Table of Contents : Annals of Saudi Medicine : 2010 - 30(1) /currentissue.asp Table of Contents:Ann Saudi Med 2010 - 30(1) The first influenza pandemic of the 21st century Al Hajjar Sami, McIntosh Kenneth Review Annals of Saudi Medicine 2010 30(1):1-100256-4947 Al Hajjar Sami, McIntosh Kenneth

Annals of Saudi Medicine 2010 30(1):1-10

The 2009 H1N1 influenza virus (formerly known as swine flu) first appeared in Mexico and the United States in March and April 2009 and has swept the globe with unprecedented speed as a result of airline travel. On June 11, 2009, the World Health Organization raised its pandemic level to the highest level, Phase 6, indicating widespread community transmission on at least two continents. The 2009 H1N1 virus contains a unique combination of gene segments from human, swine and avian influenza A viruses. Children and young adults appear to be the most affected, perhaps reflecting protection in the elderly owing to exposure to H1N1 strains before 1957. Most clinical disease is relatively mild but complications leading to hospitalization, with the need for intensive care, can occur, especially in very young children, during pregnancy, in morbid obesity, and in those with underlying medical conditions such as chronic lung and cardiac diseases, diabetes, and immunosuppression. Bacterial co-infection has played a significant role in fatal cases. The case of fatality has been estimated at around 0.4%. Mathematical modeling suggests that the effect of novel influenza virus can be reduced by immunization, but the question remains: can we produce enough H1N1 vaccine to beat the pandemic?]]>
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Pandemic influenza A (H1N1) in Saudi Arabia: Description of the first one hundred cases AlMazroa Mohammad A, Memish Ziad A, AlWadey Ali M Original Article Annals of Saudi Medicine 2010 30(1):11-140256-4947 AlMazroa Mohammad A, Memish Ziad A, AlWadey Ali M

Annals of Saudi Medicine 2010 30(1):11-14

Background and Objectives : In April 2009, the World Health Organization (WHO) declared pandemic influenza A (H1N1) "public health emergency of international concern". On June 11, 2009, WHO raised the pandemic alert level to phase 6, indicating a global pandemic. By December 2009, more than 208 countries and territories had reported swine flu cases. The descriptive epidemiology of the first reported 100 cases of this virus in Saudi Arabia are summarized in this report. Methods : Data were collected from 1 June to 3 July, 2009 using a predesigned questionnaire. Questionnaires were filled by Field Epidemiology Training Program residents. Data for the first 100 complete cases of confirmed pandemic influenza A (H1N1) were compiled and analyzed. Results : The age of reported cases was in the range of 1 to 56 years. The highest percentage of cases was in the age group of 20 to 30 years followed by the age group of 1 to 10 years. Females represented 55% of the cases; imported cases represented 47%, 58% of whom had come via the King Khaled Airport. The most common nationalities most were from Saudi Arabia and the Philippines. The main symptoms were fever (56%), cough (54%), and sore throat and the number of cases was seen to peak from the 27 to 29 June. Conclusion : Pandemic influenza A (H1N1) is still a threat to Saudi Arabia. Thus, comprehensive and effective measures for surveillance and prevention of the disease are needed to control its spread.]]>
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Mother-to-child transmission of HIV: Experience at a referral hospital in Saudi Arabia Edathodu Jameela, Halim Magid M, Dahham Muneera Bin, Alrajhi Abdulrahman A Original Article Annals of Saudi Medicine 2010 30(1):15-170256-4947 Edathodu Jameela, Halim Magid M, Dahham Muneera Bin, Alrajhi Abdulrahman A

