IN THE NAME OF ALLAH, THE MOST GRACIOUS, …vrgs.ju.edu.sa/files_jen/AUMJ-2-3.pdfMohammed Abdulaziz...

IN THE NAME OF ALLAH, THE MOST GRACIOUS, THE MOST MERCIFUL

AUMJ Editorial Board and Description

Aljouf University Medical Journal (AUMJ), 2015 September 1; 2(3): i - ii.

2015

AUMJ EDITORIAL BOARD AND DESCRIPTION

EDITORIAL BOARD

AUMJ Editor-in-Chief

Prof. Dr. Saleh Abdul Allah Al-Damegh, Professor of Radiology, General Supervisor for

Unaizah Colleges New campus at Qassim University,

Founding Dean of Unaizah College of Medicine and

Applied Medical Sciences, Qassim University, Qassim,

Saudi Arabia.

AUMJ Associate Editor-In-Chief

Prof. Dr. Tarek Hassan El-Metwally, Professor of Medical Biochemistry and Molecular

Biology& Consultant Clinical Biochemist,

Biochemistry Division, Department of Pathology,

CME Coordinator, College of Medicine, Aljouf

University, Sakaka, Saudi Arabia.

AUMJ DEVELOPMENT HISTORY

Aljouf University Medical Journal (AUMJ) was

established under the generous patronage of his esteem

Prof. Dr. Ismail M. Al-Beshry, the Rector

of Aljouf University, as an initiative of his esteem Dr Najm M. AL-Hosainy, The vice-Rector of

Aljouf University for Graduate Studies and Scientific

Research as the General Supervisor of the Journal. The

inaugural issue of AUMJ first appeared September 1,

2014 with Prof. Dr. Saleh A. Al-Damegh, Founding

Dean of Unaizah College of Medicine and Applied

Medical Sciences and General Supervisor for Unaizah

Colleges New campus at Qassim University, Qassim

University, Qassim, Saudi Arabia, as the Founding

Editor-In-Chief.

AUMJ Editors

Prof. Dr. Parviz M Pour, Professor of Pathology,

Department of Pathology and Molecular Biology,

UNMC, NE, USA.

Prof. Dr. Ibrahim M. El-Bagory, Professor

Pharmaceutical Technology, Department of

Pharmaceutics, College of Pharmacy, Aljouf

University, Sakaka, Saudi Arabia.

Dr. Adel A. Maklad, Associate Professor,

Department of Neurobiology & Anatomical Sciences,

University of Mississippi Medical Center, MS, USA.

AUMJ DESCRIPTION AND SCOPE

AUMJ (ISSN: 1658-6700) is an online Open-Access

and printed General Medical Multidisciplinary Peer-

Reviewed International Journal that is published

quarterly (every 3 months; March, June, September and

December) by the Deanship for Graduate Studies and

Scientific Research as the official medical journal of

Aljouf University, Sakaka, Saudi Arabia

(http://vrgs.ju.edu.sa/jer.aspx). AUMJ welcomes

and publishes innovative original manuscripts

encompassing all Basic Biomedical and Clinical

Medical Sciences, Allied Health Sciences - Dentistry,

Pharmacy, Nursing and Applied Medical Sciences, and

biological researches interested in basic and

experimental medical investigations. Such research

includes both academic researches (basic and

translational) and community-based practice

researches.

AUMJ AUDIENCE

Physicians, Clinical Chemists, Microbiologists,

Pathologists, Hematologists, and Immunologists,

Medical Molecular Biologists and Geneticists,

Professional Health Specialists and Policymakers,

Researchers in the Basic Biomedical, Clinical and

Allied Health Sciences, Biological Researchers

interested in Experimental Medical Investigations,

educators, and interested members of the public around

the world.

AUMJ MISSION

AUMJ is dedicated to expanding, increasing the depth,

and spreading of updated internationally competent

peer reviewed genuine and significant medical

knowledge among the journal target audience all over

the world.

AUMJ VISION

To establish AUMJ as an internationally competent

journal within the international medical databases in

publishing peer reviewed research and editorial

manuscripts in medical sciences.

AUMJ OBJECTIVES

1. To evolve AUMJ as a reliable academic reference

within the international databases for researchers

and professionals in the medical arena.

2. Providing processing and publication fee-free

open-access vehicle for publishing genuine and

significant research and editorial manuscripts for

local, regional, and international researchers and

professionals in medical sciences, along with as

being a means of education and academic

leadership.

3. Expanding, increasing the depth, and spreading of

internationally competent and updated medical

knowledge among the AUMJ target audiences for

the benefit of advancing the medical service to the

local and international communities.

AUMJ Editorial Board and Description

Aljouf University Medical Journal (AUMJ), 2015 September 1; 2(3): i - ii.

2015

4. Although insuring integrity and declaration of any

conflict of interest, AUMJ is adopting an

unbiased, fast, and comprehensively constructive

one-month peer review cycle from date of

submission to notification of final acceptance.

PUBLICATION FEE & SCHEDULE

AUMJ is processing and publication fee-free as a

strategy of Aljouf University in support of

investigators worldwide. However, subscription to the

journal and reprint (black and white or color) requests

are placed through Deanship of Library Affairs at

Aljouf University. AUMJ is a bimonthly journal.

Average processing time is 2 month; one month from

receipt to issuing the acceptance letter and one month

for providing the paginated final PDF file of the

manuscript. Abstracts and PDF formatted articles are

available to all Online Guests free of charge for all

countries of the world.

EDITORIAL OFFICE & COMMUNICATION

Aljouf University Medical Journal (AUMJ)

Aljouf University, POB: 2014

Sakaka, 42421, Aljouf, Saudi Arabia

Email: [email protected]

Tel: 00966146252271

Fax:00966146247183

SUBSCRIPTION & EXCHANGE

Deanship of Library Affairs

Aljouf University, POB: 2014

Sakaka, 42421, Aljouf, Saudi Arabia

Email: [email protected]

Tel: 00966146242271

Fax: 00966146247183

Price and Shipping Costs of One Issue is 25 SR within

KSA/25 US$ Abroad.

mailto:[email protected]

AUMJ: Table of Contents

Aljouf University Medical Journal (AUMJ), 2015 September 1; 2(1): iii.

2015

Table of Contents

Aljouf University Medical Journal (AUMJ), 2015 September 1; 2(3)

Content Pages

Description of AUMJ. i-ii

Table of Contents. iii

Comprehensive Instructions for Authors and Reviewers. iv - xvi

Original Articles:

Effect of Body Position on Oxygen Saturation and Respiratory Rate in Neonates with Respiratory Distress: A Single Center Study. Mohamed S El

Farargy, Hamed M El-Sharkawy, Marwa Abd-El-Wahab.

1 - 8

Correlation among the Glycemic Control and Lipogram Indices with Chronic Complications in Saudi Diabetic Patients: Al-Jouf Status. Abdulrahman Abdulwahab Alduraywish, Farhan Musafiq AlAnazi,

Mohammed Abdulaziz Alharbi, Faisal Musaad Al-rasheed, and, Louai T.

Alaithan.

9 - 24

Experimental Diabetic Nephropathy: TGF-beta vs. Kidney Injury Molecule-1 and Apoptotic Biomarkers. Omar A. M. Farghaly, Hosny A.

Hasan, Mohamed A. Abd-Alaziz, Hisham H. Taha.

25 - 38

The Nephroprotective Effect of Zingiber Officinale Extract Against Azathioprine-Induced Renal Damage: An Experimental Histopathological Study. Hassan Aqla Almarshad*, Ahmed Abd El-Hafez Tantawy and Talal

Afet Alenazi.

