A Case Report of 17α-Hydroxylase Deficiency in Two Saudi Siblings With Different Karyotyping

Congenital adrenal hyperplasia (CAH) consists of variable disorders of sex determination and differentiation. 17α-hydroxylase deficiency (17OHD) is an uncommon form of those disorders, which is typically characterized by hypertension, hypokalemia, failure of puberty, and ambiguous genitalia. The 17α-hydroxylase enzyme is encoded by the CYP17A1 gene and it is required for the synthesis of cortisol and sex steroids. The affected females with 17OHD usually present with primary amenorrhea and delayed puberty, which are associated with hypertension and hypokalemia while male patients might show female external genitalia, pseudohermaphroditism, or variable degrees of ambiguous genitalia with intra-abdominal testes in addition to hypertension and hypokalemia as well. We present two Saudi siblings (19 and 16 years old) who were diagnosed with the rare CAH subtype of 17OHD after presenting with long-standing hypertension, refractory hypokalemia, and failure of puberty. It is interesting that both siblings had biochemical primary adrenal insufficiency; however, both patients did not clinically present with an acute adrenal crisis, which is likely due to the effect of increased levels of deoxycorticosterone. Additionally, although both patients have similar phenotypes and clinical presentations, they have different karyotypes. This again highlights the variability of the manifestations that can result from 17OHD even with an identical mutation in the same family. Both patients were treated successfully with dexamethasone, which has led to the normalization of hypertension, resolution of hypokalemia, and discontinuation of anti-hypertensive medications and potassium supplements after several years of treatment. However, the entire management is quite challenging and requires a multidisciplinary approach regarding difficult issues such as gender identity and assignment and fertility issues in addition to a life-long follow-up.

Use of camel urine is of no benefit to cancer patients: observational study and literature review

Background

Complementary and alternative medicine is widely used in Saudi Arabia. One of the common practices is the use of camel urine alone or mixed with camel milk for the treatment of cancer, which is often supported by religious beliefs.

Aims

To observe and follow-up cancer patients who insisted on using camel urine, and to offer some clinically relevant recommendations.

Methods

We observed 20 cancer patients (15 male, 5 female) from September 2020 to January 2022 who insisted on using camel urine for treatment. We documented the demographics of each patient, the method of administering the urine, reasons for refusing conventional treatment, period of follow-up, and the outcome and side effects.

Results

All the patients had radiological investigations before and after their treatment with camel urine. All of them used a combination of camel urine and camel milk, and treatment ranged from a few days to 6 months. They consumed an average of 60 ml urine/milk per day. No clinical benefit was observed after the treatment; 2 patients developed brucellosis. Eleven patients changed their mind and accepted conventional antineoplastic treatment and 7 were too weak to receive further treatment; they died from the disease.

Conclusion

Camel urine had no clinical benefits for any of the cancer patients, it may even have caused zoonotic infection. The promotion of camel urine as a traditional medicine should be stopped because there is no scientific evidence to support it.

Fibrolamellar hepatocellular carcinoma treated with atezolizumab and bevacizumab: two case reports

Background

Fibrolamellar hepatocellular carcinoma is a unique tumor of the liver that differs from the classical hepatocellular carcinoma in diagnosis, behavior, and possibly treatment. There is usually absent underlying liver disease, and it usually occurs in young patients. The survival outcomes in localized fibrolamellar hepatocellular carcinoma are perhaps better than in classical hepatocellular carcinoma if treated early and radically. On the other hand, the prognosis remains poor for locally advanced and metastatic fibrolamellar hepatocellular carcinoma. Many reports suggested a limited benefit from systemic chemotherapy. Sorafenib also did not show major effects on fibrolamellar hepatocellular carcinoma. Given the rarity of fibrolamellar hepatocellular carcinoma, lack of large studies, and absence of standard treatment, the treatment decisions rely on case reports, previously reported cases series, and expert opinions. Recent studies have shown promising effects of immunotherapy with checkpoint inhibitors in the first- and second-line therapy of hepatocellular carcinoma. Atezolizumab with bevacizumab regimen has been approved recently as a first-line treatment for classical hepatocellular carcinoma. Currently, there are no reports yet on the use of atezolizumab with bevacizumab for fibrolamellar hepatocellular carcinoma.

Case report

In this article, we present two Arabic patients with advanced fibrolamellar hepatocellular carcinoma who received atezolizumab and bevacizumab combinations but did not show any clinical benefits.

Conclusion

While atezolizumab and bevacizumab combinations had shown benefits in classical hepatocellular carcinoma, the current data showed a lack of benefit and tumor response in fibrolamellar hepatocellular carcinoma.

