Abstract booklet by Imam Abdulrahman Bin Faisal University

Table of Content Title

The Impact of Sleep Deprivation on the Performance of Surgical and Medical Residents in the Eastern Province of the Kingdom of Saudi Arabia

Incisional Hernia ‐ Precipitating factors and Prevalence of Recurrency at King Fahd Hospital of the University

The knowledge and attitude, practice of swaddling among Saudi Arabian pregnant women

The introduction and validation of Arabic Sino‐Nasal Outcome Test (A‐Snot‐ 22 )

Prediction of Emergency Department Triage Category, Vital Signs and Presenting Symptom on Disposition and Clinical Outcome of H1N1 Patients.

Does real‐time feedback guided cardiopulmonary resuscitation improve the quality of chest compression in the bystanders provider.

Age of Presentation and Surgery of Undescended Testicle in Saudi Arabia: Did we reach the target?

Spectrum of viral skin infections in patients attending the dermatology clinic at King Fahd Hospital of the University during the period 2010‐2014

Breastfeeding Practice in Arar, Northern Saudi Arabia

The Difference in Burnout Syndrome Prevalence between Medical Students of the Traditional Curriculum and the Problem Based Curriculum

Giant cell tumor of the upper thoracic spine: report of a case and review of literature

Impact of Psoriasis on Quality of Life in Eastern Province, Saudi Arabia

Electrophysiological Properties of the Medium Spiny Neurons in the Q175 Mouse Model of Huntington’s Disease

Visual Outcomes and Patient Satisfaction After Bilateral Implantation of a New Trifocal Diffractive Intraocular Lens

Diabetic Ketoacidosis; Annual Incidence and Precipitating Factors at King Abdulaziz Medical City, Jeddah

Association between parameters of body weight, Disordered eating Attitude and Body Image among Saudi Females at Princess Nourah Bint Abdul‐ Rahman University (PNU)

Title

Perception of healthcare providers regarding the Role of Clinical Pharmacists in Saudi Arabia

Effect of metformin on BP, HR and ECG of rats administered with cardiotoxic agent doxorubicin.

Life of a Medical Student in King Faisal University in Al Ahsaa: Role of Hobbies, Social Life and Stress on Academic Performance

Acceptance of Cosmetic Surgery among Females in Princess Nourah Bent Abdulrahman University

Validation of New D‐Dimer Cutoff Values to Increase its Diagnostic Utility as Biochemical Marker in Acute Venous Thromboembolic Disease

Effects of HCN blocker, ZD7288, on pain hypersensitivity in a rat model of diabetic neuropathic pain

Guillain‐Barre Syndrome: Tertiary Center Experience in Saudi Arabia

Treatment Efforts And Survival Benefits In Pediatric Patients With Atypical Teratoid Rhabdoid Tumors (ATRT) At King Faisal Specialist Hospital And Research Centre, Riyadh, Saudi Arabia

Single Port Video‐Assisted Thoracoscopic Surgery for Diagnosis of Intrathoracic Lesions

Improving the Viability of Pseudo‐islet for Efficient Insulin Production

Complementary Medicine Practice and Perception Among Attendees of Primary Care Centers in Eastern Saudi Arabia

Association between race/ethnicity and wait time in adult patients presenting to an emergency department in emergent vs urgent presentations: A secondary analysis

Tyrosine Kinase Domain Mutations of EGFR Gene in Head and Neck Squamous Cell Carcinoma

• Case Report Abstracts

Dramatic improvement of infant with Infantile Hepatic Hemangioendothelioma After Propranolol Therapy : A Case Report

Recurrent Extensive Plunging Ranula: A Case report

Stroke in young patient with aortic valve fibroelastoma‐ A case report

Pericardial Aspergillosis‐ unusual presentation of infective endocarditis patient: A case report

Title

Phlegmasia Cerulea Dolens as a complication of improperly managed deep vein thrombosis in May Thurner syndrome: case report

Challenges in management of Adenocarcinoma of Ampulla of Vater in pregnancy: a Case report & review of literature

Laparoscopic biliopancreatic diversion for a morbidly obese patient with situs inversus totals

All guns blazing: Management and survival of massive valproic acid overdose. Case report and literature review

Sequestration Crisis in a Sickle Cell Disease patient Complicated by Splenic Abscess and Gastro‐splenic Fistula formation

The first reported case of Mal de Maleda in an Egyptian origin patient.

Right Atrial Thrombus Mimicking Myxoma in Patient with Systemic Lupus Erythematosus: A case report

Combined conjunctival intraepithelial neoplasia with corneal atypical Fibroxanthoma in Xeroderma Pigmentosum

Retained Soft Contact Lens for More Than Two Years in One Eyed Patient: A Case Report.

Eagle’s syndrome: The external surgical approach.

Infliximab Induced Psychosis in a Crohn’s disease adolescent patient: Case Report

Brain metastases & uncal herniation in a patient with ampullary adenocarcinoma in situ presenting with jaundice & memory loss, case report

Double coronary balloon usage for the treatment of Coarctation of the Aorta: A Case Report

Vaginal Fistula and Right Ovarian Prolapse Presenting as Vaginismus : A Case Report

The Use of Omental Flap For The Reconstruction Of Burn Injury To The Scalp: A Case Report

GBM, Resistant Thrombocytopenia Managed By Splenic Artery Embolization

Neurocysticercosis

The Impact of Sleep Deprivation on the Performance of Surgical and Medical Residents in the Eastern Province of the Kingdom of Saudi Arabia

Prof. A. Al-Mulhim, Dr. H. Al-Saleem, D. Al-Qourain, L. Al-Amer, M. Al-Mulhim, R. Amir, R. Al-Anazi, S. Al-Dhahri, S. Akbar, W. Gasim College of Medicine, Imam Abdulrahman Bin Faisal University King Fahd Hospital of the University Objective: Residency training is known to be a stressful and demanding period due to the long working hours and overnight calls. Therefore, residents are more susceptible than others to sleep deprivation, which in turn could affect their performance level. However, residents of different specialties are subjected to variable workloads and thus could be effected by sleep deprivation differently. The main aim of our study is to assess the variability in the impact of sleep deprivation on the performance of surgical and medical residents. This, according to our knowledge, has not been done in the Kingdom of Saudi Arabia to date. Methods: A questionnaire was distributed in person to general surgery and internal medicine residents of all levels in Saudi Commission of Health Subspecialties (SCFHS) accredited training centers in the Eastern Province of the Kingdom of Saudi Arabia. This questionnaire focused on working hours, post‐call daily functioning, and sleep requirements. The questionnaire included a modified Sleep Deprivation Index (SDI) scale, composed of 12 items, which allowed assessment of the effects of sleep deprivation on individual performance. Results: A response rate of 47% (56/119) for general surgery and 50.4% (71/141) for internal medicine residents was obtained. Overall, surgery residents reported longer post‐call working hours (averaging 6.7 versus 5.7 hours) and a nearly equivalent number of sleeping hours on a regular on‐call night compared to medicine residents (1.08 versus 1.00 hours). Surgery and medicine residents had very similar scores in the SDI scale (27.99 versus 28.35) signifying no difference in impact of sleep deprivation on performance among the two groups. Conclusion : The study demonstrates that despite working longer hours, surgery residents do not display increased impact of sleep deprivation on their performance compared to medicine residents. This could be attributed to true resilience to sleep deprivation among surgery residents or to the primary culture within the surgical field in which individuals are less accepting of natural limits of personal performance.

Incisional Hernia - Precipitating factors and Prevalence of Recurrency at King Fahd Hospital of the University

Dr. Othman Alfrayyan, Ahmed Alrahim, Abdulrahman Albassam, Anas Alhindi, Yazzed Bahamdan Imam Abdulrahman Bin Faisal University King Fahd Hospital of the University Introduction and objectives: A hernia is a protrusion of an organ or part of it through the wall that normally contains it. It is a common complication of abdominal surgery with an incidence rate 11%‐26%. After the primary surgery, 50% of the incisional hernias develop within the first two years and 74% develop after three years. Therefore, our study was designed to identify the precipitating factors associated with incisional hernia and the prevalence of recurrence. Methodology : A retrospective cohort study including all patients presented with incisional hernia and managed by the department of General Surgery over a period of 15 years starting from 1st of January 2000 till 1st of January 2015. The variables which are included in the study are the demographic data, co‐morbidity, number of pregnancy, primary surgery, duration of hospital stay, type of hernia repair, and wound infection. Other types of hernias are excluded from this research. The variables were collected from the patients’ files. The study was approved by Institutional Review Board (IRB) of our hospital. Results: The sample of the study is 96 patients with mean age 45 years, out of which 63 were females, 33 were males. BMI above 30 is the commonest group which developed incisional hernia (52.3%). Regarding Co‐morbidity, 21% of patients with incisional hernia were diabetic. Commonest surgery associated with incisional hernia development is C‐section 26.9% followed by Laparoscopic Cholecystectomy 19.4%. 12.8% of the primary surgeries that were complicated by incisional hernia were associated with wound infection .The prevalence of recurrent Incisional hernia was 22.1%, and the highest number of recurrence was 3 hernias in the same incision. Conclusion : Recurrence of incisional hernia is high and can be avoided. Current evidence suggests that the use of mesh, good wound care and the establishment of minimal invasive procedures have a significant role in reducing recurrence rate and decreasing the burden on the patients.

The knowledge and attitude, practice of swaddling among Saudi Arabian pregnant women

Ghufran AlArfaj, Munirah AlTuraiyef, Manahel AlMulhem, Hend AlShamsi, Sadat-Ali Imam Abdulrahman Bin Faisal University King Fahd Hospital of the University Background: Developmental Dysplasia of the Hip (DDH) is a condition that affects the hip joint and includes a spectrum of physical and radiological findings which ranges from mild to a total dislocation. Swaddling is one of many factors that plays a role in DDH. Objectives: To measure the prevalence of newborn swaddling among Saudi pregnant mothers. To assess the knowledge and attitude of swaddling among Saudi pregnant mothers. To identify the causes of DDH from mothers’ prospective. Methodology: The design of this study was a cross‐sectional study that conducted at King Fahad University Hospital in Al‐Khobar in 2016. The sample included 200 Saudi Arabian pregnant women whom were setting next to Obstetrics and Gynecology clinics. The non‐ Saudi or non‐pregnant women were excluded from the sample. A questionnaire was distributed that consisted of two sections, the first section was asking about demographic information, while the knowledge and attitude of Saudi pregnant women was the title of the second section. The statistical analysis was conducted by using Microsoft Excel. Results : Out of 200 Saudi pregnant mothers, 35% were primigravida while 65% of the mothers were multigravida. Among the multigravida 91.5% swaddled their children. The vast majority of the participants (89.5%) heard about swaddling from their families. The main reason (49%) to swaddle the babies from mothers’ point of view was to calm their newborns. Almost the half of participants (46.5%) believed that swaddling was always beneficial for the newborns. Regarding the cause of DDH, 45% of Saudi pregnant mothers are not aware of the exact cause of DDH. On the other hand, 37% of them believed that DDH is result of medical errors. The vast majority of the participants (53.5%) are not aware of the role of genetics on DDH. However, 32.5% of the participants wrongly thought that genetics don’t have a role on DDH. Expectedly, only 14% of the participants were aware of genetics role. Conclusion: Based on the result of our study, many misconceptions regarding DDH and swaddling were found in our community. Awareness regarding swaddling and DDH is needed among Saudi community.

The introduction and validation of Arabic Sino-Nasal Outcome Test (A-Snot22)

Mohammad Al-Bar,Abdulaziz Almazrua,Bander Alzahrani,Fahad Alsafran Imam Abdulrahman Bin Faisal University King Fahd Hospital of the University Background: The quality of life (QOL) of patients with sinonasal diseases is an important indicator for disease‐severity classification and outcome measurement in obtaining treatment, and the outcome evaluating. The sinonasal outcome test 22 (SNOT 22) questionnaire has been introduced as the best specific sinonasal instrument for QOL measurement. Objectives: perform translation, cross‐cultural adaptation, and validation of the (SNOT)‐ 22 in the Arabic language. To prepare a valid and reliable Arabic language version of SNOT 22 questionnaire. Methods: Validation of the Arabic questionnaire included translation of original SNOT‐22 items from English to Arabic, and retranslation back. We distributed with patients diagnosed with CRS at the Otolaryngology clinic in our hospital and group of healthy volunteers. Both groups answered the final draft of the Arabic version of SNOT 22. The study was previously approved by the Hospital’s research ethics committee. Inclusion criteria required to be 19‐69 years old ,Arabic native speaker , understand the purpose of the study. In cases where SNOT‐22 items were incomplete but more than 50% answered, the total score was calculated as the mean of completed items. Individuals included in the case group were patients who met the clinical criteria for CRS according to EPOS 2012. A control group of healthy volunteers without nasal pathology who met all the inclusion criteria. Results: 104 cases and 110 controls. Internal consistency was evaluated with Cronbach’s alpha test, reproducibility with Kappa coefficient, reliability with interclass correlation coefficient (ICC), validity with Mann–Whitney U test and responsiveness with Wilcoxon test. In cases, Cronbach’s alpha was .939, as for controls, it was .943. The comparison of mean SNOT‐22 scores of healthy individuals with those of patient group indicated statistically significant difference between the two groups. Conclusion : The Arabic version of the SNOT‐22 is a valid and reliable instrument for accessing sinonasal diseases in Arabic speaking people. With good internal consistency, excellent reproducibility, validity, and responsiveness for assessing patients with CRS.