Annals of Saudi Medicine 2010 30(1):15-17

Background and Objectives : The rate of mother-to-child transmission of human immunodeficiency virus (HIV) type 1 has been reported to be high in Saudi Arabia. We report the rate of such transmission among a cohort of HIV-infected women enrolled in an HIV program at a tertiary care facility in Riyadh. Methods : All HIV-infected women who became pregnant and delivered during their follow-up between January 1994 and June 2006 were included in this study. HIV viral load and CD4+ T-lymphocyte count near-term, the mode of delivery, and the HIV status of the newborn at 18 months were recorded. All women were counseled and managed according to the three-step PACTG 076 protocol. Results : Of 68 HIV-infected women in the cohort, 31 had 40 pregnancies; one aborted at 13 weeks gestation. The mode of delivery was elective cesarean delivery in 28 pregnancies (70%) at 36 weeks gestation, and 11 (27.5%) had normal spontaneous vaginal delivery. The median CD4+ T-lymphocyte count near-term was 536 cells per cubic millimeter and the median viral load for 25 pregnancies was 1646 copies/mL, with only nine pregnancies (22.5%) having viral loads of more than 1000 copies/mL. Fourteen pregnancies (35%) had undetectable HIV prior to delivery. All patients were taking antiretroviral therapy during pregnancy and delivery. All 39 newborns tested negative for HIV infection at the age of 18 months; none of the newborns was breastfed. Conclusions : Contrary to previous local experience, diagnosis, management, and antiretroviral therapy almost eliminated mother-to-child transmission of HIV-1 in our patient population.]]>
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Analysis of complications in hepatic right lobe living donors Azzam Ayman, Uryuhara Kinji, Taka Ito, Takada Yasutsugu, Egawa Hiroto, Tanaka Koichi Original Article Annals of Saudi Medicine 2010 30(1):18-240256-4947 Azzam Ayman, Uryuhara Kinji, Taka Ito, Takada Yasutsugu, Egawa Hiroto, Tanaka Koichi

Annals of Saudi Medicine 2010 30(1):18-24

Background and Objectives : Living donor liver transplantation (LDLT) has been expanding to adult recipients by using right lobe grafts. However, the incidence of complications is more frequent than that involving left lobe grafts. Hence, we aimed to analyze postoperative complications in right lobe liver donors as a step to improve the results in the donors. Methods : Three hundred and eleven right lobe liver donors were retrospectively reviewed between February 1998 and December 2003. Results : The ages of the donors ranged from 19 to 64 years (median: 46 years). Their body mass index ranged from 16.6 to 34.3 (median: 22.1). The mean duration of the operation was 6.58 (1.25) hours and blood loss was 289 (254) mL. The estimated median donor residual liver volume was 42.2% (range: 20.6-60.3%) and the median hospital stay was 14.5 days (range: 6-267 days). One donor died of liver failure due to small residual liver volume (26%) and steatohepatitis. One hundred and twenty three complications occurred in 104 donors (33.4%). Donors experienced one or more complications. According to the Clavien classification, grade I complications occurred in 71 of the episodes (57.7%), grade II complications in 9 (7.3%), grade IIIa complications in 39 (31.7%), grade IIIb complications in 3 (2.5%), and grade V complications in 1 (0.8%). Biliary complications were the most common and occurred in 37 donors (12%). Conclusion : Right lobe liver donation is a widely accepted procedure that results in the expansion of the indication for LDLT to adults and large children. However, remnant liver size and anatomical variations in the biliary tree represent important risk factors for postoperative complications.]]>
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Prevalence of elevated hepatic transaminases<b> </b>among Jordanian patients with type 2 diabetes mellitus Judi Layla, Toukan Ala, Khader Yousef, Ajlouni Kamel, Khatib M Amer Original Article Annals of Saudi Medicine 2010 30(1):25-320256-4947 Judi Layla, Toukan Ala, Khader Yousef, Ajlouni Kamel, Khatib M Amer

