexendo endodontic rotary files Emad O Alshwaimi Saudi Journal of Medicine and Medical Sciences 2019 7(3):151-155 Background: Proflexendo file (Nexen, Houston, TX, USA) is a recently developed, novel nickel-titanium rotary file. However, several physical properties of the Proflexendo system remain to be investigated. Objectives: The aim of this study was to determine the effect of sterilization on cyclic resistance of Proflexendo files. Material and Methods: A total of 120 unused Proflexendo rotary files (40 each of file sizes 40/0.04, 30/0.04 and 20/0.06) were used in this study. Each set of files was subdivided into four groups of ten files. Group 1 did not undergo any sterilization (control), Group 2 underwent two rounds (2×) of sterilization, Group 3 five rounds (5×) and Group 4 ten rounds (10×). Cyclic fatigue resistance was tested using an artificial canal with a 5-mm radius curve. Results: The nonsterilized size 30/0.04 files had the highest cycles to failure, followed by the nonsterilized size 40/0.04 and 20/0.06 files (P < 0.001). With increasing rounds of sterilization, cycles to failure reduced for sizes 40 (2×, 5× and 10×) and 30 (2×) files compared with nonsterilized sizes 40 (P < 0.05) and 30 files (P < 0.001), respectively. Conclusion: Under the conditions of the current study, the results provide preliminary evidence that autoclave sterilization of Proflexendo rotary files reduced their cyclic fatigue resistance, except for size 20 (2× and 5×) and 30 (10×) files, in which resistance increased. Single use of this file is recommended to reduce the risk of separation.

Prevalence and outcomes of sudden cardiac arrest in a university hospital in the Western Region, Saudi Arabia Abdullah Hussain Alzahrani, Maumounah F Alnajjar, Hussien M Alshamarni, Hasan M Alshamrani, Abdullah A Bakhsh Saudi Journal of Medicine and Medical Sciences 2019 7(3):156-162 Background: Sudden cardiac arrest (SCA) is a major cause of mortality, yet its epidemiological and outcome data in hospitals from Saudi Arabia are limited. Objectives: This study aimed to evaluate the prevalence, risk factors and outcomes of SCA in a teaching hospital in Jeddah, Saudi Arabia. Methods: This retrospective study included all patients aged ≥18 years with SCA who were resuscitated at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, between January 1 and December 31, 2016. Data were retrieved from the hospital medical records as flow sheets designed in accordance with the Utstein-style recommendations. Factors relating to mortality were analyzed using descriptive analyses and chi-square test. Results: A total of 429 cases of SCA met the inclusion criteria, and its prevalence was 7.76 cases/1000 adult hospital admission. Of these, 61.3% were male, and the mean age was 58.4 years, with 36.6% aged >65 years. Only 3.5% were outside-hospital cardiac arrests. The most common initial rhythm was pulseless electrical activity/asystole (93.2%), while ventricular tachycardia/ventricular fibrillation was documented in only 29 cases (6.8%). The overall rate of return to spontaneous circulation (ROSC) was 56.2%, and 56.8% in cases of in-hospital cardiac arrest (IHCA). Patients with SCA due to sepsis had significantly increased mortality (P < 0.000; odds ratio [OR] = 0.24 [0.12–0.47 95% confidence interval [CI]), while those with SCA due to respiratory causes had significantly better survival outcomes (P = 0.001; OR = 2.3 [1.5–3.8 95% CI]). No significant differences in outcomes were found between other risk factors, including cardiac causes. Conclusion: In this population, the prevalence of SCA in adults was higher than reported in many similar studies. Further, sepsis was found to affect the survival rate. Although the rate of ROSC for IHCA patients was favorable compared with other studies, it is relatively poor. This finding signifies the need to identify and control risk factors for SCA to improve survival.

Medical students' perceptions of their educational environment at a Saudi university Sahar Hassan Al-Natour Saudi Journal of Medicine and Medical Sciences 2019 7(3):163-168 Background: Students' perception of their educational environment has a significant impact on their behavior and academic progress. Aim: The aim of the study is to assess the perceptions of undergraduate medical students regarding their educational environment at Imam Abdulrahman Bin Faisal University, Saudi Arabia. Subjects and Methods: This cross-sectional study utilized the Dundee Ready Education Environment Measure (DREEM) inventory to collect data from 5th-year medical students at Imam Abdulrahman Bin Faisal University during the academic year 2010–2011 (score range: 0–200). The mean scores for each individual item and for the following five contributing DREEM domains were calculated: Perception of learning, perception of teaching, academic self-perception, perception of atmosphere and social self-perception. Results: The questionnaire was distributed to 121 students, all of whom completed the questionnaire. Of these, 65.3% were male and 34.7% were female. The mean total score was 126.4 (63%), indicating that the educational environment is satisfactory. The two lowest scoring contributory domains were academic self-perception (17.4/28; 60%) and perception of learning (29.3/48; 61%). No areas of excellence were identified (i.e., mean scores of >3.5); however, four main problematic areas were identified (mean scores of ≤2.0): Overemphasis of factual learning (1.66), difficulty with authoritarianism of teachers (1.55), students unable to memorize everything (1.82) and boredom in course (1.81). Conclusion: This study found that the overall educational environment at Imam Abdulrahman Bin Faisal University is satisfactory, with further scope of improvement. The author recommends implementation of remedial measures such as modifications in curriculum and using innovative teaching strategies to overcome problematic areas and further improve the overall educational environment.