Mechanisms of action of metformin with special reference to cardiovascular protection

Management guidelines continue to identify metformin as initial pharmacologic antidiabetic therapy of choice for people with type 2 diabetes without contraindications, despite recent randomized trials that have demonstrated significant improvements in cardiovascular outcomes with newer classes of antidiabetic therapies. The purpose of this review is to summarize the current state of knowledge of metformin's therapeutic actions on blood glucose and cardiovascular clinical evidence and to consider the mechanisms that underlie them. The effects of metformin on glycaemia occur mainly in the liver, but metformin-stimulated glucose disposal by the gut has emerged as an increasingly import site of action of metformin. Additionally, metformin induces increased secretion of GLP-1 from intestinal L-cells. Clinical cardiovascular protection with metformin is supported by three randomized outcomes trials (in newly diagnosed and late stage insulin-treated type 2 diabetes patients) and a wealth of observational data. Initial evidence suggests that cotreatment with metformin may enhance the impact of newer incretin-based therapies on cardiovascular outcomes, an important observation as metformin can be combined with any other antidiabetic agent. Multiple potential mechanisms support the concept of cardiovascular protection with metformin beyond those provided by reduced blood glucose, including weight loss, improvements in haemostatic function, reduced inflammation, and oxidative stress, and inhibition of key steps in the process of atherosclerosis. Accordingly, metformin remains well placed to support improvements in cardiovascular outcomes, from diagnosis and throughout the course of type 2 diabetes, even in this new age of improved outcomes in type 2 diabetes.

Prediabetes management in the Middle East, Africa and Russia: Current status and call for action

Most data on the burden of diabetes and prediabetes are from countries where local infrastructure can support reliable estimates of the burden of non-communicable diseases. Countries in the Middle East and Africa, together with Russia, have a total population of almost 2 billion, but have been relatively overlooked by authors in this field. We reviewed the prevalence and drivers of prediabetes and diabetes across this large region. A large, and variable, burden of dysglycaemia exists, especially in Middle Eastern and North African countries, associated with high levels of obesity and sedentariness, with a generally lower prevalence in most other parts of Africa. The design and size of studies are highly variable, and more research to quantify the scale of the problem is needed. Local barriers to care relating to issues concerned with gender, consanguinity, lack of understanding of diabetes, lack of understanding of obesity as a health issue, and limited resource at a national level for tracking and intervention for diabetes and other non-communicable diseases. Lifestyle interventions with proven local cost-effectiveness, enhanced access to pharmacologic intervention, and societal interventions to promote better diet and more activity will be an important element in strategies to combat these adverse trends.

The third clinical congress of the gulf chapter of the American Association of Clinical Endocrinologists, October, 29th-31st 2015, Dubai, UAE

These are the advance abstracts of the third clinical congress of the Gulf Chapter of the American Association of Clinical Endocrinologists to be held on 29-31 of October 2015. The educational objective of the congress is to give a “state of the art in endocrine practice”. International and regional key opinion leaders were invited to address topical issues relating to the practice of diabetes care and clinical endocrinology. We present the abstracts of the congress as submitted by the authors after minimal restyling and editing to suit the publication requirements of the journal. Several major issues and topical themes with wide interests in the profession were addressed in 9 plenary lectures. Six clinical practice symposia were developed to target the specific educational needs of the target audience subgroups. In addition to, 16 practical issues will addressed in “Meet the Expert”- type of interactive workshops. Free communications from abstracts submitted by delegates, reflecting mostly the regional epidemiology and clinical practice in diabetes care and endocrinology, were selected for presentations as either oral (10) or poster presentations (30). By publishing the proceedings of our third annual congress in this open access journal, we hope to extend the benefit to those who could not make it to the live presentations and give a safe home for all the abstracts for future reference. Making them permanently available may facilitate regional and international networking and collaboration between clinicians and academics of shared interests.

A novel pathogenic mutation of the CYP27B1 gene in a patient with vitamin D-dependent rickets type 1: a case report

Background

Rickets can occur due to Vitamin D deficiency or defects in its metabolism. Three rare genetic types of rickets with different alterations of genes have been reported, including: Vitamin D dependent rickets type 1, Vitamin D dependent rickets type 2 or also known as Vitamin D resistant rickets and 25 hydroxylase deficiency rickets. Vitamin D dependent rickets type 1 is inherited in an autosomal recessive pattern, and is caused by mutations in the CYP27B1 gene encoding the 1α-hydroxylase enzyme. We report here a new mutation in CYP27B1, which lead to Vitamin D dependent rickets type 1.

Case presentation

We report on a 13-month-old Arabic Saudi girl with Vitamin D dependent rickets type 1 presented with multiple fractures and classic features of rickets. A whole exome sequencing identified a novel pathogenic missense mutation (CYP27B1:Homozygous c.1510C > T(p.Q504X)) which results in a protein truncating alteration. Both parents are heterozygous carriers of the mutation. Based on data search in Human Gene Mutation Database, 63 CYP27B1 alterations were reported: only 28.6% are protein truncating (5 nonsense, 13 frameshift insertions/deletions, 0 gross deletions), while 61.9% are non-truncating (38 missense, 1 small in-frame insertions/deletion), and 9.5% are possible protein-truncating (5 splice, 1 regulatory).

Conclusion

The deleterious effect of this alteration, which was the only mutation detected in the CYP27B1 common gene of Vitamin D dependent rickets type 1 in the proband, and its autosomal recessive inheritance fashion, both support a pathogenic nature of this mutation as the cause of Vitamin D dependent rickets type 1.