Annals of Saudi Medicine 2010 30(1):25-32

Background and Objectives : Since the extent of elevation of liver transaminases in type 2 diabetics in Jordan and most of the Middle East is unknown, we estimated the prevalence of elevated liver transaminase levels among patients with type 2 diabetes and determined associated risk factors. Methods : This study was performed on 1014 consecutive type 2 diabetic outpatients who attended the National Center for Diabetes, Endocrinology and Genetics in Amman, Jordan. The patients' age ranged between 26-85 years with a mean age of 56.8 (+9.8). Three- hundred and fifty three (54.5%) were males with a median age of 58 years (ranging between 26-82 years), and four hundred and sixty one (45.5%) were females with a median age of 57 years (ranging between 28-85 years). Body mass index, waist circumference, lipid profile, and hepatic transaminase levels were recorded. Ultraonography was performed in those with elevated alanine transaminase levels. Results : Overall, the prevalence of elevated alanine transaminase (ALT) level was 10.4% (n=105) with the gender-wise prevalence being 12.8% (n=71) in men and 7.4% (n=34) in women. The prevalence of elevated aspartate transaminase (AST) levels was 5.4% (n=56) with the gender-wise prevalence being 5.6% (n=31) in men and 5.4% (n=25) in women.. Only 4.5% (n=44) showed elevated levels of both ALT and AST. Male gender (OR=2.35, CI:1.5-3.8) and high waist circumference (OR=1.9, CI:1.2-3.2) were associated with increased risk of elevated ALT levels. Younger patients had a higher tendency to have elevated ALT compared to those over 65 years (OR=12.4 for patients aged 25-45years, and OR=5.8 for those who were 45-65 years old). Non-insulin use was associated with a high odds ratio for elevated ALT levels (OR=1.7, CI: 1.1-2.9). Conclusions : Elevated ALT and AST levels are found in 10.4% and 5.4% of our type 2 diabetic patients respectively. Male gender, younger age, higher waist circumference; as an indicator of central obesity, as well as non insulin use are independent predictors of elevated liver transaminase levels.]]>
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Endothelial nitric oxide synthase gene Glu298Asp polymorphism in patients with coronary artery disease Salimi Saeedeh, Firoozrai Mohsen, Zand Hamid, Nakhaee Alireza, Shafiee Sayed M, Tavilani Heidar, Mohebbi Ahmad Original Article Annals of Saudi Medicine 2010 30(1):33-370256-4947 Salimi Saeedeh, Firoozrai Mohsen, Zand Hamid, Nakhaee Alireza, Shafiee Sayed M, Tavilani Heidar, Mohebbi Ahmad

Annals of Saudi Medicine 2010 30(1):33-37

Background and objectives : Endo-derived nitric oxide (NO) is synthesized from L-arginine by endothelial nitric oxide synthase (NOS3). Since reduced NO synthesis in endothelial cells has been implicated in the development of coronary atherosclerosis, we investigated the association of NOS3 gene polymorphisms and coronary artery disease (CAD) in an Iranian population. Subjects and Methods : We studied the NOS3 gene Glu298Asp polymorphism in 241 CAD patients with positive coronary angiograms (i.e., >50% stenosis affecting at least one coronary vessel) in Shahid Rajaee Heart Hospital and 261 control subjects without a history of symptomatic CAD. The NOS3 gene polymorphism was analyzed by polymerase chain reaction and restriction fragment length polymorphism. Lipid profile and other risk factors were also determined. Results : The genotype frequencies of Glu298Asp polymorphism for Glu/Glu, Glu/Asp, and Asp/Asp were 61.3%, 32.2%, and 6.5%, respectively, in control subjects, and 46.5%, 42.7%, and 10.8% in CAD patients, respectively. The genotype frequencies differed significantly between the two groups (P=.003). The frequencies of the Asp alleles were 32.2% and 22.6% for CAD patients and control subjects, respectively; the difference between the two groups was statistically significant (P=.001; odds ratio=1.6). Plasma lipids, except HDL-C, were also significantly increased in the CAD groups. Conclusion : These results suggest that CAD is associated with Glu298Asp polymorphism of the NOS3 gene in our population and that this polymorphism is an independent risk factor for CAD.]]>
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Saudi guidelines for testing and treatment of latent tuberculosis infection Al Jahdali Hamdan H, Baharoon Salim, Abba Abdullah A, Memish Ziad A, Alrajhi Abdulrahman A, AlBarrak Ali, Haddad Qais A, Al Hajjaj Mohammad, Pai Madhukar, Menzies Dick Guidelines Annals of Saudi Medicine 2010 30(1):38-490256-4947 Al Jahdali Hamdan H, Baharoon Salim, Abba Abdullah A, Memish Ziad A, Alrajhi Abdulrahman A, AlBarrak Ali, Haddad Qais A, Al Hajjaj Mohammad, Pai Madhukar, Menzies Dick