Prediction of Emergency Department Triage Category, Vital Signs and Presenting Symptom on Disposition and Clinical Outcome of H1N1 Patients.

Aisha Alsubaie, Alaa Alshamsy, Bayader Alkhliwi, Hind Alshammari, Maha Alshammari, Nosibah Telmesani, Reem Alshammari, Mohammed Alshahrani Imam Abdulrahman Bin Faisal University King Fahd Hospital of the University Introduction: Since 2009, first case of H1N1 influenza infection was reported, a seasonal outbreak still occur and patients present to the emergency department with flu‐like symptoms, but some develop severe respiratory symptoms and need admission. No available data of how can we predict admission and outcome of such patients on their initial presentation. Objectives : Our aim is to identify predictors of the need for admission and clinical outcome of H1N1 patients in emergency department. Method : Retrospective chart review of all patients who presented to the emergency department at University Hospital setting, Saudi Arabia with confirmed H1N1infection between November and December 2015. We excluded patients with no documented vital signs or triage category. Demographic data, vital signs and triage category along with presenting complains were recorded. Regression analysis conducted to look for factors that predict the outcome, which is the need for admission or discharge from the emergency department, length of hospital stay or death as a result of this illness. Results : 333 positive H1N1 patients identified, 80 patients (24%) where admitted, of those 4 patients (1.2%) died. Triage category 3 was the most frequent with 64.8%, 18% got admitted compared to 46.8%. Multivariate regression analysis showed that tachypnea was found to be more predictive for getting admitted (OR = 1.1; 95% CI: 1.02 – 1.13) (p<0.01). Another significant finding is that patients had dyspnea, they’re 4.5 times more likely to have a longer hospital stay (OR = 4.5; 95% CI: 1.2 ‐17.1) (p=0.025). The association between triage category and hospital stay was significant (χ2=6.068, p=0.037) where the proportion of triage category 3 was more in the longer hospital stay group compared to category 4. Conclusion: In H1N1 patients, the initial triage category of 3 or less, and tachypnea are found to predict the need for admission, where patients with dyspnea have higher chance of longer hospital stay.

Does real-time feedback guided cardiopulmonary resuscitation improve the quality of chest compression in the bystanders provider. Dr. Thamir AlSayed, Dr. Faisal A.Katbi, Lateefah T.AlShammari, Hussain N.AlmohammedSaleh, Ranya H.Sabri. Imam Abdulrahman bin Faisal University. Introduction: Cardiopulmonary resuscitation is lifesaving procedure that can be effectively taught to anyone. Evidence showed that bystander CPR and high quality chest compressions serve as predictors of survival. The 2015 AHA guidelines emphasized on the importance of high quality CPR for survival, describing it as the corner stone for the system of care that can optimize outcome beyond return of spontaneous circulation. In this study, we are trying to see if bystander use of real‐time feedback guided defibrillators and AEDs will help them perform higher quality CPR and thus improve patient outcome. Objectives: Assess the change in quality of chest compression rate and depth by using “real‐time feedback devices” compared to traditional BLS and first aid training for the bystander provider. Methods: This is a prospective observational study in which we are comparing chest compression quality data with and without feedback from metronome devices. Data were collected from 516 manikins simulated CPR during teaching classes for freshmen college students. The data were used to calculate the in‐target chest compression percentage which for the purposes of this study is defined as the percentage of chest compressions reaching the 2015 AHA guidelines for rate (100‐120/min), depth (2‐2.4”) and fraction (60‐80%) Results: All chest compressions were recorded through metronome guided devices looking at appropriate in‐target chest compression percentage. Each candidate were asked to preform one cycle of CPR without receiving any feedback for the quality of their chest compressions followed by one cycle of CPR with feedback from the metronomic guided device. 30 percent of chest compression were in‐target of 2015 AHA guided CPR when preformed without feedback. In‐target chest compressions reached 71 percent when preformed with assisted feedback. Conclusion: Real‐time feedback guided CPR device improved the percentage of in‐target chest compressions for bystander CPR. These simulated sessions have shown that providing feedback to bystander CPR through metronome devices gave higher quality chest compressions and thus potential improvement of survival.

Age of Presentation and Surgery of Undescended Testicle in Saudi Arabia: Did we reach the target?

Jumanah Baslelah, Abdullah Alzahrani, Abdulaziz Haji, Nasser Alalyani, Turki Alsubiani, Maha Almadhi, Ossamah Alsowayan King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia Background: The undescended testis is a common condition of childhood. Research suggesting progressive deterioration in an undescended testis has led to the reduction in the target age of orchidopexy to 6‐12 months of age. This study aims to determine the age of presentation of undescended testis to a specialist in Saudi Arabia; the age orchidopexy is carried out and whether recommend target is being met. Methods : We retrospectively reviewed the demographics of patients with undescended testes presented to King Fahd Hospital of Imam Abdulrahman Alfaisal University between 2000‐2015. Only patients born during this time line were included in the study. Those born earlier, have missing referral or surgery date were excluded. Results : A total of 278 patients with undescended testes were retrospectively reviewed. One hundred thirty‐six patients were excluded from the study, 111 born before 2000, 21 had missing referral date and 4 had missing surgery date. The median age of presentation to a specialist was 10.9 (range 0 – 99.2) months. The median age at time of surgery was 21 (range 7.5 – 103.7) months with a median waiting time of 5.1 (range 0.01 – 27.7) months. Conclusion : Although patients presented to specialists at the recommended age of orchidopexy, there was a short time margin to carry out orchidopexy at the recommended age. There is a national need to address this by educating the public and promoting early primary care/pediatrician referral directly from the routine postnatal clinic.

Spectrum of viral skin infections in patients attending the dermatology clinic at King Fahd Hospital of the University during the period 2010-2014 AlAnood AlThukair, MD, Deema Sallout, MD, Dina AbdulGhani, MD, Dina AlAfandi, MD, Hawra AlJohi, MD, Hessa AlOtaibi, MD, Lina AbuGharara, MD, Professor Iqbal Bukhari. Dermatology Department, College of Medicine, Imam Abdulrahman Bin Faisal University King Fahd Hospital of the University Introduction : Viral skin infections are an important disease group in the dermatology field. Many factors play a role in the incidence of skin diseases. There are only a few reports of surveys conducted on the prevalence of viral infections in Saudi Arabia. Our study is the first in the gulf region which can serve as a good reference for planning therapeutic healthcare measures. Objectives: To determine the prevalence of viral skin infections in patients who attended the dermatology clinic at King Fahad Hospital of the University (KFHU) in Al Khobar, Kingdom of Saudi Arabia during a period of five years. Materials and Methods: A retrospective study conducted at the outpatient clinic of the Dermatology Department of KFHU for the period between January 2010 and December 2014. After acquiring the Institutional Review Board approval (IRB 2015‐01‐ 186) the study was initiated. Patients age, gender, diagnosis were documented in a data sheet and analyzed using SPSS V.16 Results: The total number of patients seen during that period was 4798, 25.8% were in the age group of 21‐30 years, 19.5% were in the age group of 11‐20 years, and 14.1% were in the age group of 2‐10 years. The most commonly encountered skin diseases were acne (16.5%) followed by eczema (15%), pigmentary disorders (9.6%) and viral infections (7.9%). A variety of viral skin infections were diagnosed including warts, herpes labialis, herpes genitalis, chicken pox and molluscum contagiosum. Warts comprised 72.5% of the total reported viral infections while Chicken pox and herpes genitalis were the least commonly reported. Discussion : The most commonly encountered disease group among the 4798 patients seen at KFHU was acne (16.5%). The second was dermatitis and eczema (15%). Pigmentary disorders came in third place (9.6%), and viral infections followed in fourth place (7.9%). Compared to previous studies in Saudi Arabia, ours showed the lowest prevalence. Warts comprised 72%. Molluscum contagiosum (11.4%) and Herpes zoster 7.7%. The least commonly encountered viral diseases were chicken pox and herpes genitalis.

Conclusion : Viral skin diseases are one of the major health problems in the dermatology specialty. Further studies should be performed to control these conditions.

Breastfeeding Practice in Arar, Northern Saudi Arabia

Murtadha Mohammed A BinAbd, MishaelMaki A AlDawood, Zahra Mohamed A Al Muwais1, AqeelaMowsaJ Al-Redwan, EimanSaeed I Alajyan, Fatimah FalahM Aldajani Imam Abdulrahman bin Faisal University, Dammam, KSA Background : Human milk meets all the nutritional requirements of infants for the first 6 months of life, and is associated with a lower incidence of diarrhea than partial or artificial feeding. The infant should be exclusively breastfed for at least 4 months of life and if possible for 6 months, as recommended by WHO and UNICEF. Objectives : The main objective of this study was to determine the breastfeeding status for children under 24 months in Ararcity, and to determine breastfeeding practice in relation to some socio‐demographic and nutrition related variables. Participants and methods : A cross‐sectional study was carried out in Arar City, mothers were selected from the attendees of the female side of 6 randomly selected primary health care centers in the city. They interviewed and filled a questionnaire which included the needed questions. Results : Among the 400 studied children, 11.8% get exclusive breastfeeding,39.7% had both breast and artificial feeding while 48.5% depended on artificial feeding only. More than 50% of the studied children were males, 70% of the mothers weren't working. No significant relationship between type of child feeding and child age, sex, mother education, mother's working status, father's work or mother age group (P >0.05). About 2 thirds of children who had mixed feeding suffered from repeated gastroenteritis, delayed teething, standing and walking. Conclusion: In our study, 11.8% get exclusive breastfeeding, 39.7% had both breast and artificial feeding while 48.5% depended on artificial feeding only. With obvious deficiency of exclusive breastfeeding in Arar, Northern Saudi Arabia. Programs promoting exclusive breastfeeding in the first 6 months of age must be conducted to increase mothers’ awareness of the exclusive breastfeeding duration is recommended.

The Difference in Burnout Syndrome Prevalence between Medical Students of the Traditional Curriculum and the Problem Based Curriculum

Yasser Maher Al-Jehani, Aldanah Mohammed Althwanay, Hessah Mohammed Buainain, Abdulaziz Khalid Abuhaimed, Abdulaziz Mubarak Almulhim, Fatima Adel Abusrir, Fatimah Lateef Alkhabbaz and Salam Sami Almustafa King Fahd Hospital of the University Background: Many people consider stress to be part of their daily lives, regardless of their age or job. Undergraduate medical students are at particularly higher risk of feeling stressed or burnt‐out. This could be attributed to the highly demanding and competitive environment of medical school worldwide. Burnout is defined as prolonged response to chronic emotional and interpersonal stressors on the job, and is defined by the three dimensions of exhaustion, cynicism, and inefficacy. Objectives : The objective of our study is to find if there is a difference in the prevalence of burnout syndrome between medical students of the traditional and the problem‐based (PBL) curriculums at Imam Abdulrahman bin Faisal University (IAU). Methodology: A cross‐sectional study was conducted among 590 medical students of IAU from third to sixth year. Using the English version of the Copenhagen Burnout Inventory (CBI) questionnaire which was distributed along with demographic questions and other questions related to stressors of medical school. Data was analyzed using SPSS version 16.0. Results: The mean of total burnout of both PBL and traditional groups were almost similar, with a 52.49% for PBL and 50.76% for traditional groups. The total mean of burnout level considering both PBL and traditional groups was 51.69. There were significantly more PBL students than traditional students, having medical school related burnout. (57.7% and 42.3%; respectively, p<0.05). Several associations have been found with high burnout level, but the strongest was with unsupportive and inflexible faculty (OR=4.867, p= 0.000). Conclusion : The overall level of burnout was almost the same in both PBL and traditional groups. There was no significant difference of burnout in the aspects of personal and teaching staff between the two curricula. However, burnout level regarding medical school aspect was more in the PBL compared to the traditional group.

Giant cell tumor of the upper thoracic spine: report of a case and review of literature

Eid Adel Al-Shamary, Wisam Al-Issawi Imam Abdulrahman Bin Faisal University Background : Giant cell tumor (GCT) is a benign neoplasm that typically classified as a locally aggressive tumor with malignant behavior and potential metastasis to the lung, typically develops after maturity. Most GCTs of bone occur in the epiphysis or meta‐ epiphysis of long bones and are rarely found in the spine. When involving the spine, the tumors occur predominantly in the sacrum. GCTs have a female predominance of 70.8% and present primarily during the third or fourth decades of life. GCTs in the spine (excluding the sacrum) constitute less than 2% of all vertebral tumors and less than 1% of all GCTs. The purpose of this study was to demonstrate a case of giant cell tumor in the upper thoracic spine of a single center experience with reviewing the literature and demonstrating the medical as well as the surgical options and other possible adjuvant options and to show how these adjuvant therapies have contributed to the treatment of a such spinal pathological entity. Method : we retrospectively reviewed all of our case records, clinic, radiological, pathological, operative & post‐op, and follow‐up documents were reviewed thoroughly. Among the studies, we have reviewed 21 cases identified ( including ours) of GCTs involving the upper thoracic spine. All data were analyzed by SPSS Statistics. Results : Statistical analysis of our study cases revealed, Means ± Standard deviations (means ± SDs) of the age between 16 to 64 years with mean of 33.95 and ( ± SD of 13.23) years, which was consistent with the findings of a previous study that demonstrated that GCTs present primarily during the fourth decade of life. For these 21 cases ratio of men to women was approximately 1:1.5 which was consistent with the results of previous studies. Through all GCTs cases reviewed here, we found that 50% of cases were in the T1‐T7 region and the other 50% were in T8‐T12 region of the thoracic spine. the most frequent complaint was pain which was consistent with the previous studies. Conclusion: The management of patients with giant cell tumors of the spine represents a challenge, and since there is no specific treatment algorithm of this aggressive tumor, treatment option is tailored to the individual case, a biopsy is a gold standard method to diagnose spinal GCTs and en‐block total resection remains the treatment of choice.

