Background: Primary care providers are responsible for providing initial diagnosis and treatment for most ailments. The management and referral patterns related to spinal disorders vary significantly. Aims: To assess primary care practitioners management of low back pain (LBP) including referral patterns. Materials and Methods: A cross-sectional study was conducted to assess primary care practitioner's management of LBP and their awareness of the options, risks, and outcomes of spine surgery. Results: Eighty respondents completed the questionnaire. There was significant heterogeneity concerning their management of LBP. Their views of the options, outcomes, and risks of spinal surgery were not consistent with the available medical literature. Conclusion: Variability in referral patterns is influenced by both lack of implementation of clinical practice guidelines and lack of awareness of spine surgery risks and outcomes among some practitioners in the primary care setting.

Background: Data of the pattern of the anatomical variations from the Middle East are lacking as compared with the literature available elsewhere. The aim of this study was to evaluate the value of routine intraoperative cholangiogram (IOC) to find the pattern of anatomical variations of the biliary tree in patients performing laparoscopic cholecystectomy at Al Hada Military Hospital, Taif, Saudi Arabia. Materials and Methods: Performing routine IOC to all patients undergoing laparoscopic cholecystectomy from May 2010 to December 2011 and examining the cholangiograms by a single hepatobiliary surgeon to record the anatomical patterns. Results: The total number of patients was 177. Normal anatomy was found in 59% of patients. The anatomical variations included; type B (10.7%), type C₁ (11.3%), type C₂ (6.7), type D₁ (4), type D₂ (2.2), type E₁ (2.8%), type E₂ (1.1%), and type F (1.1%). In addition of 1.2% with complex nonrecorded variations. With regards to the cystic duct variations, we found the normal direct cystic duct in 74.6%, type B 14.1, and type C in 11.3. Conclusion: Anatomical variations observed in the present study is nearly similar to that reported in the literature, with two cases of complex biliary anatomy and not described before and further reappearance in other cholangiograms must be kept in mind. However, a higher number of type C cystic duct variations were observed in our study that could cause a higher number of bile duct injuries in laparoscopic cholecystectomy if not recognized.

Background: Beta-thalassemia trait (BTT) is a common genetic disorder of hemoglobin and imposes a significant burden on global healthcare. Screening of this disorder is immensely important epidemiologically as it can reduce the future incidence of thalassemia major in newborns. The present study was carried out to evaluate the role of six discrimination indices to differentiate cases of BTT from others.Materials and Methods: A single-center, cross-sectional study was conducted on consecutive 10,407 participants. In addition to common diagnostic statistics association, concordance and receiver-operating characteristic curves were assessed to judge the role of discrimination indices. Results: Shine and Lal index, Mentzer index, and Srivastava index had revealed better discriminative function compared to England and Fraser index, red cell distribution width index, and Green and King index. Conclusion: Discrimination indices are rapid, reliable, and easy tools to suspect a case of BTT and send the subject for further high-performance liquid chromatography evaluation. But the cut-off value for these indices needs to be revised to achieve the best combination of sensitivity and specificity in this population.

Context: Health is one of the commonly mentioned motivations behind food choices, and functional foods offer promising health benefits. Aims: In this study, the folklore claim of Cinnamomum tamala leaves as hepatoprotective functional food is evaluated. Settings and Design: Prophylactic and curative hepatoprotective properties of selected functional food was carried out against commonly used analgesic antipyretic paracetamol (PCM). Subjects and Methods: Prophylactic and curative hepatoprotective property of suspension of C. tamala leaves (SCT) was studied against PCM-induced hepatic damage in albino rats. Pre- and post-treatment with SCT, before and after PCM treatment, reduced the biochemical markers of hepatic damage like serum glutamic pyruvic transaminase, serum glutamic oxaloacetic transaminase, serum alkaline phosphatase, serum cholesterol, total and direct bilirubin, and tissue glutathione (GSH). Histopathological studies also revealed that pre- and post-treatment with SCT, before and after PCM treatment protected the liver from PCM-induced liver damage. In addition, an antioxidant study was carried out by in vitro lipid peroxidation. Statistical Analysis Used: Statistical analysis was performed with one-way analysis of variance (one-way) followed by Tukey test. Results: In this study, it has been found that prophylactic study showed better hepatoprotection than the curative study. Conclusions: In the prophylactic study, lipid peroxidation and protection of GSH may be the reason behind better hepatoprotection and C. tamala possess hepatoprotective activity possibly because of its antioxidant potential.