39 - 46

Serum Progesterone and Estradiol Levels and the Mast Cells Count in Skin Tags among healthy Pregnant and Non-Pregnant Women: Correlation with Age of Pregnancy and Phases of the Menstrual Cycle. Alaa A. Mohamed, Abd El-Aziz El-Rifaie, Yasser Gohary, Khalid A. El-Nesr,

and Ahmed Abd-Eltawab.

47 - 56

Case Report:

Septic hip arthritis superimposed by Reactive Arthritis. Omaima

Abdelmajeed, Amar Ahamed Ibrahim, Rabab Mahdi.

57- 60

AUMJ: Table of Contents

Aljouf University Medical Journal (AUMJ), 2015 September 1; 2(1): iii.

2015

AUMJ Comprehensive Instructions For Authors and Reviewers

Aljouf University Medical Journal (AUMJ), 2015 September 1; 2(3): v - xviii.

2015

AUMJ Comprehensive Instructions for Authors and Reviewers

INTRODUCTION

Types of submission and criteria

Original Research Communications may be offered as

Full Papers, as Short Communications or as Short

research Paper. The latter format is recommended for

presenting technical evaluations and short clinical

notes, comprising up to 1,500 words of text, 15

references, and two illustrative items (Tables and/or

Figures).

Clinical Trials and Case Reports will be accepted only

where they provide novel insight into disease

mechanisms, management, or diagnostic applications.

Reviews and Minireviews will be welcome but

prospective authors are strongly advised to seek

authorization from the Editor-in-Chief to avoid

conflict with scheduled reviews invited by the

Editorial Board. They should address new topics or

trends in basic biomedical, clinical, and allied health

sciences – Dentistry, Pharmacy, Nursing and Applied

Medical Sciences.

Policy Papers, Study Protocols and Pre-Protocols and

Method Articles.

Medical educational articles, Commentaries (on the

clinical, scientific, social, political, and economic

factors affecting health), Opinion, Meeting Summary

and Book review articles. Please contact the Editor-in-

Chief for consideration.

BEFORE YOU BEGIN

THE JOURNAL PLAGIARISM POLICY

AUMJ employs software for

plagiarism screening to verify the originality of

content submitted before reviewing. We strongly

oppose the practice of duplicate publication or any

type of plagiarism. Plagiarized manuscripts would not

be considered for publication. If plagiarism is found in

any published paper after internal investigation, a

letter would be immediately sent to all the authors,

their affiliated institutes and funding agency, if

applicable and subsequently the paper will be

retracted.

AUMJ Editorial Board trusts that authors understand

why the Journal's integrity must be protected through

preventing plagiarism. The manuscript must be free

from plagiarism according to our iThenticate®

plagiarism detection software - defined as ≤1%

similarity or "Text overlap" from any source including

your published works (self-plagiarism). iThenticate®

checks for plagiarism from world-wide databases,

including internet web sites. Even less than that rate in

the results section - case-dependently - may not be

accepted. Manuscripts with the minor plagiarism

scientific misconduct of ≥2% similarity rate per source

with multiple references will not be processed for

publication till corrected.

On initial submission, the manuscript will be tested for

similarity with iThenticate®. The iThenticate

® report

of your manuscript is color-coded such that each

"source" has a unique color that is used for each

instance of copied text (words, sentences, paragraphs)

from the source. We limit the iThenticate® software

check to Abstract, Introduction, Results, Discussion,

Table Titles and contents and Figure contents and

legends, and, it excludes Title page (including authors

names and affiliations), Methods section,

Acknowledgment section, and Literature Cited section

- since similarities in these sections is expected to be

high. However, how high the accepted similarity rates

in those sections is case-dependent and should be as

low as possible.

AUMJ encourages authors to use the Similarity Report

to write original text for the words, phrases, sentences

and/or paragraphs that have similarity of ≥2% with the

identified source published works. We understand the

importance of keeping specific key words and phrases

(molecules, models, drugs, species, equipment, assay

technique, etc). In cases with similarity of ≥2%, the

author(s) will have One of Two Options; either

withdraw the submission, or, resubmit the manuscript

after removing the indicated plagiarism so as to have

≤1% similarity rate per source as determined by

iThenticate®.

Plagiarism policy of this journal is mainly inspired

from the plagiarism policy of The Nature

(http://www.nature.com/authors/policies/plagiarism.ht

ml) and is summarized as described below:

1. Plagiarism is when an author attempts to pass off

someone else's work as his or her own. This

journal also adopted IEEE definition of plagiarism

to deal such cases. It defines plagiarism as "the

reuse of someone else’s prior ideas, processes,

results, or words without explicitly

acknowledging the original author and source.”

2. Plagiarism can be said to have clearly occurred

when large chunks of text have been cut-and-

pasted. Such manuscripts would not be considered

for publication in the journal. Papers with

confirmed plagiarisms are rejected immediately.



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3. But minor plagiarism without dishonest intent is

relatively frequent, for example, when an author

reuses parts of an introduction from an earlier

paper.

4. Duplicate publication, sometimes called self-

plagiarism, occurs when an author reuses

substantial parts of his or her own published work

without providing the appropriate references. This

can range from getting an identical paper

published in multiple journals, to 'salami-slicing',

where authors add small amounts of new data to a

previous paper. Self-plagiarism, also referred to as

‘text recycling’, is a topical issue and is currently

generating much discussion among editors.

Opinions are divided as to how much text overlap

with an author’s own previous publications is

acceptable. We normally follow the guidelines

given in COPE website. Editors, reviewers and

authors are also requested to strictly follow this

excellent guideline (Reference: Text Recycling

Guidelines: http://publicationethics.org/text-

recycling-guidelines).

5. In case of “suspected minor plagiarism”, authors

are contacted for clarification. Depending on all

these reports, reviewers and editors decide final

fate of the manuscript.

6. Use of automated software is helpful to detect the

'copy-paste' problem. All submitted manuscripts

are checked by the help of different databases,

eTBLAST, Plagiarism Detection tools, etc. At the

same time scientific implication of the case

('suspected minor plagiarism'), also judged by

reviewers and editors. Plagiarism Detection tools

are useful, but they should to be used in tandem

with human judgment and discretion for the final

conclusion. Therefore, suspected cases of

plagiarisms are judged by editors on 'case-to-case

basis'.

7. Editors have the final decision power for these

cases.

Ethics in publishing

Policy and ethics

The work described in your article must have been

carried out in accordance with The Code of Ethics of

the World Medical Association (Declaration of

Helsinki) for experiments involving humans

(http://www.wma.net); Uniform Requirements for

manuscripts submitted to Biomedical journals

(http://www.icmje.org) published by the International

Committee of Medical Journal Editors. An official

local authorized body should review the research

project before its beginning and a document

acknowledging the ethical clearance of the research

could be requested from prospective authors. This

must be stated at an appropriate point in the article

(Material and Methods). Research papers based on

animal studies should get a similar ethical clearance

from an official committee for the animal welfare.

Conflict of interest

All authors are requested to disclose any actual or

potential conflict of interest including any financial,

supplements, personal or other relationships with other

people or organizations within three years of

beginning the submitted work that could

inappropriately influence, or be perceived to influence,

their work.

Submission declaration and verification

Submission of an article implies that the work

described has not been published previously (except in

the form of an abstract or as part of a published lecture

or academic thesis or as an electronic preprint), that it

is not under consideration for publication elsewhere,

that its publication is approved by all authors and by

the responsible authorities where the work was carried

out, and that, if accepted, it will not be published

elsewhere in the same form, in English or in any other

language, including electronically without the written

consent of the copyright-holder. To verify originality,

your article may be checked by an appropriate

originality detection service.

Authorship

All authors should have made substantial contributions

to all of the following: (1) the conception and design

of the study, or acquisition of data, or analysis and

interpretation of data, (2) drafting the article or

revising it critically for important intellectual content,

(3) final approval of the version to be submitted.