Impact of Psoriasis on Quality of Life in Eastern Province, Saudi Arabia

Ali Alabdullah1*, Mousa Alhaddad2*, Yousef Alabdullah1, Ali Aljafar1, Mohammed Alhaddad1, Hassan Alnasser1,Ahmed Aleissa1, Omar Alakloby3 1. Medical Intern, IAU, Saudi Arabia. 2. Medical Student, IAU, Saudi Arabia. 3. Consultant Dermatologist, KFHU, Saudi Arabia. Background : Psoriasis is a chronic, inflammatory skin disease that can seriously impair the quality of life (QOL). It can cause anxiety or result in disability negatively influencing life activities and family relationships of patients. Unfortunately, there is a very limited amount of data in the literature about of the impact of psoriasis on the quality of life of patients living in Saudi Arabia. Objective: The aim of this study was to assess the quality of life in psoriatic patients living in the Eastern Province, Saudi Arabia. Materials and Methods: The study was a cross‐sectional questionnaire‐based study. The licensed validated Arabic version of Dermatology Life Quality Index (DLQI) instrument was used to assess the quality of life. An electronic copy of the questionnaire was distributed to the psoriatic patients who visited the dermatology department, King Fahd Hospital of the University in Al‐Khobar from September 2016 to March 2017. All the participants were informed about the content and the aim of the study. Their participations were anonymous and voluntary. Results : 84 adult patients accepted to participate in the study and completed the questionnaire. The overall average DLQI score was 7.39 out of 30. Psoriasis impaired the quality of life of 74 patients (88.1%). 18 patients (21.4%) were "very largely" or "extremely largely" affected by the disease. Groin involvement was the single statically significant factor that correlates with QOL. The patients with groin involvement (27.38% of patients) had a higher deterioration of quality of life than the patients with no involvement. The mean DLQI score with groin involvement is 9.87 compared to 6.37 without it (p‐value <0.05). Conclusion : The overall score of DQOL in psoriatic patients living in Saudi Arabia is relatively high. The factors that are associated with QOL impairment in Saudi Arabia may differ than those in the other regions of the world.

Electrophyisological Properties of the Medium Spiny Neurons in the Q175 Mouse Model of Huntington’s Disease

Dana Almedallah Imam Abdulrahman Bin Faisal University Background : Huntington’s disease (HD), is a progressive fatal autosomal dominant neurodegenerative disorder, characterized by motor, cognitive, and psychiatric symptoms. It is caused by an abnormal expansion of CAG repeats in the coding region of the huntingtin (Htt) gene encoding a polyglutamine stretch within the corresponding protein, named huntingtin. OBJECTIVE: Overall Goal is to characterize and model alterations in MSNs and striatal circuitry in the Q175 mouse model of HD. Methods : Experimental subjects: A total of 16 mice, 8 of the Q175 Knock‐In mice and 8 of the wild‐type littermate control mice at 12M (WT, n = 27; TG, n = 14 cells). Striatal slice preparation: Extraction of brains and blocking of cerebral hemispheres, then cutting of slices (300 μm thick) with a vibrating microtome and maintenance of slices in oxygenated Ringer’s solution. Cell inclusion criteria: Electrophysiology, only cells that met the following criteria were included: a resting membrane potential of ≤ ‐55 mV, stable access resistance, the presence of an AP overshoot and repetitive firing during sustained depolarizing steps. Whole‐cell patch clamp recordings: Medium Spiny Neurons (MSNs) were visualized under IR‐DIC optics and then recorded alive under patch clamp. Data acquisition: with PatchMaster (HEKA Elektronik, Lambrecht, Germany) from patch clamp. Electrophysiological properties: Analyses performed with the use FitMaster and MiniAnalysis to calculate two electrophysiological prosperities. 1) Passive membrane properties: resting membrane potential (Vr), input resistance (Rn), and membrane time constant (tau) were measured. 2) Spontaneous synaptic current (sEPSC and sIPSC) properties: both Frequency and Amplitude of both currents were measured. Results : Summary of Intrinsic membrane properties: Detailed electrophysiological analysis were performed on the medium spiny neurons (MSNs) of the Wild‐Type and the Q175 mouse model. Single action potentials (APs) of the medium spiny neuron, were significantly lower in amplitude in the Q175 in comparison to the WT (p= 0.008). Mean AP firing rates responses in response to increasing depolarizing current steps were significantly higher in the WT than the QI75.

Summary of Spontaneous excitatory events: • Spontaneous excitatory post synaptic events (EPSCs) Representative traces of sEPSCs were analyzed. The mean frequency of events was significantly lower in the Q175 versus the Wild‐Type (p= 0.0002). While the mean amplitude and area didn’t differ significantly. Average wave form show the overall smaller amplitude and faster kinetics of sEPSCs in MSNs. • Spontaneous inhibitory post synaptic events (IPSCs) Representative traces of sIPSCs were analyzed. There was no difference in mean frequency, amplitude, oof sIPSCs between the two groups (p= 0.09, p= 0.27, p= 0.18, respectively). Average wave form show the overall increased amplitude and slower kinetics of sIPSCs in MSNs. Conclusion: The significant decrease in the frequency of sEPSC in MSNs, in addition to what we know from the literature, that D2 expressing MSNs receive the major cortical inputs and changes in them are seen first in HD, could perhaps explain the clinical picture of the disease.

Visual Outcomes and Patient Satisfaction After Bilateral Implantation of a New Trifocal Diffractive Intraocular Lens

Abdulmohsen AlMulhim1, Arwa AlRomaih2, Razan AlDawod2, Khaled AlArfaj3 1‐3 Ophthalmology department, Imam Abdulrahman bin Faisal University, KFHU. 2 Interns, Imam Abdulrahman bin Faisal University, KFHU. Purpose: The aim of this study is to assess the visual outcomes, patient satisfaction and spectacle independence following implantation of a new diffractive trifocal intraocular lenses (IOLs). Setting : Ophthalmology department of 2 centers (university‐based practice and a private practice set up). Methodology : In this prospective non‐randomized study included all patients in whom underwent bilateral implantation of the diffractive trifocal AT LISA TRI 839MP IOLs (Carl Zeiss Meditec, Jena, Germany) and 8 eyes with astigmatism of > 1.25 D for whom AT LISA TRI TORIC 939MP IOLs was implanted. The study was conducted in the period from December 2016 to June 2017. Patients were verbally consented preoperatively. Follow‐up was done at 1 and 3 months postoperative to assess the visual and refractive outcomes., as well as assessing the subjective measures via a questionnaire including patient satisfaction, spectacle independence and photic phenomena after the surgery. The study is adherent to the tenets of the Declaration of Helsinki and it was approved by the local committee of research ethics. Results: Eighty‐two eyes of 41 patients underwent bilateral cataract extraction (N = 32 eyes) and refractive lensectomy (N = 50 eyes) were included. Mean uncorrected monocular distance visual acuity (UDVA) was preoperatively 0.35. Average uncorrected monocular distance/intermediate/near (UDVA/UIVA/UNVA) postoperatively were 0.90/0.87/0.91 at 3 months. 87.5% patients had SE within ± 0.50 by the 3rd month. Nearly all patients were satisfied with the surgical outcome, the reported photic phenomena by some patients were non‐disturbing, with noticeable high level of patient’s satisfaction by the third month. Conclusion: Diffractive trifocal IOLS can provide patients with satisfactory visual and refractive results along with positive impact on the performance of vision‐related daily activities with minimal level of non‐disturbing photic phenomena.

Diabetic Ketoacidosis; Annual Incidence and Precipitating Factors at King Abdulaziz Medical City, Jeddah

Asst. Prof. Hawazen Abdullah Zarif, Shahd Alblowi, Aliya Ragaban, Entisar Aljumail, Shahd Alahmadi King Saud bin Abdulaziz University for Health Sciences King Abdulaziz Medical City Ministry of National Guard‐ Health Affairs Jeddah Introduction: One of the major life‐threatening acute complications of diabetes type 1 (DM1) is Diabetic Ketoacidosis (DKA). It is considered an acute pathological state in which blood levels of glucose and ketone bodies are elevated due to inadequate insulin secretion. Some factors such as infections, insulin noncompliance, and stress increase the risk of developing DKA. Aim & Objectives: Estimation of annual incidence of DKA and exploring its precipitating factors at King Abdulaziz Medical city, Jeddah. Methods : A retrospective chart review was conducted between 2010 until 2016, at KAMC, Jeddah. A total of 350 DM1 patients ranging from 14 to 40 years old that are registered and followed up in both pediatric and adult endocrine clinics as estimated from the medical records department. Data collection sheets were used to collect information. Patients with DM1 that were younger than 14 or older than 40, or have chronic illnesses that requires the administration of corticosteroids were excluded from the study. Data was obtained from the patients’ files and from the electronic medical records. Full confidentiality and privacy was maintained. IRB approval was obtained. Results & Discussion: The annual incidence is 6.2% among the 350 DM1 patients that are registered and followed up at KAMC. Almost 21 cases per year and all of them fully recovered and were discharged in a good condition. In this poorly controlled group of DM1 patients which is demonstrated by the mean of their elevated HbA1c levels(11.95 ±3.11), the major risk factor leading to DKA is non‐compliance to insulin therapy (45%) followed by idiopathic causes(13.5%).As illustrated by other studies, non compliance to insulin is linked to psychosocial factors. The mean age is 22.82 (±5.56) years and the mean duration of having DM1 is 9.89 (±6.47) years. Conclusion / Recommendations : Most of DKA admissions are preventable if patients adhere to their treatment. In addition to Diabetes education and appropriate diabetes care offered for DM1 patient, appropriate psychosocial support to the patients and their families should be offered to encourage compliance to insulin therapy and eventually prevent future DKA episodes.

Association between parameters of body weight, Disordered eating Attitude and Body Image among Saudi Females at Princess Nourah Bint Abdul-Rahman University (PNU)

WD Sendi, Tahani Al Ruwaili, Altaf Almoallem, Sukainah Al- Subaiei, Zainab Al-habeeb, Dana Al-ajlouny Princess Nora Bint Abdul Rahman University Background : The economic transition in Saudi Arabia imposed negative consequences leading to increase in prevalence of obesity and its sequelae. Despite the commitment of high authorities in KSA to combat obesity, yet 25% of Saudis are obese. Several factors have been investigated; however, the association between obesity, disordered eating attitude and body image needs to be addressed. Aim : Explore the relationship between obesity, eating attitude and body image satisfaction among students and employee at PNU and compare between different modalities of assessing body weight. Methods: Cross‐sectional study using a convenient sampling technique comprised of 550 participants. Obesity was assessed by anthropometric measurements and body composition monitor (BF511). Eating Attitude Test (EAT26) was used to determine eating attitude and Body image satisfaction score was determined using Body Shape Questionnaire (BSQ). Results : 382 (69.5%) students and 168 employees participated in the study. Students’ mean age was 20.51±1.97 Vs 33.1± 7.3 for employees. Obesity was significantly higher among employees (48.2%) Vs 27.7% among students (P <0.001). Body fat composition showed significant positive Correlations ranging from weak (0.13) to moderate (0.44) with other body measurements for students and employee. Disordered eating attitude is maximized among obese compared to other BMI groups (F = 5.09, P<0.05). Percentage of disordered eating attitude score correlate positively with BMI: 35.2% Vs 52.3% among underweight and obese respectively (P =0 .001). There was no statistical difference in eating attitude between students and employees. BSQ score correlate positively with BMI (F=42.98, P<0.001), it was 36.73±18.68 versus 57.92±18.50 for underweight and obese respectively. BMI accounts only for 19.1% variability BSQ. Conclusion : Obesity remains a significant health problem among Saudi females. Increased BMI is associated with increased disordered food attitude and the effect of BMI on body image score was minimal.

Perception of healthcare providers regarding the Role of Clinical Pharmacists in Saudi Arabia

Anas A., Najla H. Supervisor: Dr. Kareem Ahmed El-Fass BPharm,PharmD Department of Pharmacy Practice , College of Clinical Pharmacy, Al Ahsa, Kingdom of Saudi Arabia. Background: Clinical pharmacist services should provide pharmaceutical care effectively to assure that the patients received highest level of care. Communication among different healthcare providers by their experience can lead to considerable improvement in patient health. Pharmacist can provide high level of patient care by maximizing the benefits of medication therapy, and prevent medication errors, as well as prevent diseases. Pharmacist is excellent resources for providing most recent updated information about medication, education to physician and other healthcare providers regarding medications. Objective : To examine healthcare providers perceptions and experience regarding clinical pharmacists right rules in Saudi Arabia. Method : Cross‐sectional survey, multicenter questionnaire was distributed within two months in tertiary hospitals by interviewing healthcare providers and receiving questionnaires responds in Saudi Arabia. Results: 111 respondents participated in this study with age (35+/‐ 9). They represented diverse positions in the medical team (18% consultants, 17% specialists, 14% registrars, 23% residents and 24% nurses). Most of the respondents had more than 10 years of experience in medical practice (38%), while 30% had 4‐10 years of experience. Physicians represented fourteen different specialties (17% ICU, 13% Surgery, 13% Pediatrics, and 12.5% Cardiologists) and other specialties including: Hematology, Endocrinology, Internal medicine and Nephrology. 60% of the respondents reported presence of clinical pharmacists in their departments. Results show very good acceptance (more than 80% agreement) of clinical pharmacist’s roles among medical team (cooperation in medication selection 83%, Order and follow up drug levels as needed 85%, participation in clinical research 88% and providing drug information services to the team 93%, and 84% of respondents agree to having clinical pharmacist at their settings. Conclusion : The results of our study have demonstrated high acceptance rate among medical team with its diverse hierarchical positions and diverse specialties to the roles of clinical pharmacists and that they support the presence of clinical pharmacy services in their settings.