Context: The incidence of hypopituitarism in the general population is 4 in 100,000, but there is a paucity of data on hypopituitarism. There are only two studies published from India on hypopituitarism. Aims: To study the clinical profile of hypopituitarism in a tertiary care center in Kerala. Settings and Design: This study was carried out in patients attending medicine and endocrinology outpatient and inpatient departments in Pushpagiri Medical College Hospital, Tiruvalla, Kerala between September 2013 and November 2014. Subjects and Methods: The study included 36 subjects of adult acquired hypopituitarism. Relevant clinical, hormonal, and imaging data were collected. Dynamic testing was done when necessary. Deficiency of hormones was defined based on standard recommendations. Results: The mean age was 48.6 years. There were 22 (59%) males and 14 females (41%). The most common presentation included altered sensorium (44.4%), hypogonadism, and menstrual irregularity (22.22%). As for the etiology of hypopituitarism, tumors (pre- and post-operative) comprised 58.3% of cases. Empty sella was found in 19.4% of patients with postsnake bite hypopituitarism (Simmonds syndrome) in 13.8%. Panhypopituitarism was seen in 86% of patients. Conclusions: Hypopituitarism is much more common than previously thought, and there is a delay in diagnosis either due to clinical inertia or due to its late and subtle presentation. The most common cause of hypopituitarism in a tertiary care center is pituitary tumors, and the most common presenting complaint is altered sensorium.

Background: Pulmonary artery catheterization (PAC) has been used in a "Heart Specialist Medical Centre" in the Eastern Province in the Kingdom of Saudi Arabia, for Intensive Care Unit (ICU) patients more frequently compared to other similar establishments elsewhere. Critical care nurse's knowledge toward using PAC was, therefore, surveyed to rectify this matter and ultimately form guidance, update practice, and future usage policies. Methodology: This survey included 48 ICU–Critical care nurses. A questionnaire has been designed and validated, and that was distributed to collect information on participants' relevant backgrounds and the PAC use. The raw test scores were converted to percentages and median test scores also interquartile range were calculated. The median knowledge score was compared among different attributes using Mann–Whitney U-test. The value P < 0. 05 was accepted as significant. Results: The questionnaire has been sent to 48 participants, and all participants answered the questionnaire. The median knowledge score of handling PAC is significantly related to earlier received training, their ICU experience, and their confidence of handling PAC. Conclusions: This survey highlighted the interesting statistical facts about the extent of lack of knowledge and skills among participants. More importantly, the survey also determined the important shortfalls in practice of some experienced medical practitioners. More research is needed to identify why such shortfalls exist and how they have developed. The survey finally highlights the importance of having policies and protocols for all PAC-related procedures, and the regularly associated training to guarantee patients' welfare and well-being is met.