Changes to authorship

This policy concerns the addition, deletion, or

rearrangement of author names in the authorship of

accepted manuscripts before the accepted manuscript

is published in an online and/or printed issue.

Requests to add or remove an author, or to

rearrange the author names, must be sent to the

Journal Manager from the corresponding author

of the accepted manuscript and must include: (a)

the reason the name should be added or removed,

or the author names rearranged and (b) written

confirmation (e-mail, fax, letter) from all authors

that they agree with the addition, removal or

rearrangement.

In the case of addition or removal of authors, this

includes confirmation from the author being

added or removed.

http://www.wma.net/

http://www.icmje.org/



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Requests that are not sent by the corresponding

author will be forwarded by the Journal Manager

to the corresponding author, who must follow the

procedure as described above.

Journal Deputy Editor will inform the Journal

Editor-in-Chief of any such requests and

publication of the accepted manuscript in an

online issue is suspended until authorship has

been agreed.

After the accepted manuscript is published in an

online and/or printed issue: Any requests to add,

delete, or rearrange author names in an article

published in an online issue will follow the same

policies as noted above and result in a

corrigendum.

Role of the funding source

You are requested to identify who provided financial

support for the conduct of the research and/or

preparation of the article and to briefly describe the

role of the sponsor(s), if any, in study design; in the

collection, analysis and interpretation of data; in the

writing of the report; and in the decision to submit the

article for publication. If the funding source(s) had no

such involvement then this should be stated.

Open access

Once AUMJ is launched as an open access journal,

articles are freely available to both subscribers and the

wider public with permitted reuse. No Open Access

publication fee. All articles published Open Access

will be immediately and permanently free for everyone

to read, download, distribute and copy the article, and

to include in a collective work (such as an anthology),

as long as they credit the author(s) and provided they

do not alter or modify the article.

The processing and publication fee

No processing or publication fee is required.

Language (usage and editing services)

Please write your text in good English (American or

British usage is accepted, but not a mixture of these).

Authors who feel their English language manuscript

may require editing to eliminate possible grammatical

or spelling errors and to conform to correct scientific

English may wish to use any English Language

Editing service available. The abstract content will be

translated into Arabic to accompany the published

manuscript as an Arabic Abstract. In case the author's

mother language is not Arabic, the Journal will help

preparing it.

Submission

Manuscript submission and follow up to this journal

proceeds totally online through email communications

([email protected]). Complete manuscript with tables

and figures inserted within the text at their final place

should be submitted as a single file in the two; word

and PDF formats. The submission and copyright

transfer form is available on request and is mandatory

to hand fill, sign and date by all authors before any

processing of the submitted material. The form is

provided at the last page of every issue of AUMJ.

Authors are encouraged to print and fill the form and

submit alongside with the manuscript.

Referees

A minimum of six suitable potential reviewers (please

provide their name, email addresses, title and

institutional affiliation). When compiling this list of

potential reviewers please consider the following

important criteria: They must be knowledgeable about

the manuscript subject area; must not be from your

own institution; at least two of the suggested reviewers

should be from another country than the authors'; and

they should not have recent (less than four years) joint

publications with any of the authors. However, the

final choice of reviewers is at the editors' discretion.

Types of submission and criteria

Original Research Communications may be offered as

Full Papers or as Short Communications. The latter

format is recommended for presenting technical

evaluations and short clinical notes, comprising up to

1,500 words of text, 15 references, and two illustrative

items (Tables and/or Figures).

Case Reports will be accepted only where they

provide novel insight into disease mechanisms,

diagnostic, and management applications.

Critical Reviews will be welcome but prospective

authors are strongly advised to seek authorization from

the Editor-in-Chief to avoid conflict with scheduled

reviews invited by the Editorial Board. They should

address new topics or trends in fields of the Journal

Scope.

Editorial and opinion pieces Please contact the Editor-

in-Chief for consideration.

PREPARATION

NEW SUBMISSIONS

Submit your manuscript as a single PDF file and a

single Word document file, in any format or layout

that can be used by referees to evaluate your

manuscript. It should contain high enough quality

figures for refereeing.

References

There are no strict requirements on reference

formatting at submission. References can be in any



2015

style or format as long as the style is consistent. Where

applicable, author(s) name(s), chapter title/article title,

journal title/book title, year of publication, volume

number-issue number/book chapter and the pagination

must be present. Use of DOI is highly encouraged. The

reference style used by the journal will be applied to

the accepted article at the proof stage. Note that

missing data will be highlighted at proof stage for the

author to correct.

Formatting requirements

On initial submission, there are no strict formatting

requirements but all manuscripts must contain the

essential elements needed to convey your manuscript

message; Title, Abstract, Keywords, Introduction,

Materials/Patients and Methods, Results with Artwork,

Figures and Tables with legends and titles (below the

figure and on top of the table, respectively),

Discussion, Limitations of the study and Future

directions, Gain of Knowledge, Conclusions, Conflict

of Interest, Acknowledgement (if any), and

References. Upon final acceptance, the author(s) will

be instructed to reformat their manuscript according to

AUMJ format detailed below.

If your article includes any Videos and/or other

Supplementary material, this should be included in

your initial submission for peer review purposes.

Divide the article into clearly defined sections with

title, subtitles and sub-subtitles on separate lines

whenever applicable.

Figures and tables embedded in text. Please ensure the

figures and the tables included in the single file are

placed next to the relevant text in the manuscript.

All standard and non-standard abbreviations should be

define in full at the fist mention in the text and should

be consistent throughout the paper.

In the initial submission, it is advisable to have

references in names (e.g., Smith et al, 2014) within the

text rather than numbering them. Revision and

correction frequently necessitate dropping or inserting

text with their references. Numbering references in

that stage will create the problem of renumbering them

is the text and list.

ORIGINAL RESEARCH PAPER WRITING

TEMPLATE

Papers that include original empirical data that have

not been published anywhere earlier or is not under

consideration for publication elsewhere (except as an

abstract, conference presentation, or as part of a

published lecture or academic thesis), and after

accepted for publication it will not be submitted for

publication anywhere else, in English. Null/negative

findings and replication/refutation findings are also

welcome. If a submitted study replicates or is very

similar to previous work; authors must provide a

sound scientific rationale for the submitted work and

clearly reference and discuss the existing literature.

Submissions that replicate or are derivative of existing

work will likely be rejected if authors do not provide

adequate justification. Studies, which are carried out to

reconfirm/replicate the results of any previously

published paper on new samples/subjects (particularly

with different environmental and/or ethnic and genetic

background) that produces new data-set, may be

considered for publication. But these types of studies

should have a ‘clear declaration’ of this matter. The

English language in submitted articles must be clear,

correct, and unambiguous.

Title page information

Page 1 of the typescript should be reserved for the

title, authors and their affiliation and addresses.

Title. Concise, informative and reflects the study

content. Titles are often used in information-retrieval

systems. Avoid abbreviations and formulae where

possible.

Author names and affiliations. Where the family name

may be ambiguous (e.g., a double name), please

indicate this clearly. Present the authors' affiliation

addresses (where the actual work was done) below the

names. Indicate all affiliations with a superscript

Arabic number immediately after the author's name

and in front of the appropriate address. Provide the full

postal address of each affiliation, including the country

name and the e-mail address and phone number (with

country and area code) of each author.

Corresponding author. The corresponding author

should be indicated in addition with a superscript

asterisk * immediately after his/her affiliation

superscript Arabic number. The corresponding author

will handle correspondence at all stages of refereeing,

publication, and post-publication. Contact details must

be kept up to date by the corresponding author.