Annals of Saudi Medicine 2010 30(1):38-49

Pulmonary tuberculosis is a common disease in Saudi Arabia. As most cases of tuberculosis are due to reactivation of latent infection, identification of individuals with latent tuberculosis infection (LTBI) who are at increased risk of progression to active disease, is a key element of tuberculosis control programs. Whereas general screening of individuals for LTBI is not cost-effective, targeted testing of individuals at high risk of disease progression is the right approach. Treatment of those patients with LTBI can diminish the risk of progression to active tuberculosis disease in the majority of treated patients. This statement is the first Saudi guideline for testing and treatment of LTBI and is a result of the cooperative efforts of four local Saudi scientific societies. This Guideline is intended to provide physicians and allied health workers in Saudi Arabia with the standard of care for testing and treatment of LTBI.]]>
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Trauma care systems in Saudi Arabia: an agenda for action Al-Naami Mohammed Y, Arafah Maria A, Al-Ibrahim Fatimah S Perspective Annals of Saudi Medicine 2010 30(1):50-580256-4947 Al-Naami Mohammed Y, Arafah Maria A, Al-Ibrahim Fatimah S

Annals of Saudi Medicine 2010 30(1):50-58

Saudi Arabia is undergoing a rapid population growth that along with improved socioeconomics has led many individuals to own a car or even a number of cars per family, resulting in a greater number of vehicles on the roads. The reduced focus on good public transportation systems and the dependence on cars for transportation have created a diversity of drivers who are unfamiliar with the local driving rules and lack the basic skills for safe driving. This is in addition to some young drivers who frequently violate traffic laws and tend to speed most of the time. This unplanned expansion in road traffic has resulted in more car accidents, injuries, disabilities, and deaths. Accompanying that is an increased socioeconomic burden, depletion of human resources, emotional and psychological stress on families, and a strain on healthcare facilities. If this continues without prompt intervention, it will lead to increased insurance premiums and may become unmanageable. To minimize this impact, a national or regional multidisciplinary trauma system has to be developed and implemented. A trauma system is a preplanned, comprehensive, and coordinated regional injury response network that includes all facilities with the capability to care for the injured. Essential components of the system include trauma prevention, prehospital care, hospital care, rehabilitation, system administration, trauma care education and training, trauma care evaluation and quality improvement, along with the participation of society. Research has documented a significant decrease in morbidity and mortality from trauma after the implementation of such systems, depending on their efficiency. The purpose of this review is to discuss the problem of road traffic accidents in this country and address the trauma care system as an effective solution.]]>
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Characteristics of pandemic influenza A (H1N1) infection in patients presenting to a university hospital in Riyadh, Saudi Arabia BinSaeed Abdulaziz A Brief Report Annals of Saudi Medicine 2010 30(1):59-620256-4947 BinSaeed Abdulaziz A

Annals of Saudi Medicine 2010 30(1):59-62

Background and Objectives : A national plan of management for flu-like illnesses was developed by the Saudi Ministry of Health after the first outbreak in Saudi Arabia in June. We describe the clinical presentation of the H1N1 cases attending King Khalid University Hospital (KKUH) between July through September 2009 and identify the high-risk age groups. Methods : All patients presenting with influenza-like illnesses (ILI) in the H1N1 clinics during the specified period were clinically examined and tested using reverse transcription polymerase chain reaction (RT-PCR). Those who were clinically diagnosed and confirmed positive for novel influenza A (H1N1) were included in the study. Results : Over a 6-week period, 117 cases of laboratory-confirmed cases were reported in KKUH with a mean (SD) age of 19.6 (16.7) years, of whom 72 (62.1%) were males. Most reported cases were Saudis (n=99, 85.3%); 94 (81%) had no travel history outside the country; 100 (86.2%) had had no contact with an H1N1-identified patient; 33% were aged 5-14 years and 28.4% were aged 15-29 years. The most commonly reported symptoms were fever in 99 (85.3%), cough in 9 (81%), runny nose (33.6%) and sore throat (21.3%). All 117 cases were confirmed positive using real time RT-PCR testing. Thirty-one cases (26%) were admitted and 22 of those (71%) recovered after receiving oseltamivir. Two deaths were attributed to the 2009 pandemic. One patient died of chronic pulmonary disease. The other cause of death was unknown. Conclusion : These findings indicate indigenous influenza A (H1N1) transmission, and confirm the urgent need for prevention strategies which specifically target children and young adults, who appear to have a higher risk of infection and hospitalization. Such measures include immunization, improved personal hygiene, and increased ventilation in habitations.]]>
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Appendiceal ascariasis in children Wani Imtiaz, Maqbool Muddasir, Amin Abid, Shah Firdous, Keema Arshad, Singh Jang, Kitagawa Maki, Nazir Mir Brief Report Annals of Saudi Medicine 2010 30(1):63-660256-4947 Wani Imtiaz, Maqbool Muddasir, Amin Abid, Shah Firdous, Keema Arshad, Singh Jang, Kitagawa Maki, Nazir Mir