Second clinical congress of the gulf chapter of the american association of clinical endocrinologists, october, 23rd-25th 2014, Abu Dhabi, United Arab Emirates

These are the advance abstracts of the second clinical congress of the Gulf Chapter of the American Association of Clinical Endocrinologists to be held on 23-25 of October 2014. The declared educational objectives of the congress is to give a “state of the art in endocrine practice”. To this end, the organizing committee invited international and regional key opinion leaders to meet the objectives of the congress. We present the abstracts of the congress as submitted by the authors after minimal restyling and editing to suit the publication requirements of the journal. Many major issues and topical themes with wide interests in the profession were addressed in 5 plenary lectures. A clinical practice debate was included to highlight the pros and cons of the recently published lipid lower guidelines from both sides of the Atlantic. More focused issues were included in 12 clinical practice symposia to suite the specific educational needs of the target audience subgroups. Practical issues were addressed in “Meet the Expert”-type of interactive workshops. A selection of free communications from abstracts submitted by delegates, reflecting mostly the regional epidemiology and clinical practice in diabetes care and endocrinology, were selected for presentation as either oral or poster presentations.

We hope that by publishing them in this journal we extend the benefit to those who could not make it to the live presentations. The focus of this year's congress included bone health, molecular endocrinology, pituitary and adrenal disease, new advances in diabetes care, nuclear medicine in endocrinology and select topical issues in addition to many other day to day concerns in diabetes care and clinical endocrinology.

Rapid infusion rituximab changing practice for patient care

Rituximab is a chimeric anti-CD20 monoclonal antibody. Its intravenous administration is associated with substantial infusion related-toxicity. Recommended infusion durations are prolonged (average 5-6 h for first infusion and 3-4 h for subsequent infusions). We aimed to explore the safety and tolerability of short infusion rituximab, (over 90 min), in Non-Hodgkin's lymphoma patients at Riyadh Military Hospital. Adult oncology patients diagnosed with Non-Hodgkin's lymphoma, who were to receive rituximab, were included in the study. The schedule of administration for cycle one was unaltered and delivered according to the product monograph (5-6 h). All subsequent cycles were administered over a total infusion time of 90 min (20% of the dose in the first 30 min then the remaining 80% over 60 min, total dose delivered in 500 mL sodium chloride). All patients were observed for infusion related reactions during the rituximab infusion and for 30 min after the infusion. In addition, all patients were advised to report any reaction occurring within 24 h after rituximab infusion.From April 2007 to September 2007, 21 patients with non-Hodgkin's lymphoma were treated with rituximab-based chemotherapy. A total of 126 infusions were administered with average of 6 infusions per patient. The majority of patients were treated with CHOP-Rituximab or CHOP-like regimen. The 90-min Rituximab infusion schedule was well tolerated with no grade 3/4 infusion related adverse events observed. A rapid infusion rituximab over 90 min is well tolerated and safe when administered as the second and subsequent infusions in the course of therapy. This shortened infusion schedule has resulted in a substantial reduction in resource utilization. Our institution has adopted this as routine practice.

Laparoscopic vs. open adrenalectomy: experience at King Faisal Specialist Hospital and Research Centre, Riyadh

BACKGROUND

The laparoscopic approach for adrenalectomy is now widely accepted and preferred over the conventional open approach. We describe our experience of adreanalectomy and compare the results of open and laparoscopic approach.

PATIENTS AND METHODS

From March 1999 to March 2002, we performed 23 adrenalectomies. An anterior transabdominal approach was used for the open procedure, and a lateral transperitoneal approach for the laparoscopic procedure. Data from both groups were analyzed and compared.

RESULTS

There was no difference in tumor size or pathology between two groups. The tumor size was smaller, operative time was longer and estimated blood loss was less in the laparoscopic procedure group, however these differences were statistically insignificant. The mean length of hospital stay was shorter (5.1 vs. 9.2 days, P<0.01), the mean use of postoperative narcotic analgesia was less (4.2 vs. 8.1 injections, P<0.05), and the mean time for resumption of oral intake was faster (1.17 vs. 2 days, P<0.01) in the laparoscopic procedure group compared to the open adrenalectomy group.

CONCLUSION

Laparoscopic adrenalectomy is a safe procedure that can be performed for most adrenal pathology. It is associated with faster recovery, less postoperative pain, and shorter hospital stay.

Impacted cuspids in a Saudi population: prevalence, etiology and complications

The prevalence, etiology and related complications of impacted maxillary and mandibular cuspids were studied among a convenient sample of 4,898 Saudi patients aged 13 years and older. Results indicate that 175 patients (3.6%) out of a sample had at least one impacted cuspid. Most (22.9%) possessed multiple involvement. Female patients were found to be more concerned about the problem (p < .001). The maxillary arches were usually affected more frequently. The most common location of maxillary cuspid impactions was palatal and the lingually located impaction in the mandible was found to be very rare. In most of the subjects the lack of arch space was the main etiological factor. Cuspid impactions were found to be occasionally associated with various unfavorable sequelae.