Present/permanent address. If an author has moved

since the work described in the article was done, or

was visiting at the time, a 'Present address' (or

'Permanent address') may be indicated as a footnote to

that author's name. The address at which the author

actually did the work must be retained as the main,

affiliation address. Superscript lower-case letters are

used for such footnotes.

Abstract

Page 2 of the typescript should be reserved for the

abstract which should be presented in a structured

format and should not exceed 300 words. The



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following headings should be included for research

articles followed by a colon: a) Background, b)

Hypothesis/Objectives: c) Materials/Patients and

Methods: d) Results: e) Conclusions (should be data

justified). Suitable headings could be used for other

types of publications (Case reports, Review articles,

etc).

A concise and factual abstract is required. The abstract

should state briefly the purpose of the research, the

principal results and major conclusions. An abstract is

often presented separately from the article, so it must

be able to stand alone. For this reason, References

should be avoided. Non-standard or uncommon

abbreviations should be avoided, but if essential they

must be defined at their first mention in the abstract

itself.

Keywords

Immediately after the abstract, provide a maximum of

10 keywords for full papers, or 5 keywords for Short

Communications, using American spelling and

avoiding general and plural terms and multiple

concepts (avoid, for example, "and", "of"). Please use

terms from the most current issue of medical subject

headings of Index Medicus. The key words should

cover precisely the contents of the submitted paper and

should give readers sufficient information as to the

relevance of the paper to his/her particular field. Be

sparing with abbreviations: only abbreviations firmly

established in the field may be eligible. These

keywords will be used for indexing purposes.

Introduction

Provide adequate background that highlights the

importance and gap information of your research point

in relation to previous studies, but avoiding a detailed

literature survey. State the hypothesis or rationale and

objectives of the work and a brief description of how

you planned to approach them.

Materials or Patients and Methods

Provide sufficient detail to allow the work to be

reproduced, with details of supplier and catalogue

number when appropriate. Methods already published

should be indicated by a reference: only relevant

modifications should be described.

Patients and Normal Subjects

If human participants were used in the experiment

please make a statement to the effect that this study

has been approved by your Institution Ethics Review

Board for human studies, and, that patients or their

custodians have signed an informed consent that also

states right of withdrawal without any consequences.

Sample sized should be appropriately calculated. The

manuscript should describe how the size of the

experiment was planned. If a sample size calculation

was performed this should be reported in detail,

including the expected difference between groups, the

expected variance, the planned analysis method, the

desired statistical power and the sample size thus

calculated. For parametric data, variance should be

reported as 95% confidence limits or standard

deviations rather than as the standard error of the

mean. Normal participants and patients criteria,

inclusion and exclusion criteria should be stated.

Name and address where the work was done and when

it was done (time period, from …. to …..) should be

clearly stated, too.

Experimental animals

When animals were used in the experiments, a local

Institutional Ethics Review Board for animal studies

should review and approve the experiment and that all

animal procedures were in accordance with the

standards set forth in guidelines for the care and use of

experimental animals by Committee for Purpose of

Supervision of Experiments on Animals (CPCSEA)

and according to National Institute of Health (NIH)

protocol. The precise species, strain, substrain and

source of animals used should be stated. Where

applicable (for instance in studies with genetically

modified animals) the generation should also be given,

as well as the details of the wild-type control group

(for instance littermate, back cross etc). The

manuscript should describe the method by which

animals were allocated (randomized) to experimental

groups, particularly for comparisons between groups

of genetically modified animals (transgenic, knockout

etc), the method of allocation to for instance sham

operation or focal ischemia should be described.

Experimental

Provide sufficient detail to allow the work to be

reproduced. Methods already published should be

indicated by a reference: only relevant modifications

should be described. Where and when the study was

conducted should be stated.

Results

Results should be clear and concise. Data should be

presented in an appropriately organized tables, figures

and/or artworks. The statistical analysis used should be

suitable for the objectives of the study and type of data

analyzed. Prospective authors are highly advised to

consult a biostatician.

Footnotes

Footnotes should be used sparingly. For table

footnotes, indicate each footnote in a table with a

superscript lowercase letter or add them into the title.



2015

Graphical abstract

A Graphical abstract is optional and should summarize

the contents of the article in a concise, pictorial form

designed to capture the attention of a wide readership

online. Authors must provide images that clearly

represent the work described in the article. Please

provide an image with a minimum of 531 × 1328

pixels (h × w) or proportionally more. The image

should be readable at a size of 5 × 13 cm using a

regular screen resolution of 96 dpi. It is preferable to

be inserted at its normal place to the relevant text or

otherwise be submitted as a separate TIFF, EPS, PDF

or MS Office files.

Discussion

This should explore the significance, interpretation and

reasoning of the results of the work vs. other studies.

Do not repeat describing the results in this section. A

combined Results and Discussion section is

acceptable. Avoid extensive citations and discussion of

published literature. In the same time, avoid

speculations without a supporting literature. Avoid

discussion based on "Data not Shown" or "Personal

Communications".

Limitations and Future Prospective

The authors may wish to pinpoint the limitations of the

study and their reason and foresee the next step to go

from their study. This may be presented in a short

Limitations and Future Prospective section standing

alone or as a separate paragraph in the Discussion or

Results/Discussion section.

Conclusions

The main conclusions of the study may be presented in

a short Conclusions section standing alone or as a

separate paragraph at the end of the Discussion or

Results/Discussion section. Conclusions should not be

biased and should be based on the data, presented and

discussed inside the manuscript only.

Gain of Knowledge

Following the conclusion section, it is mandatory for

manuscripts submitted for final publication in AUMJ

to have a Gain of Knowledge section that is consisted

of 2 - 5 bullet points (maximum 90 characters,

including spaces, per bullet point) that convey the core

findings of the article.

Acknowledgements

Collate acknowledgements in a separate section at the

end of the article before the references. List

individuals or organizations that provided help during

the research (e.g., providing language help, writing

assistance or proof reading the article, etc.). Whoever

would be acknowledged should be informed and a

verification for that could be requested by AUMJ

Editor.

Appendices

If there is more than one appendix, they should be

identified as A, B, etc. Formulae and equations in

appendices should be given separate numbering: Eq.

(A.1), Eq. (A.2), etc.; in a subsequent appendix, Eq.

(B.1) and so on. Similarly for tables and figures: Table

A.1; Fig. A.1, etc.

CASE REPORT WRITING TEMPLATE

Title. Include the words “case report” in the title.

Describe the phenomenon of greatest interest (e.g.,

symptom, diagnosis, diagnostic test, intervention, and

outcome).

Abstract. Summarize the following information if

relevant: 1) Rationale for this case report, 2)

Presenting concerns (e.g., chief complaints or

symptoms, diagnoses), 3) Interventions (e.g.,

diagnostic, preventive, prognostic, therapeutic

exchange), 4) Outcomes, and 5) Main lesson(s) from

this case report.

Key Words. Provide 3 - 8 key words that will help

potential readers search for and find this case report.

Introduction. Briefly summarize the background and

context of this case report.

Presenting Concerns. Describe the patient

characteristics (e.g., relevant demographics - age,

gender, ethnicity, occupation) and their presenting

concern(s) with relevant details of related past

interventions.

Clinical Findings. Describe: 1) the medical, family,

and psychosocial history including lifestyle and

genetic information; 2) pertinent co-morbidities and

relevant interventions (e.g., self-care, other therapies);

and 3) the physical examination (PE) focused on the

pertinent findings including results from testing.

Timeline. Create a timeline that includes specific dates

and times (table, figure, or graphic).

Diagnostic Focus and Assessment. Provide an

assessment of the; 1) diagnostic methods (e.g., PE,

laboratory testing, imaging, questionnaires, referral),

2) diagnostic challenges (e.g., financial, patient

availability, cultural), 3) diagnostic reasoning

including other diagnoses considered, and, 4)

prognostic characteristics (e.g., staging) where

applicable.