Effect of metformin on BP, HR and ECG of rats administered with cardiotoxic agent doxorubicin.

Promise Madu Emeka, Anas Al Ahmed Department of Pharmaceutical Sciences, College of Clinical Pharmacy, King Faisal University, Al Ahsa, Saudi Arabia. Background: The appearance of cardiovascular complications in the use of drugs and in the presence of chronic diseases causes morbidity and mortality. Drugs such as doxorubicin are very well known cardiotoxic agents used in cancer chemotherapy. The observation that metformin improves cardiovascular outcome has been under investigations because of it is indicated to mitigate myocardial infarction. Both drugs are reported to modulate the activities of AMPK. This enzyme is a master switch that controls the cellular energy metabolism. Objective: The aim of this study is to investigate the effect of metformin on BP, HR, and ECG, after administration of doxorubicin in rats. Method: Animals will be divided into 4 experimental groups consisting of group I as the control, group II, will be given metformin, group III, will receive doxorubicin, while group IV will be given metformin plus doxorubicin. The study will run for 4 weeks after initial 2 weeks acclimatization of the animals in the lab. Result : Metformin was able to significantly (p<0.01), attenuate the effects of doxorubicin in all the parameters assessed. BP effects were also affected by Doxorubicin, but the administration of metformin, mitigated this effect on both the systolic and diastolic BP in rats significantly (p<0.01). Conclusion : In all cases, metformin was able to restore both the mechanical functions and normal action potential in our experimental rats. In addition, data further supports the use of cardiac function parameters such as ECG, HR, and BP in the monitoring of cardiac injury during Doxorubicin therapy.

Life of a Medical Student in King Faisal University in Al Ahsaa: Role of Hobbies, Social Life and Stress on Academic Performance

Ameera Al Ramadan, Jawaher Al Rashada, Lujain Al Ahmed, Rawan Buhligah, Roaa Buhligha, Sayed Ibrahim Ali College of Medicine, King Faisal University, Al Hasa, Saudi Arabia Abstract : To assess the relationship between lifestyle prior to and after joining medical school, non‐academic interests and hobbies on the academic performance of medical students. Background : It is well known that medical students are especially vulnerable to academic stress due to the demanding environment of medical schools, which results in reduction of hobbies and social activities. Methods: A cross sectional study was conducted among the medical students of the new curriculum of GMCA 2012 at the College of Medicine, King Faisal University. A questionnaire was distributed voluntarily among 142 medical students belonging to the 1st to the 3rd year of this college. Results: The results of the questionnaire were analyzed in detail. It was found that the majority of the students were undertaking less hobbies than they used to do prior to joining the college of medicine. Also, as the students progressed in studying years, the time spent on extracurricular activities and interests became progressively less. Female students were found to be less interested in doing their hobbies than males However, Chi square test revealed that there is no significant relationship between spending time on hobbies in medical school and academic performance. Conclusion: Joining medical school was noted to lead to a major change in lifestyle of the students with sacrifice of hobbies, and recreational activities, especially more among females and those in the higher years. However, the study showed that continuing extracurricular activities has no adverse impact on the grades in medical school. In fact, it is thought that it could act as a stress relaxant and a concentration booster, helping in improved grades and superior academic performance.

Acceptance of Cosmetic Surgery among Females in Princess Nourah Bent Abdulrahman University

Khairiah A. Alsumali – Rawan A. Al shammari – Sahar M. Al shammery – Wafa Al saab – Bashayer Al Zayed – Nourah Al-Rashed – Norah Al shehri – Suhad Al Nasser Princess Nora University Riyadh, Saudi Arabia Introduction: After being almost restricted to celebrities and the wealthy members of society decades ago, cosmetics nowadays have reached their peak and became a very popular trend among all classes and age groups, especially the youth. Saudi Arabia was ranked 23rd with a total number of 96,667 surgical and non‐surgical procedures, among 25 countries with the highest rates of Cosmetic procedures worldwide. The present study purpose was to ascertain the factors that influence or motivate patients to accept cosmetic surgery. Objectives: This study was conducted to identify the factors influencing acceptance of cosmetic procedures rather than studying the acceptance rates only with respect to " sociodemographic state, self‐esteem and religious considerations" among students in Princess Nourah University, Riyadh. Methodology : Cross‐sectional study of a convenient sample encompassed 500 students in all colleges at Princess Nourah Bent Abdul‐Rahman University (82.6% from non‐health collages and 17.4% from health collages ). It was conducted between 1st of September 2014 and 5th of June 2015. Self‐administrated questionnaire was distributed to all participants. Data collected included; socio‐demographic data, validated cosmetic surgery acceptance scale, Self‐esteem assessment scale and religious beliefs of plastic surgeries. Result : The mean age of the overall participants was 20.9±1.9 years. Students who were divorced/widow significantly scored higher acceptance scores when compared to other students (44.7 versus 24.0, p=0.04). Students who reported having minor or major cosmetic procedures, themselves or their relatives, had shown higher acceptance scores when compared to those who did not have similar history. In contrast to that, students who believed that cosmetic surgeries are prohibited by Islam, scored lower acceptance score (23.6±13.8) when compared to those who disagreed (27.8±15.2). Negative correlation was confirmed between self‐esteem and acceptance of cosmetic procedures.

Discussion: The data from this study were analyzed by marital status, which revealed that Females who were divorced or widows had significantly more acceptance rate to undergo cosmetic procedures. This was supported by Salehahmadi et al who have done a similar study. Furthermore, it studied the impact of religious beliefs, which showed that students who believed that cosmetic surgeries are prohibited by Islam or reported that they will ask for “Fatwa” before deciding to have a cosmetic surgery scored the lowest acceptance rate. This is supported by a review done in 2008 by Atiyeh et al stated that the rule in Islam is that individuals should be satisfied with the way Allah has created them. A negative correlation was confirmed between acceptance of cosmetic surgeries and self‐esteem scores. This confirms the finding brought by Thornton et al which indicated that women's negative emotional feelings about their body image were more strongly accepting of cosmetic surgery to help improve their appearance and functioning. Conclusion : These finding clearly suggests that the level of acceptance of plastic surgeries among female university students is vastly affected by their marital status and their perceived self‐esteem. Relatives and friends own experience of plastic procedures intensively encourage the female students to decide for themselves. Religious beliefs are crucial in taking the decision to undergo plastic surgery.

Validation of New D-Dimer Cutoff Values to Increase its Diagnostic Utility as Biochemical Marker in Acute Venous Thromboembolic Disease Dalal Nemenqani, Manal H, Soha Ahmad, A., Hala Elnashar, Haneen Asaad Hammadi College of Medicine, Taif University Background and aim of the work: Diagnosis of venous thromboembolic disease (deep venous thrombosis and pulmonary embolism) is usually difficult as the presenting signs and symptoms are nonspecific. Numerous clinical trials have shown that D‐dimer which is a coagulation marker has a sufficient specificity to assist in the diagnosis of the disease. The purpose of this study was to validate the utility of D‐dimer as a diagnostic biomarker for DVT using a higher cutoff values which may improve the test specificity. Subjects and methods: It was a retrospective chart review study performed in King Abdul Aziz Specialist Hospital, Al Taif ‐ Saudi Arabia. The files of all subjects who underwent D‐ dimer assay in the hospital from January 2011 to October 2013 were reviewed. The study involved 141 individuals; 25 who were proved to be normal were chosen to serve as control group (Group I), 61 patients who were positive for DVT by duplex scanning (Group II) and 55 patients who had symptoms of DVT but showed negative results on duplex ultrasound (group III). Results: The demographic, clinical, and hematological data revealed statistically insignificant difference between all studied groups except for Hb level which was significantly higher in control group. However, highly significant differences were detected between different studied groups as regards D‐dimer. Analysis of the receiver operator characteristic curve to establish the cut‐off level of the studied marker in the diagnosis of DVT, verified that D‐dimer value of 0.92 mg/L can accurately differentiate patients who were positive for DVT on duplex scanning from control group. Level of 2.81 mg/L for D‐dimer was considered as a cut‐off point that can differentiate patients who were duplex negative and free from thrombosis from the start from those who eventually developed thrombosis. Conclusion: This study suggests the importance of using modified D‐dimer cut‐off points for safe differentiation between patients who are free from venous thromboembolic disease from others who are positive for the disease sparing patients the unnecessary risks of anticoagulation. In addition it can detect the patients who will eventually develop thrombosis regardless their primary duplex ultrasound scanning results, so, they could receive anticoagulation treatment.

Effects of HCN blocker, ZD7288, on pain hypersensitivity in a rat model of diabetic neuropathic pain

Alessa A , Alkhamis A, Alturki H , Alwesaibie A King Faisal University, Kingdom of Saudi Arabia Introduction: Diabetes is a chronic metabolic disorder that affects millions of people world‐wide. It can have negative impact on many systems including the nervous system. Indeed chronic peripheral nerve pain, also known as peripheral neuropathic pain (NP), is one of the most common complications of diabetes. Previous studies using different animal models of chronic pain have shown that pain hypersensitivity in such models is caused, at least partially, by increased excitability of primary afferent dorsal root ganglion (DRG) neurons that send the sensory information from the periphery to the brain. However the mechanism of this hyperexcitability is not known. Objectives : Test the hypothesis that Hyperpolarization‐activated Cyclic Nucleotide gated (HCN) channels (that are known to regulate neuronal excitability) are involved in the pathophysiology of diabetic neuropathic pain (DNP). Materials & Methods: To examine this hypothesis, we used a rat model of diabetic neuropathy (which involved an injection of 60 mg/kg, i.p., of streptozotocin (STZ), a toxin of pancreatic β‐cells that release insulin), and tested the effects of blocking the HCN channels with a selective blocker, ZD7288, on two pain behaviours (mechanical hypersensitivity/allodynia, and heat hypersensitivity/hyperalgesia) in these STZ treated rats. Results : We found that intraplantar administration of ZD7288 (100 μM) reduced mechanical allodynia but not heat hyperalgesia. Conclusions: These results are in agreement with previous studies that used other models of chronic pain, and suggest that HCN channels may be a good target for developing new analgesics (painkillers) for chronic pain.

Guillain-Barre Syndrome: Tertiary Center Experience in Saudi Arabia

Roula Alhdyan, Ahmad Abulaban, Abdullah Alzahrani , Budoor Alsalman , Muhannad Alsharidah, Ali Alshehri MCST Introduction : Guillain‐Barre´ syndrome (GBS) is an acute onset, immune‐mediated disorder of the peripheral nervous system. The underlying etiology and pathophysiology of GBS is still not fully understood. However, It’s classified into three subtypes and seven rare variants. The diagnosis relies mainly on criteria supported by clinical and laboratory features. Methods: This retrospective chart review was to find and clarify the clinical profile of GBS patients in the last 10 years. After reviewing the chart of 174 patients, only 66 fulfilled our criteria. The data collected as non‐probability consecutive sampling technique. This study was recruited from neurology department at NGH. All statistical analysis were done by using SPSS. Discussion : In our study the male to female ratio was 2:1 which is similar to literature data of 1.7:1 ratio. The most common GBS variants among the patients were AIDP 39.4% and AMAN 36.4%.in similar study AIDP present in 85.2% of patient while AMAN present in 10.6%. AIDP was the most common variant among male patients and AMAN was the commonest variant among female patients, which is statistically significant (pvalue= 0.037). 39.4% of patients were admitted to ICU. However, in Dahbour study most of the patients 80% were admitted to ICU. Most of our patients 87.9% were treated with IVIG, while only 7.9% with therapeutic plasma exchange (TPE), and 3% with both. Literature data showed 53% were treated with IVIG, 22% with TPE and 3% with both respectively. Around half of the patients 48% recover completely. In Dahour study, most of patients 75% had full clinical recovery. Results : There were 44(66.7%) male and 22(33.3%) female with mean age of 37±24.9. The study showed that acute inflammatory demyelinating polyradiculoneuropathy (AIDP) was the most common GBS variants among the patients, which represent 39.4% . AIDP was the most common variant among male patients. On the other hand, (AMAN) Acute Motor Axonal Neuropathy was the commonest variant among female patients. Lower limb weakness was the most common presenting symptoms which represent 89.4% among all GBS patients. 39.4% of patients have upper respiratory tract infection preceding the symptoms of GBS. The hypertension was the most frequent comorbidity among GBS patients, which constitute 27.3%. Percentage of patients who have been admitted into ICU were 39.4%. one patient (1.5%) died because of cardiac arrest.

Conclusions: AMAN was seen more in female patients as compared to male. Also, in this study we observed that AMAN is more common in our center as compared to north America and other regional studies.