Background: Primary open-angle glaucoma is the most common type of glaucoma. Objectives: This study aims to explore the anti-glaucoma activity of pomegranate (Punica granatum), against hydroxylpropylmethylcellulose (HPMC). Materials and Methods: Twenty-four rabbits were used and divided into four groups such as Group 1: Control, Group 2: Glaucoma rabbits, Group 3: Normal rabbits fed on commercial diet containing 20% pomegranate, and Group 4: Glaucoma rabbits fed on commercial diet containing 20% pomegranate. Intraocular pressure (IOP) levels were determined. The activities of catalase (CAT), superoxide dismutase (SOD), and reduced glutathione (GSH) were assessed. The level of malondialdehyde (MDA) and nitric oxide (NO) and lipid profiles (total cholesterol [TC], triacylglycerol [TAG], low-density lipoprotein-cholesterol [LDL-C], high-density lipoprotein-cholesterol [HDL-C], and very low-density lipoprotein-cholesterol [VLDL-C]), and liver functions were also measured. Results: A significant decrease in IOP was observed in glaucoma rabbits treated with diet containing 20% pomegranate. A significant increase in the levels of reduced GSH (P < 0.011), CAT (P < 0.034), and SOD (P < 0.001) activities was observed in the rabbits fed on diet containing 20% dried pomegranate comparing to glaucoma group. The levels of MDA and NO were decreased after pomegranate administered. In glaucoma group, the levels of lipid profiles TC, TAG, LDL-C, HDL-C, and VLDL-C were 166.5 ± 0.96, 175.00 ± 3.61, 82.2 ± 3.85, 41.5 ± 2.1, and 35.00 ± 0.72 (mg/dl), respectively. After rabbits fed on 20% dried pomegranate, the levels of lipid profiles were improved. Conclusion: The results suggest that pomegranate is very efficient to reduce IOP in HPMC experimental rabbits induced glaucoma. This protective effect appears to occur by maintaining the antioxidant defense system, possibly by preventing depletion of antioxidant enzymes and inhibition of lipid peroxidation. We suggest that pomegranate act as a protective and may be useful in improving the complications of glaucoma and stop the progression glaucoma development.

Background: The prevalence of asthma has increased considerably in the last few years. Aims: The aim of this study was to assess the prevalence of asthma and its related risk factors among children in Taif, Saudi Arabia. Materials and Methods: A cross-sectional prospective study was carried out. Pretested well-designed questionnaires were distributed during the period from May to October 2014. Results: Parents of 1700 children out of 4000 have completed the questionnaire with a response rate of 42.5%, 1082 (63.6%) of them were male. Asthma prevalence among girls (14.4%) was higher than boys (12.4%), but this was insignificant. Asthma prevalence was significantly higher among Saudi participants (14.4%) than non-Saudi (5.9%). Nature of residency, the presence of a plant or presence of pets at home had no significant effect on asthma prevalence. A smoking of family member and a history of asthma in the family had an important association on asthma prevalence rate. The highest prevalence of asthma (29.7%) was among the younger children (<3 years). Symptoms of asthma enhanced during exercise. The positive association between asthma and both cough and breathlessness was noted. Asthma had no effect on schools absenteeism, visiting or admission to hospitals. Body mass index had no effect on the prevalence of asthma. Conclusion: The asthma prevalence rate among children was 13.1%, whereas smoking and a history of asthma in the family increased this rate. Future studies are recommended to investigate asthma prevalence based on clinical and laboratory diagnosis to explore the link between asthma and obesity.

Hemangiopericytoma is a hypervascular tumor, originating from the pericytes of the capillary vessels and occurs anywhere in the body, but it is a rare mediastinal tumor. In this case report, I will present a 45-year-old male patient with huge mediastinal hemangiopericytoma compressing the heart and occupying most of the anterior mediastinum. To my knowledge, it was the first case reported in the Middle East and the largest in the English literature. Complete excision was performed but unfortunately, the patient becomes arrested and died at the end of the first postoperative day. Though mediastinal hemangiopericytoma is a rare mediastinal mass, it must be considered in differential diagnosis, and if it is suspected radiologically, the Tru-cut needle biopsy must be avoided and the tumor hypervascularity can be reduced by preoperative embolization or radiotherapy to facilitate its resection.

Necrotizing soft tissue infections are uncommon, seen most frequently in immune-compromised patients. The infections occur most frequently along the lower aspects of the body, such as the legs, perineum, and lower abdomen. It is extremely uncommon for necrotizing fasciitis to occur along the chest wall, with only a few of such cases have been reported. We discuss a case of anterior chest wall necrotizing fasciitis that involves the areola and infra axillary region with their successful management.