Therapeutic Focus and Assessment. Describe: 1) the

type(s) of intervention (e.g., preventive,

pharmacologic, surgical, lifestyle, self-care) and 2) the



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administration and intensity of the intervention (e.g.,

dosage, strength, duration, frequency.

Follow-up and Outcomes. Describe the clinical course

of this case including all follow-up visits as well as 1)

intervention modification, interruption, or

discontinuation, and the reasons; 2) adherence to the

intervention and how this was assessed; and 3) adverse

effects or unanticipated events. In addition, describe:

1) patient-reported outcomes, 2) clinician-assessed and

‐reported outcomes, and 3) important positive and

negative test results.

Discussion. Please describe: 1) the strengths and

limitations of this case report including case

management, 2) the literature relevant to this case

report (the scientific and clinical context), 3) the

rationale for your conclusions (e.g., potential causal

links and generalizability), and 4) the main findings of

this case report: What are the take-away messages?

Patient Perspective. The patient should share his or

her experience pr perspective of the care in a narrative

that accompanies the case report whenever

appropriate.

Informed Consent. Did the patient or their custodian

give the author of this case report informed consent?

Provide if requested .

Case Report Submission Requirements: 1) Competing

interests, are there any competing interests?, 2) Ethics

Approval, Did an ethics committee or institutional

review board review give approval? If yes, please

provide if requested, 3) De‐Identification, Has all

patient's related data been de-indentified?

RANDOMIZED CLINICAL TRIALS WRITING

TEMPLATE

In this particular type of original study, individuals are

randomly allocated to receive or not receive a

preventive, therapeutic, or diagnostic intervention and

then followed up to determine the effect of the

intervention. All randomized clinical trials should

include a flow diagram and authors should provide a

completed randomized trial checklist (see CONSORT

Flow Diagram and Checklist; http://www.consort-

statement.org) and a trial protocol.

Authors of randomized controlled trials are

encouraged to submit trial protocols along with their

manuscripts.

All clinical trials must be registered (before

recruitment of the first participant) at an appropriate

online public that must be independent of for-profit

interest (http://www.clinicaltrials.gov;

http://www.anzctr.org.au; http://www.umin.ac.jp/ctr;

http://isrctn.org;

http://www.trialregister.nl/trialreg/index.asp).

Each manuscript should clearly state an objective or

hypothesis; the design and methods (including the

study setting and dates, patients or participants with

inclusion and exclusion criteria, or data sources, and

how these were selected for the study); the essential

features of any interventions; the main outcome

measures; the main results of the study; a comment

section placing the results in context with the

published literature and addressing study limitations;

and the conclusions.

Data included in research reports must be original. A

structured abstract not exceeding 300 words is

required. Clinical trials are limited to 2700 words (not

including abstract, tables, figures, and references), 40

references, and no more than 5 tables and figures.

REVIEW, MINIREVIEW AND META-

ANALYSIS PAPERS

These papers will not have empirical data acquired by

the authors but will include historical perspectives,

analysis and discussion of papers published and data

acquired in a specific area.

Systematic reviews and meta-analyses are a particular

type of original articles that perform systematic,

critical assessment of literature and data sources

pertaining to clinical topics, emphasizing factors such

as cause, diagnosis, prognosis, therapy, or prevention.

All articles or data sources should be searched for and

selected systematically for inclusion and critically

evaluated, and the search and selection process should

be described in detail in the manuscript. The specific

type of study or analysis, population, intervention,

exposure, and tests or outcomes should be described

for each article or data source. A structured abstract of

less than 300 words is required. The text is limited to

3500 words (not including abstract, tables, figures, and

references); about 4 tables (a flow diagram that depicts

search and selection processes as well as evidence

tables should be included) - and no reference limit.

Minireview is a brief historical perspective, or

summaries of developments in fast-moving areas

covered within the scope of the journal. They must be

based on published articles; they are not outlets for

unpublished data. They may address any subject

within the scope of the journal. The goal of the

minireview is to provide a concise very up-to-date

summary of a particular field in a manner

understandable to all readers.

http://www.trialregister.nl/trialreg/index.asp



2015

SHORT COMMUNICATION AND SHORT

RESEARCH ARTICLE

Short Communications are urgent communications of

important preliminary results that are very original, of

high interest and likely to have a significant impact on

the subject area of the journal. A Short

Communication needs only to demonstrate a ‘proof of

principle’. Authors are encouraged to submit an

Original Research Paper to the journal following their

Short Communication. There is no strict page limit for

a Short Communication; however, a length of 2500-

3500 words, plus 2-3 figures and/or tables, and 15-20

key references is advisable. Short Research Article

may be smaller single-result findings as a brief

summary that include enough information, particularly

in the methods and results sections, that a reader could

understand what was done.

POLICY PAPER

The purpose of the policy paper is to provide a

comprehensive and persuasive argument justifying the

policy recommendations presented in the paper, and

therefore to act as a decision-making tool and a call to

action for the target audience.

COMMENTARIES/OPINION ARTICLES

An opinion-based article on a topical issue of broad

interest, which is intended to engender discussion.

STUDY PROTOCOLS AND PRE-

PROTOCOLS

AUMJ welcomes publishing protocols for any study

design, including observational studies and systematic

reviews. All protocols for randomized clinical trials

must be registered and follow the CONSORT

guidelines; ethical approval for the study must have

been already granted. Study pre-protocols (i.e.,

discussing provisional study designs) may also be

submitted and will be clearly labeled as such when

published. Study protocols for pilot and feasibility

studies may also be considered.

METHOD ARTICLES

These articles describe a new experimental or

computational method, test or procedure, and should

have been well tested. This includes new study

methods, substantive modifications to existing

methods or innovative applications of existing

methods to new models or scientific questions. We

also welcome new technical tools that facilitate the

design or performance of experiments or operations

and data analysis such as software and laboratory and

surgical devices, or of new technologies to assist

medical diagnosis and treatment such as drug delivery

devices.

Maximum length of submissions

Full length original research articles should not

exceed 5000 words (maximum 40 references), and up

to 6 tables and/or figures.

Short communications comprising up to 1800 words of

text, maximum 15 references, and two illustrative

items (Tables and/or Figures).

Letters and Case Reports (provide novel insight into

disease mechanisms, diagnostic and management

applications). Clinical Laboratory Notes (technical

evaluation or important insight into analytical

methodology), or Letters to the Editor (focused on a

specific article that has appeared in Aljouf Medical

Journal within 4 weeks of print issue date of article).

For all 3 types of letters listed above, the text should

not exceed 600 words, with no abstract, a maximum of

1 table or figure and up to 5 references.

Review Articles, Surveys, Essays, and Special Reports

may exceed the word and reference limit for Full-

length articles as per the comprehensive nature of

these articles. However, both of these articles

(Reviews and Special Reports) will still require an

abstract (unstructured, 250 word maximum).

Editorials, Meeting summary, Commentaries, Book

review and Opinion pieces will not require an abstract

and will be limited to 2000 words and up to 20

references. A book review is a brief critical and

unbiased evaluation of a current book determined to be

of interest to the journal audience. Publication of a

submitted book review is at the discretion of the

editor.

Artwork

General points

Make sure you use uniform lettering and sizing of your

original artwork. Preferred fonts: Arial (or Helvetica),

Times New Roman (or Times), Symbol, Courier.

Number the illustrations according to their sequence in

the text. Use a logical naming convention for your

artwork files. Indicate per figure if it is a single, 1.5 or

2-column fitting image. For Word submissions only,

you may still provide figures and their captions, and

tables within a single file at the revision stage.