Treatment Efforts And Survival Benefits In Pediatric Patients With Atypical Teratoid Rhabdoid Tumors (ATRT) At King Faisal Specialist Hospital And Research Centre, Riyadh, Saudi Arabia

Al-Kofide Amani, Elshail Essam, Siddiqui Khawar, Hassonah Maher, Mary Grace Barria, AlFawaz Ibrahim, Ali Afshan, Ayas Mouhab, Anawar Haq, Khafagh Yasser, Mousa Amr, Mesheal Fouda, Hassan Dababo, Hind AlHinde King Faisal Specialist Hospital and Research Centre (KFSHRC) Introduction: Atypical Teratoid/Rhabdoid Tumor (ATRT) is a rare embryonal tumor of the central nervous system with preponderance in very young children, the majority of whom are younger than 3 years of age at diagnosis [1]. Because ATRT is a rare disease of infancy carrying a grim prognosis, focus on long‐term outcome, especially neurocognitive remained very limited. With new era of multimodality therapy, an increasing proportion of patients are now long‐term survivors [2]. Historically, outcomes of this aggressive disease, even with extensive multimodal therapy, have been dismal. Recent improvements have come from therapies directed exclusively towards ATRT, but misdiagnosis or delays in the correct diagnosis lead to significantly worse survival rates. ATRTs most commonly occur supratentorially but have been described in virtually all central nervous system locations, including the cerebellopontine angle cistern, meninges, and spinal canal, and extradural locations [1]. Several large series have reported achieving gross‐total resection (GTR) in less than 50% of patients due to the lesions' large size, vascularity, and limited blood volume in young patients. While neoadjuvant chemotherapy for choroid plexus carcinomas in pediatric patients has become widely accepted, it has not been used as widely for other pediatric brain tumors [3]. Aims : Because atypical teratoid rhabdoid tumor(ATRT) is a rare disease of infancy carrying a grim prognosis [2], focus on long‐term outcome, especially neurocognitive remained very limited. With new era of multimodality therapy, an increasing proportion of patients are now long‐term survivors. The purpose of this research was to evaluate the efficacy of multimodal therapy in children with ATRT. Materials and Methods: Design: Medical charts of pediatric patients diagnosed with ATRT between 1993‐ 2013 at King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia, were reviewed and their treatment profile and outcome data were analyzed.

Sample size: 43 Pediatric patients diagnosed with ATRT, age at diagnosis <= 14 years. Inclusion criteria: Children aged 1–14 years treated at King Fahad National Centre for Children's Cancer, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia, with confirmed diagnosis of ATRT. Exclusion criteria: Contrary to the above. The Patients : Forty three cases were evaluated. Median age at diagnosis among males (n=23, 53.5%) was 1.8 years (0.03‐20.7) compared to 2.1 years (0.17‐20.1) among females (n=20, 46.5%). All patients underwent surgery: 6 had biopsy only; 23 subtotal resection (STR), and 14 gross total resection (GTR). VP‐shunt was inserted in 9 patients prior to surgery and in 17 after surgery. Integrase Interactor 1 (INI 1) was absent in all but one patient. Disease was localized in 65.1% (28) and disseminated in 34.9% (15). Results: Rhabdomyosarcoma‐ based chemotherapy was given to 30 (68.9%) patients. Nineteen patients received radical dose of radiation therapy. Eight patients received focal irradiation while 11 had whole craniospinal axis irradiation followed by localized boost to primary lesion. Patients who were treated with focal radiation only, had no clinical, radiological or cytological evidence of spinal seeding. The total radiation dose for localized field ranged from 50‐50.4 Gy in 28‐32 fractions, while the craniospinal axis radiation dose ranged from 30.6 Gy to 36 Gy delivered in 17‐20 fractions. At the last follow‐up, 22(51.2%) of our patients were alive; 2(9.1%) in CR, 5(22.7%) with SD and the remaining 15(68.2%) had disease progression (PD). With a median follow‐up of 25.1 months, the probability of five year overall survival was 31%, having a median survival time of 19 months (95% CI: 5.6‐ 32.4). Conclusions: ATRT outcome remains unsatisfactory despite multimodality treatment.

Single Port Video-Assisted Thoracoscopic Surgery for Diagnosis of Intrathoracic Lesions

Haneen Asaad Hammadi, Dr Mjed Al Mourgi College of Medicine, Taif University Background and aim of the work: The use of uniportal VATS is becoming accepted worldwide for diagnosis and treatment of minor and major thoracic and mediastinal pathologies with promising results. VATS has been proved by many investigators to be feasible and associated with less postoperative morbidity and fast recovery. In this retrospective chart review study we will present our experience in diagnostic VATS at King Abdul Aziz Specialist Hospital, Taif Saudi Arabia. Research methodology : This is a retrospective chart review study involved 162 patients who performed single port diagnostic VATS in King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia from January 2013 to November 2015. After approval of ethical committee of the hospital and taking informed consents from patients or their relatives, data were collected by revising the patient files focusing on demographic factors, pattern of presentation, imaging reports, operative findings, histopathology and bacteriological culture results . Data were gathered and analyzed and with exclusion of incomplete reports. Also cases with lesions invading the chest wall and those requiring rib spreading were excluded from the study. Main results: The 162 patients were 112 males (68.2%) and 50 females with mean age of 37.4±9.3 years. Mean operative time was 27.5±6.6 minutes. The most common morbidity was intraoperative bleeding which occurred in 22 cases (13.6%) and it was controlled, failure of VATS occurs in 4 cases (2.47%) due to massive adhesions where minithoracotomy was done, reinsertion of intercostal tube was required in 18 cases (11.1%). The mean duration to remove the intercostal tube was 4.3±1.1 days. The mean hospital stay was 5.7±1.4 days. No operative or early postoperative mortality was recorded. Conclusion and recommendations: Uniportal VATS is a safe and effective method for diagnosis of intrathoracic lesions and allows resection of small localized lesions and has a limited operative time which is improving with progress in the learning curve.

Improving the Viability of Pseudo-islet for Efficient Insulin Production

Khalid Alwusaidi, Mohammed Almasri, Ali Howaidi, Prof. Ying Yang, Ajile Elttayef Imam Mohammed bin Saud Islamic University Guy Hilton Research Center, Institution of Science and Technology in Medicine, Keele University. Introduction: The Incidence of type 1 diabetes mellitus (T1DM) has been increasing lately and many new therapies are being studied to find the effective treatment. A novel solution for this disease is the formation of Pseudo‐Islet (PI) cells, which are beta cells aggregations that mimic the function of normal human beta cells. However, oxygen and nutrients supply to the centre of these cells’ aggregation is insufficient, leading to central necrosis which prevent the therapeutic future. Objectives : The primary aim of the study is to overcome the central necrosis of PIs by incorporation it with gelatin beads (GBs). Which, characterized to be friendly to the cell environment, high diffusion rate and its ability to be a drug carriers e.g. Anti‐ inflammatory agents. Furthermore, measure the drug releasing profile using fluorescence technique. Lastly, Assist the cell viability in response to the anti‐ inflammatory agents. Methodology : The rat pancreatic β cell (BRIN‐BD11 cells) were grown in RPMI 1640 media and were maintained in the incubator at 37⁰C. Before incorporation of GBs into the PIs, the size, shape and the cross‐linkage time of GBs were controlled to increase the diffusion rate and avoid the dissolution of the beads in the water‐medium. The central area was then replaced with 30μm GBs injected with different concentrations of anti‐ inflammatory agent (IL‐10). Florescence test was conducted to ensure the capability of GBs to release the agents and CCK‐8 was used to assess the viability of the cells. Results: Increased in viability was seen in the 30μm GBs after cross‐linking for six hours. After adding different concentrations of IL‐10 into the PIs with GBs 30�� m, it reveals that 10 ng/ml concentration of IL‐10 in the PIs obtain the best response after 8 days of injection. Conclusion : Introducing GBs injected with Anti‐Inflammatory agent to PI cells can improve the viability and eventually decrease necrosis of these PIs when taking the concentrations of the Anti‐inflammatory agents in consideration. Many results regarding increasing the viability of PIs contributes in the possible strategies for developing a therapeutic application for T1DM.

Complementary Medicine Practice and Perception Among Attendees of Primary Care Centers in Eastern Saudi Arabia

AbdulHameed R, Taha A, MD, AlShehry S, MD, Almusalmi A, Almulaify M, Alkhabbaz F Background : Complementary medicine refers to the use of medical practices together with conventional medicine,Nearly half the population in many developed countries regularly use some form of CAM. A study conducted in Riyadh, Saudi Arabia, showed that 85% of people had used CAM. Through this research we aimed to examine the extent and frequency of usage of various forms of complementary medicine and its reasons, among the Saudi population of Eastern Province. Specific forms of CAM included in this study were: herbal medicine,(regular and chinese), dry and wet hijama, Quran, zamzam water, etc. Objectives : The specific objectives of this study were to determine the use of different CAM modalities among attendees of primary health care centers (PHCCs) in Dammam and Al‐Khobar cities, eastern Saudi Arabia and to assess the attendees’ attitudes towards CAM. Methods : A cross‐sectional study was conducted at primary health care centers (PHCCs) in Dammam and AlKhobar cities, eastern region. Data was collected using a self‐administered questionnaire designed by the investigators in Arabic language after reviewing the literature on CAM use. The study population was attendees of PHCCs, both patients and their relatives, ages from 18 years and above. The total number of attendees interviewed was 2114. Conclusion: The use of CAM is common among the participants of this study. Users of CAM in the last 12 months represent 52.5% of the participants. Different types of CAM have different popularity of use which can be attributed to many religious and cultural reasons with the majority using honey and Quran. Recommendations from relatives and friends were reported as the most common reason for using CAM in this sample.

Association between race/ethnicity and wait time in adult patients presenting to an emergency department in emergent vs urgent presentations: A secondary analysis

Charu Madhwani, Kunal Parmar, Moeen Aboabdo, Grettel Castro, MPH, Pura Rodriguez de la Vega, MPH, Juan Ruiz Pelaez, M.D., MMedSci., Juan Zevallos M.D., Marcia Varella M.D., PhD. Introduction : Evidence suggests that increasing wait times in the ED leads to detrimental health outcomes. Specific race/ethnic groups were shown to have varying wait times which could lead to health disparities. Aim: to determine whether there is an association between race/ethnicity and wait time on the bases of emergent and urgent presentation in ED. Methods: We performed analysis of adult participants of the 2013 National Hospital Ambulatory Medical Care Survey (NHAMCS) who arrived at the ED presenting with emergent (shortness of breath/chest pain) or urgent (abdominal pain/ back pain) symptoms. Associations were assessed using logistic regression models. Stratification by emergent and urgent symptoms of presentation was performed to examine potential effect modification. Results : We studied 2836 patients, of which 61% were Non‐Hispanic whites, 23% were non‐Hispanic blacks, 13% were Hispanics and 3% were other races. Fifty‐three percent of non‐Hispanic blacks waited for >30 minutes compared to 39% of non‐ Hispanic whites. In the stratified adjusted analysis, among participants with emergent symptoms, non‐Hispanic blacks had significantly higher odds of waiting > 30 minutes as compared to non‐Hispanic whites [OR=1.8, 95%CI=1.04‐3.30]. No differences were found for the other race categories. In the group presenting with urgent symptoms, the odds of waiting > 30 minutes in Hispanics was significantly lower [OR=0.6, 95%CI=0.4‐0.9] than those among Non‐ Hispanic whites. Other categories showed no significant differences. Conclusion : Our findings suggest that, as compared to non‐Hispanic whites, non‐ Hispanic blacks are more likely to have longer waiting times when presenting with emergent symptoms at ED across the US.

Tyrosine Kinase Domain Mutations of EGFR Gene in Head and Neck Squamous Cell Carcinoma

Saleh Tawfeeq Alshreadah Background: Epidermal Growth Factor Receptor (EGFR) is a commonly altered gene identified in various cancers, including Head and Neck Squamous cell carcinoma (HNSCC). Therefore, EGFR is a promising molecular marker targeted by monoclonal antibodies and small molecule inhibitors targeting the Tyrosine Kinase (TK) domain. Objective: To investigate the spectrum of mutations in exon 18, 19, 20 and 21 of the EGFR gene in HNSCC patients. Methods : This retrospective study included 47 confirmed HNSCC cases. The mutations in the TK domain, exon 18, 19, 20 and 21 of the EGFR gene, were detected by Scorpion® chemistry and ARMS® technologies on Rotor‐Gene Real‐time PCR. Results: The tumors exhibited EGFR‐TK domain mutations in 57% of cases. Four cases of T790M mutations were reported for the first time among HNSCC patients. Out of the total mutations, L861Q (exon 21), exon 20 insertions and deletions of exon 19 accounted for the majority of the mutations (21%, 19% and 17% respectively). EGFR mutation status was correlated with the higher grade (p=0.026) and advanced stage (p=0.034) of HNSCC tumors. Conclusion : The higher frequency of EGFR‐TK domain mutations together with the presence of the T790M mutation suggests that identification of these mutations might streamline the therapy and provide a better prognosis in HNSCC cases.