Annals of Saudi Medicine 2010 30(1):63-66

Background : The propensity of Ascaris lumbricoides to wander leads to varied surgical complications in the abdomen. Wandering A lumbricoides may sometimes reach the vermiform appendix and its presence there may remain silent or incite pathology. Our aim was to study ascariadial appendicitis. Methods : Over a period of 3 years, we identified children who were found to have appendiceal ascariasis during surgery for different intestinal complications due to ascariasis. We studied the relationship between ascariasis and its lodgement inside the vermiform appendix in these patients. No preoperative diagnosis was made in this series. Results : We found 11 patients with appendiceal ascariasis. It was incidentally found that 8/11 (72.7%) patients had worms inside their vermiform appendix but not appendicitis, whereas the remaining three patients (27.2%) were found to have Ascaris-associated appendicitis. The characteristic finding in Ascaris-infested vermiform appendix was that the worm is positioned with its head at the base and its tail at the tip of the appendix. Conclusion : Migration of A lumbrocoides inside the vermiform appendix is an incidental finding and tends to pursue a silent course in most patients. Only rarely does the presence of Ascaris inside the vermiform appendix cause appendicitis.]]>
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Bleeding duodenal ulcer after Roux-en-Y gastric bypass surgery: The value of laparoscopic gastroduodenoscopy Issa Hussain, Al-Saif Osama, Al-Momen Sami, Bseiso Bahaa, Al-Salem Ahmed Case Report Annals of Saudi Medicine 2010 30(1):67-690256-4947 Issa Hussain, Al-Saif Osama, Al-Momen Sami, Bseiso Bahaa, Al-Salem Ahmed

Annals of Saudi Medicine 2010 30(1):67-69

Roux-en-Y gastric bypass is a common surgical procedure used to treat patients with morbid obesity. One of the rare, but potentially fatal complications of gastric bypass is upper gastrointestinal bleeding, which can pose diagnostic and therapeutic dilemmas. This report describes a 39-year-old male with morbid obesity who underwent a Roux-en-Y gastric bypass. Three months postoperatively, he sustained repeated and severe upper attacks of upper gastrointestinal bleeding. He received multiple blood transfusions, and had repeated upper and lower endoscopies with no diagnostic yield. Finally, he underwent laparoscopic endoscopy which revealed a bleeding duodenal ulcer. About 5 ml of saline with adrenaline was injected, followed by electrocoagulation to seal the overlying cleft and blood vessel. He was also treated with a course of a proton pump inhibitor and given treatment for H pylori eradication with no further attacks of bleeding. Taking in consideration the difficulties in accessing the bypassed stomach endoscopically, laparoscopic endoscopy is a feasible and valuable diagnostic and therapeutic procedure in patients who had gastric bypass.]]>
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Combined occurrence of diabetes mellitus and retinitis pigmentosa Al-Adsani Afaf, Gader Fadl Abdel Case Report Annals of Saudi Medicine 2010 30(1):70-750256-4947 Al-Adsani Afaf, Gader Fadl Abdel