Formats

Regardless of the application used, when your

electronic artwork is finalized, please 'save as' or

convert the images to one of the following formats

(note the resolution requirements for line drawings,

halftones, and line/halftone combinations given

below). Please do not supply files that are optimized

for screen use (e.g., GIF, BMP, PICT, WPG); the

resolution is too low, supply files that are too low in



2015

resolution, and, submit graphics that are

disproportionately large for the content.

EPS (or PDF): Vector drawings. Embed the font

or save the text as 'graphics'.

TIFF (or JPG): Color or grayscale photographs

(halftones): always use a minimum of 300 dpi.

TIFF (or JPG): Bitmapped line drawings: use a

minimum of 1000 dpi.

TIFF (or JPG): Combinations bitmapped

line/half-tone (color or grayscale): a minimum of

500 dpi is required.

Color artwork

Please make sure that artwork files are in an

acceptable format (TIFF (or JPEG), EPS (or PDF), or

MS Office files) and with the correct resolution. If,

together with your accepted article, you submit usable

color figures the Journal will ensure that these figures

will appear in color on the Web regardless of whether

or not these illustrations are reproduced in color in the

printed version. Because of technical complications

which can arise by converting color figures to 'gray

scale' please submit in addition usable black and white

versions of all the color illustrations.

Figure captions

Ensure that each illustration has a caption (Legend). A

caption should comprise a brief title below the figure

that describes its content and not to be general. Keep

text in the illustrations themselves to a minimum but

explain all symbols and abbreviations used in the

legend. Figure caption should stand for itself (self-

explanatory) without the need for consulting the text.

Tables

Number tables consecutively in accordance with their

appearance in the text. Place footnotes to tables below

the table body and indicate them with superscript

lowercase letters within the table. If necessary, such

footnotes could be placed at the end of the table title.

Avoid vertical rules. Be sparing in the use of tables

and ensure that the data presented in tables do not

duplicate results described elsewhere in the article

(Figures or text). The table caption (Title) should be

brief but describes its content and not to be general.

Explain all symbols and abbreviations used in the table

in the footnote. Table title should stand for itself (self-

explanatory) without the need for consulting the text.

The table structure should be scientifically organized

(columns and rows) and its message should be easily

comprehendible.

The Editor-in-Chief, on accepting a manuscript, may

recommend that additional tables and/or graphs

containing important backup data, too extensive to be

published in the article, may be published as

supplementary material. In that event, an appropriate

statement will be added to the text. However, the

author should submit such material for consideration

with the manuscript.

References

References cited should be relevant, up-to-date and

adequately cover the field without ignoring any

supportive or conflicting publications. Please ensure

that every reference cited in the text is also present in

the reference list (and vice versa). If present,

unpublished results and personal communications may

be mentioned in the text and not in the reference list.

Citation of a reference as 'in press' implies that the

item has been accepted for publication, and shows up

on PubMed literature search or a copy of the title page

of the relevant article must be submitted. DOI of the

references - whenever applicable should be presented.

Reference management software

This journal has standard templates available in key

reference management packages EndNote

(http://www.endnote.com/support/enstyles.asp) and

Reference Manager

(http://refman.com/support/rmstyles.asp). Using plug-

ins to word processing packages, authors only need to

select the appropriate journal template when preparing

their article and the list of references and citations to

these will be formatted according to the journal style,

which is described below.

Reference formatting

There are no strict requirements on reference

formatting at submission but should be consistent,

complete and up-to-date. Where applicable, author(s)

name(s), chapter title/article title, journal title/book

title, year of publication, volume number-issue

number/book chapter and the pagination must be

present. For the book reference, the edition number,

editors (if they are not the authors), publisher and its

main address (City and Country) should be added as

described below in the example. The reference style

used by the journal should be applied to the accepted

article at the proof stage. Note that missing data will

be highlighted at proof stage for the author to correct.

Use peer-reviewed references only except for national

and international organizational reporting and

registers. If you do wish to format the references

yourself they should be arranged according to the

following examples:

Reference style

Indicate references by number(s) in curved brackets as

a bolded superscript at the end of the cited text(s)

before the full stop, e.g., ………. shorter hospital stay

and lower cost(20)

. The actual authors can be referred



2015

to, but the reference number(s) must always be given.

Number the references in the list in the order in which

they appear in the text. The authors list should not be

shortened, all authors’ names should be mentioned.

For further details you are referred to 'Uniform

Requirements for Manuscripts submitted to

Biomedical Journals' (J Am Med Assoc 1997; 277:

927-34) (see also

http://www.nlm.nih.gov/bsd/uniform_requirements.ht

ml).

Examples:

Reference to a journal publication: Format your

journal publications according to the following

examples depending on whether; 1) It is already

published with specific page numbers, 2 and 3) It is

already published with article ID number and pages

from 1 to …, or 4) It is published put ahead of print.

1. Van der Geer J, Hanraads JAJ, Lupton RA. The

art of writing a scientific article. J. Sci.

Commun., 2010;163(1):51-9.

2. Leta S, Dao TH, Mesele F, Alemayehu G.

Visceral Leishmaniasis in Ethiopia: An

Evolving Disease. PLoS Negl Trop Dis., 2014;

8(9):e3131;1-7.

3. Arjmand MH, Ahmad Shah F, Saleh

Moghadam M, Tara F, Jalili A, Mosavi Bazaz

M, Hamidi Alamdari D. Prooxidant-antioxidant

balance in umbilical cord blood of infants with

meconium stained of amniotic fluid. Biochem

Res Int., 2013;2013:ID270545;1-4.

4. Teferra RA, Grant BJ, Mindel JW, Siddiqi TA,

Iftikhar IH, Ajaz F, Aliling JP, Khan MS,

Hoffmann SP, Magalang UJ. Cost

minimization using an artificial neural network

sleep apnea prediction tool for sleep studies.

Ann Am Thorac Soc., 2014 Jul 28 (Epub ahead

of print).

Reference to a book:

Strunk Jr W, White EB (Editors). The elements of

style, 4th

Edition, Longman, New York; 2000, pp. 210-

9.

Reference to a chapter in an edited book:

Mettam GR, Adams LB. How to prepare an electronic

version of your article. In: Jones BS, Smith RZ

(Editors), Introduction to the electronic age, 1st

Edition, E-Publishing Inc., New York, 2009, Chapter

2: pp. 281-304.

Reference to a homepage:

It is acceptable to refer to an Organizational

Guidelines, Reports, Forms, Data sheets,

Questionnaires, etc. It should follow the following

format. World Health Organization. Non-

communicable Diseases (NCD) Country Profile, 2014

(http://www.who.int/globalcoordinationmechanism/pu

blications/ncds-country-profiles-eng.pdf; last accessed

June, 3, 2015).

Journal abbreviations source

Journal names should be abbreviated according to the

List of Title Word Abbreviations:

http://www.issn.org/services/online-services/access-to-

the-ltwa/.

Abbreviations and units

Standard abbreviations as listed in the Council of

Biology Editors Style Manual may be used without

definition. Use non-standard abbreviations sparingly,

preceding their first use in the text with the

corresponding full designation. Use units in

conformity with the standard International System (SI)

of units.

Video data

The journal accepts video material and animation

sequences to support and enhance your scientific

research. Authors who have video or animation files

that they wish to submit with their article are strongly

encouraged to include links to these within the body of

the article. This can be done in the same way as a

figure or table by referring to the video or animation

content and noting in the body text where it should be

placed. All submitted files should be properly labeled

so that they directly relate to the video file's content. In

order to ensure that your video or animation material is

directly usable, please provide the files in one of our

recommended file formats with a preferred maximum

size of 50 MB. Video and animation files supplied will

be published online in the electronic version of your

article. Since video and animation cannot be

embedded in the print version of the journal, please

provide text for both the electronic and the print

version for the portions of the article that refer to this

content.