Case Report Abstracts

Dramatic improvement of infant with Infantile Hepatic Hemangioendothelioma After Propranolol Therapy : A Case Report

Abdulmalik A. Suhail, Lama I. Aloraini King Fahad University Hospital Imam Abdulrahman Bin Faisal University Background: Infantile hepatic hemangioendothelioma is the most common hepatic vascular tumor in infants less than 6 months of age which is benign. Its clinical course vary depends on many factors like size, location and complications. Clinical manifestations are palpable diffuse abdominal mass, hepatomegaly, cutaneous hemangiomas and heart failure symptoms like failure to thrive, poor feeding and respiratory distress. Also can present with hypothyroidism symptoms like lethargy and weight gain. It may lead to sever complications like congestive heart failure & liver failure which may end up with liver transplantation Objective : To understand and report the dramatic effect of propranolol therapy which lead to complete improvement and remission of infantile hepatic hemangioendothelioma Method: This is a case report of a patient who had a hepatic tumor which had been evaluated thought a year with multiple admissions. A routine abdominal examination was done, full history with physical examination were done to rule out other causes of the tumor. Case (results) : A 2 months old Somalian female infant presented to emergency room at King Fahad university Hospital in Khobar complaining of acute generalized abdominal distension & discomfort, poor feeding, lethargy for 10 days duration. She’s medically free of any chronic diseases or systemic diseases, or family history or any medications have been used, by examination liver span was 15 cm not tender palpable also cutaneous lesions were found like left post auricular hemangioma & left arm hemangioma Conclusion : We conclude that propranolol is potentially beneficial and highly recommended in case of infantile hepatic hemangioendothelioma.

Recurrent Extensive Plunging Ranula: A Case report

Manahel Almulhem Imam Abdulrahman Bin Faisal University A Ranula is a mucus retention cyst that extends to the sublingual or submandibular space. It occurs as a result of sublingual gland duct obstruction. With time, further secretions accumulate in the sublingual space that leads to an extension along that space anteriorly and posteriorly. In case of posterior extension that reaches beyond mylohyoid muscle, it is considered as Plunging Ranula. A cystic mass in the lateral side of the neck with or without history of intraoral lesion is the usual presentation. The exact prevalence of Plunging Ranula is not yet identified. However, it has been reported to be more in the third decade with male predominance. We discuss a rare case of an extensive Plunging Ranula that reaches the parapharyngeal space in a 17 years old Saudi female. History from the patient revealed that she had recurrent swelling in right side of floor of the mouth in the last 6 months that continuously changes in size. On examination, a right neck swelling with the size of 5*4*7 cm was found. CT scan shows right extensive cystic lesion reaching para‐pharyngeal space, right floor of the mouth, right submandibular and right sublingual spaces. The cystic lesion is anterior to sternocleidomastoid muscle with no evidence of septation or enchantment. The swelling was treated with repeated evacuation. After that, she underwent right cystic and submandibular gland excision. In this occasion – two months after the surgery, the cystic lesion recurred in right sublingual and submandibular space. Patient has complete resolution after last operation with no recurrence till date. Ranula excision through cervical incision approach along with excision of right sublingual gland and floor of the mouth cyst were done this time. In the case of Plunging Ranula, the diagnosis is very challenging especially in the case of absence of oral lesion. As a result, comprehensive history, clinical presentation and radiological findings together are the main diagnostic tools. Several modalities of treatment can be used. However, sublingual gland and Ranula excision has very low recurrence rate. Concluding that this modality is one of the best modalities.

Stroke in young patient with aortic valve fibroelastoma- A case report

Feras Ahmed Al-Kuwaiti, Dr. Yasser Farag Elghonaimy, Dr. Sami Nemr Ghazal Imam Abdulrahman Bin Faisal University King Fahad Hospital of the University Cardiac papillary fibroelastoma (CPF) is a benign and rare form of primary intracardiac tumors. Such tumors are associated with substantial complications especially cerebral embolism. Our case is a 40 years old male had a sudden onset of aphasia, left ataxia and imbalanced gait. He is a known case of sickle cell disease and had a stroke by 11 years ago. The patient was alert and oriented. Magnetic resonance imaging (MRI) of brain revealed a multifocal area of diffusion restriction within the right cerebral peduncle, superior cerebellar peduncle and both cerebellar hemisphere and an acute ischemic stroke was confirmed. Furthermore, transesophageal echocardiography (TEE) confirmed the presence of aortic valve fibroelastoma and patent foramen ovale (PFO). Excision of identified mass in aortic valve and direct ASD closure was performed to prevent the further formation of emboli. The patient’s postoperative course was smooth and administered with necessary medications. Specifically, our case presented with papillary fibroelastoma of the aortic valve, which is a rare cause of embolic stroke and also PFO. To date, only 7 cases of papillary fibroelastoma associated with congenital heart disease have been reported, and specifically, 5 of the cases had an ASD. This case report serves as a reminder that this kind of fibroelastoma and PFO have to be focused during the detection and management of emboli stroke.

Pericardial Aspergillosis- unusual presentation of infective endocarditis patient: A case report

Dr Yasser El Ghoneimy, Feras Ahmed Alkuwaiti Imam Abdulrahman Bin Faisal University King Fahad Hospital of the University Background : Aspergillosis is a rare fungal infection which affects the heart and pericardium either due to disseminated fungemia or invasive aspergillosis in immunocompromised patients. The risk factors for Aspergillus infection include prolonged use of antibiotics, immunosuppressive agents, and parenteral nutrition [1]. Here, we report a case of pericardial aspergillosis with infective endocarditis, and splenic infarction. Case Summary : A 36‐year‐old female was recently diagnosed with bacterial infective endocarditis, and she was referred to the Cardiac Surgery Unit for further evaluation. She presented with a severe abdominal pain with recent exacerbation. She also experienced orthopnea, exertional dyspnea, paroxysmal nocturnal dyspnea, cough, and fatigue. Her past medical history includes rheumatic heart disease, antiphospholipid syndrome with multiple miscarriages, transient ischemic attacks, and deep venous thrombosis. In treatment history, she was under medications such as rivaroxaban and prednisolone for a longer period. On physical examination, her blood pressure was normal but she had tachycardia and tachypnea. She also had decreased oxygen saturation (88%) and bilateral course crepitation in her chest. The heart sounds were s1+s2 with a pan‐systolic murmur at the apex. There were no stigmata of infective endocarditis. A computed tomography (CT) scan of abdomen and chest, which was performed to further define the cause of her abdominal pain, revealed a splenic abscess. An echocardiogram showed an incidence of infective endocarditis with valvular affect. A mitral regurge with a mass attached to the tips of Anterior Mitral Leaflets, likely vegetation, and pericardial effusion was observed. An aortic regurge with large mass attached to the ventricular aspect of posterior cusp. Based on the results of various examinations, her condition was diagnosed as infective endocarditis complicated with splenic infarction. The patient was prepared for emergent splenectomy and double valve replacement with tissue valve. During her double valve surgery, we found a tissue in the pericardium fortuitously. Samples was taken for bacterial and fungal culture, and the result was positive for Aspergillus. Conclusion : In such case, fungal culture for the valve vegetation and the blood are needed to detect the source. Hence, pericardial aspergillosis is a rare disease. Because of the rarity, we have a limited information on clinical features. A high degree of clinical suspicion is required for early detection and diagnosis, because it has nonspecific clinical manifestations. Once diagnosed, an aggressive antifungal treatment is needed.

Phlegmasia Cerulea Dolens as a complication of improperly managed deep vein thrombosis in May Thurner syndrome: case report

Abdullah ALQattan, Noora ALAyyaf Imam Abdurrahman Bin Faisal University King Fahad Hospital of the University Background: Phlegmasia Dolens is an extremely rare limb & life threatening disorder caused by a massive deep venous thrombosis that is associated with venous congestion & compartment syndrome. Several treatment options have been suggested to reduce the rate of morbidity & mortality but due to the rarity of this condition, a gold standard treatment plan is still controversial. Case summary: We present a case of a 56 years old male diabetic with a history of a long travel 2 days prior to presentation, who was otherwise medically free with no history of trauma or recent surgery or previous history of coagulopathy. He presented to another hospital complaining of left leg swelling, pain & shortness of breath of 2 days duration where he was diagnosed as a case of extensive femoral deep vein thrombosis & pulmonary embolism. He was admitted in their ICU & kept on systemic thrombolysis & heparin. 2 days after his admission he started to develop cyanosis of the affected limb, severe edema and blistering extending up to the scrotum with signs & symptoms of compartment syndrome & subsequent foot drop where he was referred to our facility with as a picture of complicated DVT. A venogram & CT angiogram showed an extensive venous thrombosis of the left femoral vein extending to the left common iliac vein up to the inferior vena cava (confirming the diagnosis of Phlegmasia Cerulea Dolens), presence of May Turner syndrome , filling defect in right inferior pulmonary artery , conforming the diagnosis of Phlegmasia Cerulea Dolens & pulmonary embolism. we decided to adopt a limb preserving approach by using a catheter directed pharmacological thrombolysis & mechanical thrombolysis & fasciotomy. The patient recovered fully and a complete resolution of his foot drop. Conclusion : Our case shows that despite the late presentation of such a rare condition there still a role for a limb preserving approach.

Challenges in management of Adenocarcinoma of Ampulla of Vater in pregnancy: a Case report & review of literature

Abdullah ALQattan1,Mohammed AL-Qahtani2,Feras Alkuwaiti3,Elham Alghusnah4 1‐3‐4Medical student, Imam Abdurrahman Bin Faisal University. 2Consultant, Department of General surgery, KFSH‐D. Background: Ampullary adenocarcinoma is a malignant tumor and accounts for 0.2% of tumors of the gastrointestinal tract and 6% of periampullary tumors. These tumors are rare during pregnancy and only few cases have been reported in literature. The only treatment modality for resectable tumor with best outcome is surgical resection. Case summary : A 22 years old pregnant lady, complained of abdominal pain and jaundice at 28 weeks of gestation. Ultrasound revealed ampullary lesion with dilated intra‐hepatic biliary system. ERCP revealed stricture around the ampulla and distal CBD. CBD was stented and biopsy was taken .The patient was transferred to our facility as case of ampullary adenocarcinoma with pregnancy for further management .On admission Gynecological examination confirmed single 28 weeks intrauterine pregnancy with appropriate growth for dates. No familial cancer history. Laboratory investigation showed normal tumor markers and picture obstructive jaundice on her liver function test. MRCP showed dilated CBD with mildly prominent intra hepatic biliary tree. Gallbladder and pancreatic duct were grossly unremarkable. The opinion ob/gyn was sought and they planned to induce labour after 3 weeks for fetal well‐being and survival. On the 4th day postpartum they were discharge. A week after that she had an elective pylorus preserving pancreaticoduodenectomy. The patient underwent a laparotomy there was a palpable mass at region of ampulla. There was no evidence of local vascular invasion or metastasis. Patient postoperative course was unremarkable and discharged 1 week after surgery. Histopathology revealed invasive adenocarcinoma of ampulla of vater moderate to poorly differentiated. All resection margins were free of malignancy. Three out of thirteen lymph nodes revealed metastatic carcinoma. She was referred to medical oncology and received adjuvant chemotherapy. After 1 year of follow up CT and PET was normal. Conclusions: Safe management of ampullary adenocarcinoma in a pregnant patient presenting in her last trimesters to conduct early viable delivery followed by definitive surgery in the form of pancreaticoduodenectomy.

Laparoscopic biliopancreatic diversion for a morbidly obese patient with situs inversus totals Abdullah ALQattan1, Muntadar Alalqam2 , Khalid Merza3, Hassan Albusaleh4 1 Senior medical student, Imam Abdurrahman Bin Faisal University, KFUH. 2 Senior medical student, Imam Abdurrahman Bin Faisal University, KFUH. . 3 Department of General surgery, Imam Abdurrahman Bin Faisal University, KFUH. 4 Department of General surgery, KFSH‐D.

Background: In the modern era obesity is becoming an epidemic in most areas of the world (in the developed countries). Hence, many pharmacological & surgical approaches to treat obesity & the metabolic diseases associated with it have been devolved over the recent years. Bariatric surgery has been shown to be the most effective treatment of the morbid obesity. Adopting a laparoscopic approach in these types of surgeries is a technically demanding procedure. Nevertheless, any deviation from the normal anatomy in those patients as the case in patients with Situs inversus totalis which is a rare genetic condition where the thoracic and abdominal anatomy is a mirror image to the normal anatomy which poses even a greater challenge intra operatively . Case summary: We present the intra‐operative challenges of a case of a 39 years old obese female with a BMI of 50 kg/m2, a known case of situs inverses totals. Who underwent a successful laparoscopic biliopancreatic diversion, cholecystectomy, & appendectomy. Conclusion: An advanced laparoscopic surgery as biliopancreatic diversion in patients with situs inversus totals is feasible and can be performed safely if it is done by an experienced surgeon.

All guns blazing: Management and survival of massive valproic acid overdose. Case report and literature review

Shaikhah Al Jawder 1, Eiman AlJishi 2, Shaikhah Al-Otaibi3, Mohammed S. Al- Shahrani4 1. King Hamad Hospital of the University. Bahrain 2. King. Fahad Hospital of the University 3. King. Fahad Hospital of the University 4. King Fahad Hospital of the University Imam Abdulrahman Ben Faisal University

A 51‐year‐old‐woman, who intentionally ingested a massive dose of approximately 60 grams of valproic acid which she was using as a mood stabilizer for bipolar affective disorder, presented within 30 minutes of ingestion to the emergency department (ED). The patient was asymptomatic, and was immediately started on decontamination therapy with activated charcoal. Drug serum levels, liver functions, and ammonia levels were tested and followed up on during treatment. Due to the massive ingestion and continuous rise in serum drug levels, the patient received regular multiple doses of activated charcoal, as well as L‐carnitine for liver protection. The patient was started on extra‐corporeal therapy in the form of renal replacement therapy in the intensive care unit, followed by intermittent hemodialysis. Drug serum levels significantly dropped. Ammonia levels showed improvement with treatment. The patient was discharged from the intensive care unit after 14 days of treatment. She was stable and in good condition with no residual hepatic or CNS manifestations.