Annals of Saudi Medicine 2010 30(1):70-75

The combined occurrence of diabetes mellitus (DM) and retinitis pigmentosa (RP) is rare. It has been reported in the form of four different syndromes that are inherited in an autosomal recessive fashion. We describe two cases of DM and RP occurring together. The first case was a 35-year-old male who presented with insulin-treated diabetes, obesity, hypertension, polydactyly, normal cognitive functions, an ataxic gait, blindness secondary to RP, dyslipidemia, impaired renal function, and multiple renal cysts. He was diagnosed clinically as having Bardet-Biedl syndrome. The second case was a 34-year-old male who presented with insulin-resistant diabetes, hypertension, blindness secondary to RP, deafness, normal cognitive functions, primary infertility, renal, and liver impairment. He was diagnosed clinically as having Alström syndrome. Because of overlapping clinical manifestations and the cost and time involved in genetic studies, clinical criteria can be used for diagnosis and as a guide for genetic mapping in these patients.]]>
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Hydrogen sulfide exposure in an adult male Doujaiji Bassam, Al-Tawfiq Jaffar A Case Report Annals of Saudi Medicine 2010 30(1):76-800256-4947 Doujaiji Bassam, Al-Tawfiq Jaffar A

Annals of Saudi Medicine 2010 30(1):76-80

Hydrogen sulfide (H 2 S) is responsible for many incidents of occupational toxic exposure, especially in the petroleum industry. The clinical effects of H 2 S depend on its concentration and the duration of exposure. H 2 S is immediately fatal when concentrations are over 500-1000 parts per million (ppm) but exposure to lower concentrations, such as 10-500 ppm, can cause various respiratory symptoms that range from rhinitis to acute respiratory failure. H 2 S may also affect multiple organs, causing temporary or permanent derangements in the nervous, cardiovascular, renal, hepatic, and hematological systems. We present a case of occupational exposure to H 2 S leading to multi-organ involvement, acute respiratory failure, organizing pneumonia, and shock resembling acute sepsis. The patient also developed mild obstructive and restrictive pulmonary disease and peripheral neuropathy.]]>
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Solitary coronary artery nourishing the entire heart Yaymaci Bengi, Ugurlucan Murat, Basaran Murat, Selimoglu Ozer, Kocailik Ali, Akyildiz Senay, Coskun Orhan, Us Melih Case Report Annals of Saudi Medicine 2010 30(1):81-830256-4947 Yaymaci Bengi, Ugurlucan Murat, Basaran Murat, Selimoglu Ozer, Kocailik Ali, Akyildiz Senay, Coskun Orhan, Us Melih

Annals of Saudi Medicine 2010 30(1):81-83

Coronary artery anomalies are being more frequently diagnosed these days both because increasing numbers of patients are undergoing diagnostic studies and because advanced radiographic imaging methods are now commonly available. An isolated single coronary artery giving rise to the main coronary branches is a rare congenital anomaly. In this report we present a patient with a solitary coronary ostium, with both the left and right coronary artery systems arising from it, and then following their usual courses. This case was diagnosed incidentally during conventional angiography.]]>
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Gilbert syndrome in Iran, Fars Province Hemmati Fariba, Saki Forugh, Saki Nasrin, Haghighat Mahmood Letter Annals of Saudi Medicine 2010 30(1):84-840256-4947 Hemmati Fariba, Saki Forugh, Saki Nasrin, Haghighat Mahmood

Annals of Saudi Medicine 2010 30(1):84-84

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Estimated average glucose: A new term in diabetes control Dib Jean G Letter Annals of Saudi Medicine 2010 30(1):85-850256-4947 Dib Jean G

Annals of Saudi Medicine 2010 30(1):85-85

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A case of atrial fibrillation due to <i>Momordica charantia</i> (bitter melon) Erden Ismail, Ordu Serkan, Erden Emine C, Caglar Sabri O Letter Annals of Saudi Medicine 2010 30(1):86-870256-4947 Erden Ismail, Ordu Serkan, Erden Emine C, Caglar Sabri O

Annals of Saudi Medicine 2010 30(1):86-87

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Reactive macrophage activation syndrome in a patient with parvovirus B19 infection, lymphocytic lichenoid vasculitis, urticaria and angioedema Soldo-Juresa Dragica, Radman Maja, Pejsa Vlatko, Bozikov Velimir Image Annals of Saudi Medicine 2010 30(1):88-890256-4947 Soldo-Juresa Dragica, Radman Maja, Pejsa Vlatko, Bozikov Velimir

Annals of Saudi Medicine 2010 30(1):88-89

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