AudioSlides

AUMJ encourages authors to create an AudioSlides

presentation with their published article as

supplementary material. This gives authors the

opportunity to summarize their research in their own

words and to help readers understand what the paper is

about. Authors of this journal will automatically

receive an invitation e-mail to create an AudioSlides

presentation after acceptance of their paper.

Supplementary data

AUMJ accepts electronic supplementary material to

support and enhance your scientific research.

http://www.nlm.nih.gov/bsd/uniform_requirements.html

http://www.nlm.nih.gov/bsd/uniform_requirements.html



2015

Supplementary files offer the author additional

possibilities to publish supporting applications, high-

resolution images, background datasets, sound clips

and more. Supplementary files supplied will be

published online alongside the electronic version of

your article. In order to ensure that your submitted

material is directly usable, please provide the data in

one of our recommended file formats. Authors should

submit the material in electronic format together with

the article and supply a concise and descriptive caption

for each file.

Supplementary material captions

Each supplementary material file should have a short

caption which will be placed at the bottom of the

article, where it can assist the reader and also be used

by search engines.

THE COPYRIGHTS

The copyrights of all papers published in this journal

are retained by the respective authors as per the

'Creative Commons Attribution License'

(http://creativecommons.org/licenses/by/3.0/). The

author(s) should be the sole author(s) of the article and

should have full authority to enter into agreement and

in granting rights to the journal, which are not in

breach of any other obligation. The author(s) should

ensure the integrity of the paper and related works.

Authors should mandatorily ensure that submission of

manuscript to AUMJ would result into no breach of

contract or of confidence or of commitment given to

secrecy.

Submission checklist

The following list will be useful during the final

checking of an article prior to sending it to the journal

for review. Please consult this Guide for Authors for

further details of any item.

To avoid unnecessary errors you are strongly advised

to use the 'spell-check' and 'grammar-check' functions

of your word processor.

Ensure that the following items are present:

One author has been designated as the corresponding

author with contact details for all authors:

• E-mail address.

• Full postal address.

• Telephone.

All necessary files have been uploaded, and contain:

• Keywords.

• All figures and their captions.

• All tables (including title, description, footnotes).

Further considerations

• Manuscript has been 'spell-checked' and

'grammar-checked'.

• All references mentioned in the Reference list are

cited in the text, and vice versa.

• Permission has been obtained for use of

copyrighted material from other sources

(including the Web).

• Color figures are clearly marked as being

intended for color reproduction on and in print,

or to be reproduced in color electronically and in

black-and-white in print.

PEER REVIEW PROCESS

High quality manuscripts are peer-reviewed by

minimum of two peers of the same field along with a

biostatician in the case the study requires. Pre-

reviewing advice and help will be provided by the

Editor-In-Chief on first submission for initial

improvements to meeting the minimum criteria of

peer-reviewing. The journal follows strict double blind

fold constructive review policy to ensure neutral

evaluation. During this review process identity of both

the authors and reviewers are kept hidden to ensure

unbiased evaluation. A cycle of one-month reviewing

process is the target of the journal from submission to

final acceptance. For meeting this goal, the Editor-In-

Chief is expecting strict compliance from author

hastening corrections and replying editorial requests.

Continuous post-publication open peer reviewing is

highly encouraged through submitting comments to

the Editor on any of the published article that will

show up with author reply in the subsequent issue to

the journal.

The reviewers’ comments are sent to authors once

received. With the help of the reviewers’ comments,

FINAL decision (accepted or accepted with minor

revision or accepted with major revision or rejected)

will be sent to the corresponding author. Reviewers are

asked if they would like to review a revised version of

the manuscript. The editorial office may request a re-

review regardless of a reviewer's response in order to

ensure a thorough and fair evaluation.

In order to maintain this journal’s mission of one-

month publication cycle, authors are encouraged to

submit the revised manuscript within one week of

receipt of reviewer’s comment (in case of minor

corrections). However, revised manuscript submission

should not go beyond 2 weeks (only for the cases of

major revision which involves additional experiment,

analysis etc.). Along with corrected manuscript

authors will be requested to submit filled a point-by-

point answers to the reviewers' comments and any

rebuttal to any point raised. The Editor-In-Chief of the

journal will have exclusive power to take final



2015

decision for acceptance or rejection during any

dispute.

Under special circumstance, if the review process

takes more time, author(s) will be informed

accordingly. The editorial board or referees may re-

review manuscripts that are accepted pending revision.

Manuscripts with latest and significant findings will be

handled with the highest priority so that it could be

published within a very short time. The journal is

determined to promote integrity in research

publication. In case of any suspected misconduct, the

journal management reserves the right to re-review

any manuscript at any stages before final publication.

Our massage to AUMJ potential reviewers says

“Although the Manuscript General Evaluation Form is

attached, we like to instigate a policy of constructive

reviewing and to do our best to make the submitted

manuscripts publishable - provided that it is genuine

and contain no major frauds of republication, duplicate

use of self data or plagiarism of intellectual properties

of the others. Please, make your changes and insert

your corrections, comments and suggestions directly

into the manuscript text but in a different color. Please

also make sure that the author(s) presented an

inclusive and updated list of genuine references,

applied proper statistics and extracted justified

conclusions”.

Manuscript General Revision Form

The Manuscript Assigned Number and Title: ……..

The Manuscript Evaluation Score: Please, score the

manuscript from 0 to 4 (highest) for each of the

following items, and sum the total score. Please, also

check if the statistics of the results require revision.

Items Scores 0 1 2 3 4 Item

Score

The Study is a Priority

Problem

Originality

Significance of the Work

Research Design

Quality and Clarity of the

English Writing

Standard and Reproducible

Methodology

Results Presentation and

Appropriate Statistics

Relevant Discussion and

Justified Conclusions

Tables/ Illustrations/ Figures

References: Inclusive and

Updated

Total score

Requires Statistical Revision (Mark Please) Yes No

The Decision: Should AUMJ publish the

manuscript? Please, check the appropriate box.

Yes, without any revision: Accepted

Yes, with minor revision

and alterations:

Accepted with

revision

Yes, with major revision

and alterations:

Re-Evaluation after

substantial revision

No, this manuscript should

be denied publication: Denied

Justification for Decision & Feedback for the

Author (REQUIRED): AUMJ recommends the

reviewer to introduce such justifications and feedback

into the text at the appropriate places within the

manuscript (Specific and Comprehensive Revision).

Note to the Editor (WELCOMED): AUMJ welcomes

reviewer writing a note to the Editor including conflict

of interest that will not be disclosed to the Author(s).

AFTER ACCEPTANCE

Online proof correction

Corresponding authors will receive an e-mail with

annotation for correction of MS format proofs and

resend the corrected version. All instructions for

proofing will be given in the e-mail we send to

authors. We will do everything possible to get your

article published quickly and accurately - please

upload all of your corrections within 48 hours. It is

important to ensure that all corrections are sent back to

us in one communication. Please check carefully

before replying, as inclusion of any subsequent

corrections cannot be guaranteed. Proofreading is

solely your responsibility.

Offprints

The corresponding author, at no cost, will be provided

with a PDF file of the article via email (the PDF file is

a watermarked version of the published article and

includes a cover sheet with the journal cover image

and a disclaimer outlining the terms and conditions of

use). For an extra charge, paper offprints can be

ordered via the offprint order form, which is sent once

the article is accepted for publication. Both

corresponding and co-authors may order offprints at

any time.

PATIENT CONSENT FORM

Date: ………………...

Place: ………………………….

Title of the article

Name of the Author(s)

Patient’s name:

I give my consent for this material to be published in

Aljouf University Medical Journal and associated



2015

publications without limit on the duration of

publication.