Sequestration Crisis in a Sickle Cell Disease patient Complicated by Splenic Abscess and Gastro-splenic Fistula formation

Fozia K. Alsugair, Ali S. Al Sinan, Moslem Alelq, Saeed Alshomimi. Imam Abdulrahman Bin Faisal University King Fahad Hospital of the University Introduction: Sickle cell disease is a common disorder in the eastern region of Saudi Arabia. Splenic abscess is not a very common presentation of this disease, fistula tract formation to adjacent structures could be formed as a com‐plication of the cases especially with delayed management. Case History : A 15‐years‐old boy who presented suddenly with left side abdominal pain and symptoms of acute anemia admitted to ICU, investigated and found to have massive splenomegaly and sickle cell disease documented by hemoglobin electrophoresis with Hemoglobin S level of about 45% , patient received blood transfusion and stabilized and later referred to our hospital for further management, three weeks later upon presentation to our hospital , he was febrile pale and slightly jaundiced. Abdominal examination revealed left hypochondriac tenderness and massive splenomegaly. A CT scan showed a massive splenomegaly with splenic infraction and possible superimposed infection. He was started on antibiotics and planned to be operated later on after his condition improved. Prior to surgery, he had an episode of vomiting which thought to be coffee‐ground vomitus, endoscopy was done and the edematous gastric mucosa in the funds which was misinterpreted as large gastric varices at the time of the study. Patient underwent open splenectomy, multiple infarcts and abscesses were seen. The spleen was fused to the stomach. Upon dissection of the adhesions, a fistulous tract was found connecting the stomach to the spleen, which was managed by partial gastrectomy. The patient had a smooth recovery period and was discharged home 10 days post‐op. Discussion : Gastro‐splenic fistula is uncommon entity, many cases described in the literature due to gastric or splenic malignancy and few related to trauma or surgery, up to our knowledge this is the first case to be published de‐scribing a gastro‐splenic fistula in a young patient with sickle cell anemia as a first presentation of his disease.

The first reported case of Mal de Maleda in an Egyptian origin patient.

Khalid M. Al-Husain, MD, Ahmed A. Al-Thubaiti, MD, Prof. Iqbal A. Bukhari, Imam Abdulrahman Bin Faisal University Mal de Meleda is a rare genodermatosis with an autosomal recessive inheritance. Mutations in the SLURP1 gene are the cause of this disease. Clinically, it is characterized by progressive palmoplantar hyperkeratosis exhibiting a transgradiens pattern i.e. extending to the dorsal aspects of the hands and feet in a glove and stocking pattern. It is also associated with hyperhidrosis, nail changes, subungual hyperkeratosis and perioral erythema. Here we report the first case of this disorder in a patient of an Egyptian origin. A 13 year old Egyptian boy presented to the dermatology outpatient clinic in King Fahd Hospital of the University complaining of erythematous slightly itchy patches over the body which started when he was 3 months old in a waxing and waning course. It was associated with palmoplantar hyperkeratosis which was extending to the dorsal aspects of the hands and feet. There was hyperhidrosis but no nail changes or perioral erythema. There was negative family history of the same condition and the parents are first degree relatives. Conclusion : our approach for reaching the diagnosis was mainly based on history and clinical features of the disease. Our future plan is to confirm the diagnosis by genetic analysis.

Right Atrial Thrombus Mimicking Myxoma in Patient with Systemic Lupus Erythematosus: A case report

Badriah Al-Omari , Mohammad Anas, Manal Hassan Imam Abdulrahman Bin Faisal University King Fahad Hospital of the University Introduction : Systemic Lupus Erythematosus (SLE) is a multisystemic autoimmune disorder. The mechanism of the disease is related to the production of auto‐ antibodies and deposition of immune complexe in injured tissues. Cardiovascular system is frequently affected in SLE. One of the possible manifestations of SLE is right atrial mass. However, the published medical literatures regarding this condition are few and limited to case reports. Case report : 43 years old female, presented with progressive bilateral lower limbs swelling, exertional dyspnea, purpuric rash, on & off bilateral knees, elbows & wrists pain with painful range of motion and acute renal failure. No history of chest pain, orthopnea or PND. No history of periorbital edema or urinary symptoms. There is no joint swelling, redness or morning stiffness. No history of photosensitivity. No history of recent URTI or fever. On examination: Middle age lady, lying comfortably, not pale or jaundiced. Not in pain or respiratory distress. T 37.2, BP 135/70, pulse 80/min and RR 18/min. Normal JVP. CVS …. Chest examination showed bilateral basal crepitations. CNS, AND abdominal examinations were within normal. Lower limb examination showed pitting edema grade 4+. Investigation: WBC = 3300, Hgb = 8.6 g/dl, MCV = 88, MCH = 28.9 Platelets = 117,000, Albumin= 2 mg/dl. BUN = 40 mg/dl, creatinine = 2.5 g/dl, protein 300 mg/dl ANA = 1280 (homogenous pattern). Anti Ds DNA =1280. Depending on history and investigation, patient was diagnosed as lupus nephritis. Renal biopsy was performed and showed Lupus Nephritis class IV. Echocardiogram also was done and describes two large masses, one attached to the posterior wall of right atrium & the other is attached to the roof of the right atrium. Discussion: SLE can affect the pericardium, endocardium, myocardium, coronary and pulmonary vessels as determined in several clinical and autopsy studies.(1) The prevalence of cardiac involvement is >50%.(2) Several auto‐antibodies present in patient with SLE can mediate cardiac damage. Despite the cardiac manifestations can present at any time during the course of the disease, they can be fetal if not diagnosed early.

Patient with SLE can present with valvular disease, frequently mitral regurgitation, pericardial disease, usually an asymptomatic effusion, myocardial dysfunction, Coronary artery disease and cardiac mass. (3) This mass can be vegetations, thrombus, atrial myxoma, Libmansacks syndrome. (3) However, the differentiation between the nature of those masses are difficult with non‐invasive procedures, and usually the surgical intervention carries a high risk for those patients. For our patient, blood culture was negative so she is not filling the criteria of infective endocarditis, and echocardiogram pictures is less likely to be myxoma, so believed that this mass is atrial thrombus. Patient was giving anti‐coagulation therapy followed regularly by echocardiogram to evaluate the mass size. The treatment successfully improved the patient’s clinical status and showed dramatic reduction in the size of the mass and it’s resolved within one year. Conclusion : Cardiac manifestations are frequently seen in patient with SLE. However, right atrial myxoma is uncommon but carries high mortality and morbidity risk. Obtaining a confirm diagnosis of cardiac mass in SLE patients is challenging because of similar appearance in non‐invasive modalities, and surgical interventions are not always feasible. The importance of early investigations for cardiac manifestations in SLE patients is the goal to diagnose the disease as early as possible and provide treatment that may adjust the disease course and improve the prognosis of those patients.

Combined conjunctival intraepithelial neoplasia with corneal atypical Fibroxanthoma in Xeroderma Pigmentosum

Luluah K Bubshait, Motazz A Alarfaj, Adnan Talib Al-Awami, Abdulaziz Alsomali, Muhanna Y Al-Jindan Imam Abdulrahman Bin Faisal University Background : Xeroderma pigmentosum (XP) is a rare autosomal recessive disease caused by a mutation in the DNA repair gene leading to increased sensitivity to UV radiation. Objective: To report the clinical and histologic appearance of a rare neoplasm that is unusual to occur at a young age (17 years‐old) consisting of both corneal atypical fibroxanthoma and concurrent conjunctival intraepithelial neoplasia. Methods: One Case Report. Results : Excisional biopsy was done and showed atypical fibroxanthoma and overlying mild to moderate epithelial dysplasia. The sections revealed infiltration of corneal lamina propria by pleomorphic, spindly, and bizarre multinucleated tumor giant cells, some having lipidized cytoplasm. The overlying corneal squamous epithelium shows mild to moderate dysplasia with scattered dyskeratotic cells. Cells infiltrating the lamina propria are variably positive for CD68 and negative for Pan CK, p63 and Melan‐A excluding melanoma. Conclusion: Atypical fibroxanthoma is a mesenchymal skin tumor related to UV sun damage. It has also been reported in the cornea and conjunctiva in older patients with XP, however it’s unusual to occur in such a young patient.

Retained Soft Contact Lens for More Than Two Years in One Eyed Patient: A Case Report.

Shorooq A Alenazi , Abdulrahman F. AlBloushi Taibah University, College of Medicine, Medina, Kingdom of Saudi Arabia King Saud University, Department of Ophthalmology, Riyadh, Kingdom of Saudi Arabia Purpose: To report a case of a retained bandage contact lens (BCL) for two years and six months in its primary position which was associated with distinct clinical appearance over the patient's only seeing eye. Observations : A 70‐year‐old female one‐eyed patient with history of systemic hypertension and poor vision in the left eye due to old trauma presented with right eye spontaneous corneal perforation and leak. The case was managed with cyanoacrylate corneal glue along with bandage contact lens (BCL). For the unclear reason, patient lost her follow‐up and presented after two years and six months with the retention of the BCL in its original position. The retained BCL developed a strange clinical appearance in form of granular deposits along the edges which were made of mixed epithelium and mucus deposition. We hypothesize that this deposition occurred as an adaptive mechanism and probably was the reason in BCL stabilization and prevention of serious contact lens‐related complications. Conclusions and Importance: To our knowledge, long‐term in‐place retention of BCL and/or appearance this distinct clinical appearance has not been described before. In addition, despite the long period of retention, the lens didn't migrate to the common places and didn't cause any serious complications. This report guides us to the importance of proper patient education and counseling especially those like our patient to ensure the patient compliance and prevents unfavorable future complications.

Eagle’s syndrome: The external surgical approach.

Maram AlGhumlas Eagle’s syndrome is a condition where the styloid process is elongated or the stylohyoid ligament is ossified. In ES the result of such deformity is the compression of the V, VII, IX, and X of the carinal nerves. Patient presentation varies and they can present with one or more of the following symptoms otalgia, dysphagia, foreign body sensation, facial pain, headache, tinnitus, odynophagia, increased salivation, or voice changes. Introduction: Eagle’s syndrome is a condition where the styloid process is elongated or the stylohyoid ligament is ossified. Patient presentation varies and they can present with a variety of symptoms making the diagnosis to be delayed. Objectives: To raise the awareness about the condition among young physicians and to describe the external surgical approach. Methods: A case study where a patient had a symptomatic elongated styloid process Results and conclusion : If you don’t know about it most probably you will miss diagnosing it.

Infliximab Induced Psychosis in a Crohn’s disease adolescent patient: Case Report

Kawther Almubayedh Introduction : Infliximab has been used successfully to treat inflammatory bowel disorders (IBD). It has well‐established efficacy and safety. Side effects of this treatment include infection and malignancy. However, a few case reports have shed the light on the psychiatric side effects related to infliximab treatment. We report a case of an adolescent female with Crohn’s disease who developed acute psychotic symptoms during Infliximab therapy. Case Description: A 14‐year‐old female with a recent diagnosis of Crohn’s disease on Corticosteroid 40 mg .Two weeks later she was stared on infliximab therapy. The patient was presented to our emergency department with 5 days history of behavioral disturbance in the form of irritability, hyperactivity, talkativeness, lack of sleep, physical aggression, self‐talking and disorganized behavior. These symptoms started 2 days following her first Infliximab infusion. Extensive workup results were all within normal limits. A diagnosis of acute psychotic disorder was made and she was treated effectively with olanzapine 5 mg. Corticosteroid treatment was discontinued for more than two weeks with no improvement of symptoms therefore a diagnosis of Infliximab induced psychosis was made. After eight weeks of treatment patient’s symptoms have been improved. She returned to her baseline mental status. Patient continued to follow up with us. There has been no relapse in her psychiatric state. Discussion: To date, there are a few case reports described psychiatric side effects of Infliximab; Most of them were in adult age group. Psychosis was reported with anti‐ TNF medication other than inflaximb like Etanercept. Only one case was found reporting acute psychosis in adolescent with Crohn’s disease after infliximab therapy, this case in addition to our case report both were treated successfully with Olanzapine. Conclusion: Internists should be aware of this rare complication when administering infliximab for various medical illnesses. In addition, management with an atypical antipsychotic is preferred if infliximab induced psychosis has been suggested. However more studies are required to confirm this recommendation.

Brain metastases & uncal herniation in a patient with ampullary adenocarcinoma in situ presenting with jaundice & memory loss, case report

Omar AlGhamdi Periampullary carcinoma includes heterogeneous group of neoplasms arising from the head of the pancreas, the distal common bile duct, the duodenum and ampulla of Vater itself. Ampullary carcinoma arises either in the Ampulla of Vater or on the papilla of Vater (duodenal papilla). Extra‐abdominal metastases of ampullary carcinoma is much less common than intra‐abdominal ones. We present a case of a 41 years old male, medical free presented to our hospital as a case of obstructive jaundice that was associated with abdominal pain, loss of appetite, and weight loss over the last month. ERCP was done to investigate & relive his jaundice. During which an ampullary mass was found & biopsy was taken for histopathology analysis. After a one week follow up for the result of the histopathology which was found to be adenocarcinoma in situ, the patient's wife noticed on her husband memory loss , headache, blurred vision and ataxia. Full metastatic work up was done, which reviled besides his primary tumor that he had two brain metastatic lesions located at partial lobe extending into the frontal lobe and the other is in the occipital lobe, liver and lung Mets. as well. Perhaps owing to the aggressive nature of pancreatic adenocarcinoma and the fact that most patients do not survive long enough to experience clinical manifestations of brain metastasis. It is also a possibility that the actual incidence is higher than reported as many patients may not be evaluated for a CNS lesion as first presentation late in the course of the disease is extremely common with pancreatic carcinoma. Local tumor extension or hepatic involvement is common; other common sites include the peritoneum and lung. Ampullary cancer usually metastasizes to regional nodes, liver, but rarely to brain and our case report is the third case worldwide.