Malignant peritoneal mesothelioma (MPM) is a very rare diagnosis with an incidence of 1 case per 4–5 million of the population. It accounts for 20–30% of all mesothelioma type cancers. Its diagnosis is challenging for both surgeon and pathologist. The clinical and radiological features of the disease are usually nonspecific, most of cases diagnosed after laparotomy; even the gross appearance during laparotomy is confusing. In this article, we report a case of a young patient who never been exposed to asbestos, presented with clinical picture of bowel obstruction, computed tomography scan with contrast was done for abdomen, showed rim of free fluid in Morrison pouch with localized collection in right lower abdomen and fat stranding. Laparotomized twice for acute abdomen, ended with right hemicolectomy and we could confirm the diagnosis of MPM after completion of immunohistochemical staining of specimens. Patients with peritoneal mesothelioma often present late, and as a result treatment is often palliative. Interventions include cytoreductive (debulking) surgery and intraperitoneal chemotherapy or radiotherapy. There are a number of factors that have been consistently recognized as important in predicting better outcome in patients undergoing cytoreduction and hyperthermic intraoperative intraperitoneal perfusion with chemotherapy, such as age, histology, and the ability to achieve a complete gross cytoreduction. We present this case to draw attention of both surgeons and pathologists to this rare type of malignancy, especially when patient comes in vague abdominal symptoms and signs.

Accessory cleido-occipitalis muscle is an additional muscle fascicle derived from occipital portion of trapezius muscle inserted into the clavicle. Since its location is confined to neck region, it is also known as cleido-occipitalis cervicis. In the present case, we report a unique case of accessory cleido-occipitalis muscle derived from trapezius muscle. It was more tendinous than muscular and its tendon was extending medially, crossing the supraclavicular triangle of the neck horizontally in close approximation of clavicle. A narrow gap between them was a passage for the external jugular vein with its possible entrapment. The external jugular vein is a clinically important superficial venous channel required for many therapeutic interventions. The possible entrapment of it could hinder these approaches and also could lead to several complications.

Pharyngocutaneous fistula is a rare complication of anterior cervical approach for spinal surgery. In this report, I will present the case of a 25-year-old Indian male who developed pharyngocutaneous fistula after fixation of cervical vertebral fracture using the anterior approach. The condition was diagnosed first as wound infection, and the pharyngeal injury was confirmed by computed tomography scan with contrast. The repair was done using sternocleidomastoid muscle flap. Being familiar with pharyngocutaneous fistula as a complication of anterior cervical approach for spinal surgery is essential for early diagnosis and repair of the fistula. Reinforcement by sternocleidomastoid muscle flap is proved to be effective to prevent recurrence.

Extracranial pseudoaneurysms of the carotid artery are extremely uncommon lesions. Trauma, which is nowadays mostly iatrogenic, is responsible for the majority of these cases. Inflammation is uncommon etiology. Clinically, these aneurysms may present as neck swelling with expansion into adjacent structure and pressure symptoms, cerebral embolization, stroke, and rarely rupture. The treatment is usually by endovascular or open surgical techniques. Therapy must be individualized with major and prime objective being the prevention of neurological complications. We present a case of iatrogenic pseudoaneurysm of the common carotid artery resulting due to iatrogenic injury during cervical exploration at a Rural Health Center.

Segmental resection of the mandible destroys the balance and symmetry of function, leading to altered mandibular movements and deviation of the residual fragment toward the resected side. Prosthodontic management of unilateral hemimandibulectomy is aimed to reduce mandibular deviation and to improve the masticatory effiency. This clinical report describes a simple and efficient method utilizing customized wire-made-guide removable prosthesis to aid in reducing the mandibular deviation and enhances the masticatory efficiency.

Hereditary gingival fibromatosis [HGF] is a genetically heterogeneous disorder causing gingival enlargement. This condition is generally diagnosed alone or occasionally in association with various other abnormalities or syndromes. Here, we present and discuss a case of HGF in a 45-year-old female patient.