Sociodemographic characteristics of adult Saudi patients with mood disorder subtypes Mahdi Saeed Abumadini Saudi Journal of Medicine and Medical Sciences 2019 7(3):169-174 Background: The demographic profile and clinical manifestations of mood disorder subtypes can differ across regions; however, there is a lack of studies from Saudi Arabia on the sociodemographic characteristics of adult Saudi patients with mood disorder subtypes. Objective: The study aims to explore the sociodemographic profile of adult Saudi patients with different types of mood disorders. Methods: This retrospective study analyzed the data of all adult Saudi patients (aged ≥18 years) who were diagnosed with a mood disorder and attended the psychiatric outpatient clinic at King Fahd Hospital of the University (KFHU), Al Khobar, Saudi Arabia, between 1982 and 2011. Patients with psychiatric comorbidity were not included in the analyses. Major depressive disorder (depression), bipolar disorder, adjustment disorder and dysthymia were the four subtypes of mood disorder identified in the sample, and all eligible patients were categorized accordingly. Results: A total of 340 patients were included in this study. Slightly less than half (42.4%) the study population were aged 18–30 years. Further, 58% of the patients were females, 67.6% were married and 58.8% were unemployed. Depression was the most common mood disorder (~73%). Of the patients with bipolar disorder (n = 38), more than half were male and aged 18–30 years (~58% each); these percentages were higher than that observed in other subtypes. Conclusion: This study found that among patients at KFHU, depression is the most common mood disorder and that most patients are females. In contrast, bipolar disorder is more common among males. Further in-depth studies in a larger sample size may provide better patient profiling, which can be used for developing effective screening programs.

Unusual presentation of aspergillus pericarditis: A case report Feras Ahmed Alkuwaiti, Yasser Elghoneimy, Eman Ahmed Alabdrabalrasol, Saleh Tawfeeq Alshreadah Saudi Journal of Medicine and Medical Sciences 2019 7(3):175-178 Cardiac aspergillosis is a rare fungal infection that affects the heart and/or pericardium of immunocompromised patients. Here, the authors report a rare case of a 36-year-old female with aspergillus pericarditis. The patient was diagnosed with infective endocarditis and splenic infarction and treated with emergency splenectomy and double-valve replacement surgery. During the surgery, a fibropurulent pericardial tissue was found and excised. The culture report of the tissue confirmed the diagnosis of aspergillus pericarditis. The patient was successfully managed with intravenous voriconazole. Aspergillus do not usually infect the pericardium and such infections are rarely detected premortem, especially during a cardiac surgery. In this report, the infection was accidentally detected during the double-valve surgery. The authors conclude that because of its nonspecific clinical manifestations, a high degree of clinical suspicion is required for the early diagnosis and treatment of aspergillus pericarditis.

Glued intraocular lens combined with endothelial keratoplasty: A case report Arwa Z Al-Romaih, Mohanna Y Al-Jindan, Saud M Al-Johani Saudi Journal of Medicine and Medical Sciences 2019 7(3):179-182 In an aphakic eye with corneal edema, performing Descemet's stripping automated endothelial keratoplasty (DSAEK) combined with implantation of intraocular lens can be a challenge. This case report describes a surgical technique for postsurgical aphakia with endothelial decompensation in a 42-year-old female with Marfan syndrome and subluxated lens. This technique comprised implanting DSAEK with fibrin glue-assisted sutureless posterior chamber intraocular lens. The donor lenticels were formed on a 60-kHz femtosecond laser platform (IntraLase®). Two partial-thickness scleral flaps and sclerotomies were created, and then, the Descemet's membrane was scored and stripped. A posterior chamber intraocular lens was implanted, and its haptics was pulled out through the sclerotomies and tucked beneath the flaps. The flaps were then apposed with fibrin glue. The donor lenticule was introduced to the anterior chamber and unfolded. Air tamponade was used to stabilize and center it. This technique significantly improved the uncorrected and best-corrected visual acuities of the patient, and no donor dislocations were reported. This case corroborates the findings of few similar cases that have found combined use of glued intraocular lens with DSAEK to be beneficial in such cases.

Management of failing dental implants following orofacial trauma: A case report Hamad Saleh AlRumaih Saudi Journal of Medicine and Medical Sciences 2019 7(3):183-186 Dental implant failure can be caused by several biomechanical and biological factors. Management of failed multiple adjacent dental implants can be challenging, as the amount of bone loss around these implants is often high. This necessitates the need to restore the supporting bone and replace the failed implants with new implants in optimal positions and with a favorable dental prosthetic option. This report describes a case of a 27-year-old female who presented with failed multiple adjacent maxillary dental implants following orofacial trauma and with a significant amount of supporting bone loss. The patient was managed by implants removal, bone grafting and implant-supported fixed hybrid prosthesis, which resulted in a positive outcome, despite several challenges.