Double coronary balloon usage for the treatment of Coarctation of the Aorta: A Case Report

Sarah K Aldhahri Coarctation of the aorta is a congenital heart disease in which an area of the aorta is constricted or “coarcted”, usually at the insertion of the ductus arteriosus. It accounts for 5‐8% of all congenital heart defects and was first reported in 1945 by Crofoord as the first discovered congenital heart defect. With an incidence of approximately 3 cases per 10000 births, coarctation of the aorta is usually managed according to the patient’s age at presentation, size of the constricted region, associated abnormalities and arch anatomy. Since the 1940s, various surgical techniques have been implemented to treat coarctation of the aorta; such as resection and end‐to‐end anastomosis, tubular bypass graft, patch aortoplasty, and left subclavian flap aortoplasty. Balloon angioplasty was adopted later on to treat native coarctation of the aorta and post‐surgical re‐coarctation. We are reporting the first case of double coronary balloon usage in infants. A 10‐week‐old male infant underwent successful surgical repair for severe coarctation of the aorta at the age of 14 days with end‐to‐end anastomosis. The procedure was successful with a significant drop in pressure gradient and substantial angiographic improvement. Nine months post‐procedure there was no re‐coarctation and the infant was stable, asymptomatic and thriving well; signifying the safety and efficacy of using high pressure coronary balloons in infants.

Vaginal Fistula and Right Ovarian Prolapse Presenting as Vaginismus : A Case Report

Dr Haifa Alturki, Nourah K, Moath We describe the case of a 32‐year old, para 1+0, 32 year old lady presented to the infertility and assisted reproductive unit with a 7 years history of secondary infertility. She gave a history of vaginismus that was unexplained by her family doctor nor responsive to multiple treatments, and patient had an episode of heavy vaginal bleeding 3 years back while after undergoing a vaginal scan. Patient complained of vague discomfort on the right lower abdomen. There was no history of infection or any vaginal discharge. She had undergone 4 trials of ovulation induction for secondary infertility. General physical examination was unremarkable. On pelvic examination the vulva looked normal with no apparent discharge, and she was unable to undergo vaginal examination due to severe pain. Any further vaginal examination was deferred. An abdominal ultrasound was done with no significant findings. Hysterosalpingography was performed in the radiology department under sedation did show normal uterus and patent tubes. After discussion with the patient and her husband an in vitro fertilization (IVF) was recommended. She was scheduled for ovum pick up under sedation. A detailed examination of the cervix showed a hamartomatous‐like lesion on the posterior wall of the vagina. On close inspection it was found that part of the right ovary was visible in the vaginal posterior vaginal fornix (Figure 1 and II). A diagnosis of ovarian‐to‐ vaginal fistula was made. The fistula was closed surgically. The objective of reporting this rare case (3rd in the English Language literature) that that a good history and proper and thorough clinical examination is needed to make the diagnosis early and limit the distress and suffering of a similar presentation, particularly in patients who had prior difficult labor.

The Use of Omental Flap For The Reconstruction Of Burn Injury To The Scalp: A Case Report

Noor Al-Lababidi Omental free flaps are used in reconstructing a wide range of clinical indications in the head and neck. The first omental flap case to be reported was in 1972 by McLean and Buncke. This is a case of omental free flap reconstruction of the scalp after a burn in a young male. It is first to be reported in Saudi Arabia at King Faisal Specialist Hospital and Research Center, Riyadh, 2012. A 14‐year‐old young male had an extensive flame burn at the age of 2 years in the head and neck area. He received multiple skin grafting procedures and an amputation of the right hand, the patient was admitted for removal of the unstable ulcer sting and scarred skin of the scalp and for coverage with omental free flap and split thickness skin graft. The coverage of wounds in the head and neck is usually done by using a local skin flap. The disadvantage of using the traditional skin flaps is difficulty to shape it in irregular, large wounds. The use of omental flap is the new recommended method in scalp and neck reconstruction .Owing its large size in covering wide defect, easy to shape in irregular edges over the bony surfaces, and high vascularity. More over minimal or no complications were recorded in both donor and recipient site.

GBM, Resistant Thrombocytopenia Managed By Splenic Artery Embolization

Omar Alii Thrombocytopenia is a pathological finding caused by different mechanisms that lead to platelet count below 150,000/μL. A reduced platelet count may arise by one of two mechanisms: the first mechanism is by decreased or abnormal production of platelets due to bone marrow failure or hereditary thrombocytopenia. The second mechanism is by increased consumption of platelets through immune mediated reactions and mechanical pooling (sequestration) like in hypersplenism due to liver diseases. It has been shown in the literature a very clear link between tumors and coagulopathy. Tumors enhance the pro‐thrombotic state through tissue mediators resulting in high consumption of platelets precipitating and worsening thrombocytopenia. Surgical procedures like splenic artery embolization (SAE) can be the choice of management in many cases of resistant thrombocytopenia. The aim of this report is to show the application of SAE in resistant thrombocytopenia in case of chemotherapy and brain tumor, Glioblastoma multiforme (GBM) is well known to be the most malignant and commonest encountered primary brain tumor. We present a case of GBM in which her debulking surgery was cancelled many times due to resistant thrombocytopenia, SAE was preformed to manage thrombocytopenia then surgery carried out successfully.

Neurocysticercosis

Fatimah Alzaher, Dhabia Aldossari Introduction : Post‐partum seizures can result from many causes. There may be a considerable overlap in the presenta‐tion of these conditions resulting in difficulties in diagnosis and treatment. Convulsions presenting in the puerperium should be treated as eclampsia until proven otherwise. Every effort to identify other causes of convulsions should be made. We present a case of postpartum seizures in a female who is previously known to have epilepsy since childhood. Case Report : A 36‐year‐old, Gravida 3, Para 2 (G3P2 + 0), Indian female nurse presented to the emergency depart‐ment. She is a known case of epilepsy since childhood. She had only one episode at the age of eight years. She is not on medication and did not have any subsequent episodes. She presented with generalized tonic‐clonic seizure 6 days after normal vaginal delivery (24/10/16). Her antenatal course was uncomplicated and her delivery was without a lumbar epidural\dural puncture during labour. Both the immediate and the first 5 days postpartum were uneventful until the 6th day post party when the patient experienced generalized tonic‐clonic seizures and tongue bitting. This was wit‐nessed by her husband. There was no history of prodromal symptoms, nausea, vomiting, raised temperature, neck ri‐gidity, headache, dizziness, vision disturbances, focal neural deficit, passing urine or stool, history of head trauma or similar attack antenatally or in previous pregnancies. The patient’s gestational period was uncomplicated. No history of gestational diabetes, hypertension, pre\eclampsia or thrombotic event. Also, her delivery was spontaneous vaginal delivery without regional anesthesia or complications. She had normal lochia with no increase in the blood pressure in the postpartum period. The patient is not alcoholic. She was on calcium and folic acid only with no illegal or over the counter drug use. At the time of arrival, the patient was conscious, alert but slightly confused, soon after arrival, she became oriented to place, time and person). Her vital signs were within normal limits. Examination revealed no abnormality with normal deep tendon reflexes and no focal deficit. Abdominal examination was unremarkable. On the day of presentation, the investigations showed a low Hemoglobin level of 11.7 gm/dl (12.0‐16), low hematocrit 34.0% (37.0‐47.0) and low RBC 3.76 k/ul (4.2‐5.5) corresponding to the delivery loss. All other CBC levels were within normal range including the WBCs. She also had normal renal function test, normal urine dipstick, insignificant growth in urine culture and normal urine analysis. The liver function test was normal.

The patient was given Mg sulfate 10 grams Injections in form of two doses 4 g (8ml) and one dose 2 gm. The patient underwent MRI with contrast on the following day (25/10/16) that has revealed a structural lesion; neurocysticercosis (Multiple ill‐ defined rounded foci of hyper‐intense T2/FLAIR signal within the left middle frontal gyrus, left post central sulcus, left superior frontal sulcus, anterior aspect of left Sylvian fissure and along the anterior inter‐hemisepheric fissure, this demonstrates blooing artifact on gradient image. The left middle frontal gyrus lesion demonstrates focal edema and smooth ring enhancement in post gadolinium administration). A spinal MRI with contrast was done 6 days later to rule out any associated pathology with no defensive intramedullary lesions, or pathological enhancement. Ver‐tebral body height, spinal intensity, and alignment are preserved. Para vertebral soft tissues appear unremarkable. In addition, an Axial un‐enhanced CT scan of the brain with coronal and sagittal reformatted was done in the same day that revealed Calcification along the previously seen lesions described in the previous MRI with No mass effect, or midline shift, no hydrocephalus and with normal ventricular system and cisterns. So Neurocysticercosis would be the primary consideration. Discussion: Postpartum seizures contribute for one of the life‐threatening conditions that need an urgent intervention. Although that any patient presenting with convulsions in the the puerperium must be treated as a case of postpartum eclampsia, every effort must be done to reach the diagnosis. Putting in mind the chronic diseases that might precipitate the event as hypersensitive encephalipathy and uremia, post‐partum seizures could be also the first presentation or a recurrent episode of epilepsy. In addition, it might be a consequence of hypoglycemia, electrolytes imbalance (hypocalcemia, hypomagnesemia, hyponatremia or hypernatremia) or drug/alcohol poisoning or withdrawal. Moreover, head trauma, vascular events as intracranial hemorrhage, cerebral vascular occlusion or ischemia and space occupying lesions such as tumor or abscess are all in the list of the differential diagnosis. Patients with fever, contact with sick people or with recent infection must be also investigated for meningitis, encephalitis, tetanus or HIV infection. Our patient was investigated vigorously to reach the diagnosis since she was previously a known case of epilepsy in childhood and had a very smooth uneventful pregnancy. Radiological imaging was started with MRI with contrast revealing a structural lesion; neurocysticercosis (Multiple ill‐defined rounded foci of hyper‐ intense T2/FLAIR signal within the left middle frontal gyrus, left post central sulcus, left superior frontal sulcus, anterior aspect of left Sylvian fissure and along the anterior inter‐hemisepheric fissure, this demonstrates blooing artifact on gradient image.

The left middle frontal gyrus lesion demonstrates focal edema and smooth ring enhancement in post gadolinium administration) followed by MRI of spine with contrast to rule out spinal pathology which was unremarkable. Moreover, Axial um‐ enhanced CT scan of the brain with coronal and sagittal reformatted to confirm the diagnosis was done revealing Calcification noted along the previously seen lesions described in the previous MRI within the left middle front gyrus, left superior frontal sulcus, anterior aspect of the left sylvan fissure and along the anterior r inter‐ hemisepheric fissure which are again suggestive of infective etiology‐ (NCC) with normal ventricular system and cisterns and no mass effect, or midline shift, no hydrocephalus. For that, inflammatory markers including ESR and CPR which both were high with level of 47 and 1.7 consequently and blood culture which showed no growth were taken. Our patient was treated as a case of neurocystecrosis (seizures due to Taenia solium (ie, pork tapeworm infestation). She has been on Anti‐epilptic drug; Keppra (Levetiracetam ) 500 mg PO BiD as a prophylaxis for subsequent seizures. She was also started on Anti‐parasitic therapy including Praziquantel 3600 mg PO OD and Albendazol 100 mg PO OD. Since the patient is receiving Anti‐parasitic therapy, she was started on Dexamethasone 7mg IV OD to reduce the in‐flammation associated with the dying organisms. All the therapies are used up to present except Dexamethasone 7mg IV OD that was lastly given on Jan. 23. 17. WHO recommendations for neurocystecrosis (NCC) management include long courses with praziquantel and/or Al‐bendazole, as well as supporting therapy with corticosteroids and/or anti‐epileptic drugs, and possibly surgery. The dos‐age and the duration of treatment can vary greatly and depend mainly on the number, size, location and developmental stage of the cysts, their surrounding inflammatory edema, acuteness and severity of clinical symptoms or signs. Patients who have multiple active and inactive parenchymal cysts; administration of Anti‐iparasitic therapy (albendazole 15 mg/kg/d in two daily doses for 8 to 15 days) together with high‐dose steroids is the most favorable treatment. Since patients with NCC are at risk of tuberculosis and strongyloidiasis, which can disseminate during treatment with corticosteroids, patients with NCC must be screened for such infection prior to corticosteroid therapy. Surgical intervention is saved for symptomatic patients with hydrocephalus. Endoscopic removal of the cysticerci in the ventricles is recommended for patients without acute symptoms.

DAMS ABSTRACTS BOOKLET Supervised by: Dr. Mohammed Alshahrani Reviewed by: 1‐Anas Talal AlHindi 2‐Abdullah saleh Al‐Qattan 3‐Mohammed sami Almulaify 4‐Hussain ali alshabeb 5‐Monaliza Kathreen Banez Designed by: Musa’ad AlJughaiman