I understand that the material will be published in

Aljouf University Medical Journal will be included in

any reprints of the published article. I understand that

my name will not be included in the published article,

and that every effort will be made to keep my identity

anonymous in the text and in any images. However, I

understand that complete anonymity and control of all

uses cannot be guaranteed.

Signed: …………………………………………

Full name of the relative: …………………..........

Relation: ……………………………………….

Patient’s Name and Contact Address

Corresponding Author’s Name and Contact Address

Alternative:

I have been offered the opportunity to preview the

material in the format it will eventually appear and I

am satisfied with it.

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El Farargy et al - Effect of body position on oxygen saturation and respiratory …….

Aljouf University Medical Journal (AUMJ), 2015 September 1; 2(3): 1 - 7.

2015 2015

Original Article

Effect of Body Position on Oxygen Saturation and Respiratory Rate in Neonates with Respiratory Distress: A

Single Center Study

Mohamed S El Farargy1*

, Hamed M El-Sharkawy1, Marwa Abd-El-Wahab

2

Departments of 1Pediatrics and

2Medical Microbiology, Faculty of Medicine, Tanta

University, Tanta, Egypt.

*Corresponding Author: [email protected]

Abstract

Background: Respiratory distress is defined as a condition in which the patient is not

able to get enough oxygen or defined as a progressive impairment of the lung to

exchange gas. Aim: We studied the effect of different positions on oxygen saturation

of respiratory distressed newborn and the duration required in each position. Patient

and Methods: the study consisted of 50 neonates suffering from respiratory distress in

Neonatal Intensive Care Unit at Tanta University Hospital. Three Tools were used to

collect data: Structured questionnaire sheet, physical assessment sheet and position's

record sheet. Results Our results revealed that there was a statistical significant

difference in the three positions after 120 minutes of mean value of respiratory rate

with different durations in relation to positions and period of follow up. The study

revealed that there was a statistical significant difference in the three positions during

the five duration regarding the mean value of oxygen saturation in relation to position

and period of follow up. The study showed that the best time for maximum oxygen

saturation was 120 min in Semi-Fowler position. Conclusion: Changing the body

position has a significant beneficial effect on the oxygenation of the neonates suffering

from respiratory distress. It was found that Semi-Fowler position was the best position

to improve oxygen saturation compared to supine and prone position. The duration

required to achieve maximum oxygen saturation in the three positions was 120 minute.

El Farargy MS, El-Sharkawy HM, Abd-El-Wahab M. Effect of body position on

oxygen saturation and respiratory rate in neonates with respiratory distress: A

single center study. AUMJ, 2015 September 1; 2(3): 1 - 7.

Key Words: Body Positioning, Respiratory distress, Respiratory rate, Arterial blood

oxygen saturation, Neonates.

Introduction

The number of world-wide deaths among

babies 0 - 28 days of life decreased from

4.4 million in 1990 to 3.1 million in

2010. In Egypt, the neonatal mortality

rate during the year 2005 accounted for

20% of all live births. While the neonatal

mortality rates in Tanta University

hospital in the years 2010 and 2011 were

24% and 21%, respectively(1-3)

. One of

the most common health problems in

neonates is respiratory distress (RD). RD

is the primary diagnosis in nearly 50% of

newborn admitted to neonatal intensive

care unit and is a common cause of

cardiopulmonary arrest. The more

premature the newborn, the more likely




2015 2015

respiratory distress occur. RD is a

progressive impairment of the lung to

exchange gas which lead to difficulty of

breathing and increased respiratory

effort(4-6)

.

RD found in different diseases and there

is a wide variety of congenital and

acquired disorders that can present in the

newborn and cause RD. The most

common causes of RD are transient

tachypnea, RD syndrome (RDS),

meconium aspiration syndrome (MAS),

infection (congenital or acquired), and

pneumonia. There are less common

causes such as pneumothorax, pulmonary

interstitial emphysema, pulmonary

hypoplasia, cardiac disease as (pulmonary

hypertension, and cyanotic congenital

heart disease), surgical condition as

(congenital diaphragmatic hernia, and

hemangioma) and airway obstruction as

(choanal atresia, esophageal atresia and

trachea-esophageal atresia)(7)

.

The basic aim of treatment in neonates

with RD is observation and monitoring

neonate closely. A careful assessment,

positioning and O2 administration can

reduce RD. Body position plays an

important role in reducing RD. Therefore,

newborn should be positioned to

encourage maximum chest expansion

with the head of bed elevated or head at

45 degree. Position of baby depends on

the pulmonary abnormalities. Turning

baby regularly will not only assist in the

prevention of pressure ulcers but also

facilitate pulmonary postural

drainage(8,9)

.

Patients and Methods

Research Design and Patients: a quasi

experimental design was used in this

study. The study was conducted at

Neonatal Intensive Care Unit of Tanta

University Hospital from February 2013

to February 2014. The study included

fifty neonates who had a gestational age

of more than 32 weeks and they had RD

with the following criteria: Tachypnea

more than 60 c/m, retraction, and

grunting. Exclusive criteria included:

Neonates who were not able to tolerate

the different positions due to (secretion,

presence of nasogastric tube,

cephalohematoma or sudden drop in

saturation) or with congenital heart

disease or had a major malformation. A

written approval for data collection from

custodian of the neonate was obtained in

Neonatal Intensive Care Unit (NICU) at

Tanta University Hospital after

explanation of the study aim that was

approved by the local medical ethical

committee was obtained.

Tools of data collection: Three tools were

used for data collection. 1) Structured

questionnaires sheet for demographic and

clinical data that included; gender,

gestational age, birth weight, and

diagnosis. 2) Physical assessment sheet

for respiratory rate, oxygen therapy its

flow rate and oxygen saturation. 3) Body

position record's sheet to determine the

effect of applied three positions; supine,

prone and Semi-Fowler. The respiratory

rate and oxygen saturation were recorded

at base time, after 30, 60, 90 and120

minutes for each body position.

Body Positioning: Each newborn was

studied for two consecutive days in three

positions; supine, prone and Semi-

Fowler, each position was maintained for

a maximum of 120 minutes. 1) The

Supine position was performed by putting

the head, body and feet in the midline.

Small rolls were placed under the knees

to support flexion of the legs and a small



2015 2015

roll was placed under the head and

shoulders. 2) The Prone position was

performed by putting the newborn on the

abdomen, the arms were closed to the

body and the hands were closed up to the

mouth, the legs were flexed towards the

chest. This position was maintained by

using a rolled sheet against the feet. 3)

The Semi-Fowler position was performed

by putting the newborn in a semi setting

position by elevating the head of the bed

30 degrees.

Respiratory rates were checked 5 times at

each of baseline time and 30, 60, 9 and

120 minutes in each position. Oxygen

saturation was recorded 5 times at same

time points. The mean of readings was

calculated. Electronic monitor results and

pulse oximetry result were checked once

at the same time. Time for maximum

oxygen saturation in the three different

positions was recorded. Died and

discharged newborns during the time of

the study were excluded from the study.

Statistical Analysis: The data collected

were organized, tabulated, and

statistically analyzed using SPSS

(Software Statistical Computer Package

Version 18). For quantitative variables,

range, mean and standard deviations were

used. Student's "t" test and ANOVA were

used to compare groups and time points.

For qualitative variables, the number and

percentage distribution were used.

Significance was adopted at p≤0.05.

Results

Table 1 shows the characteristics of the

investigated neonates. Gender-wise, the

majority of the neonates were females

reaching 62.0%. The mean of gestational

age of the studied neonates was 35.16 ±

1.78 wks and mean birth weight was 2.30

± 0.73 kg. Seventy percent of the

neonates had RDS, 18.0% had

pneumonia, and the rest of them suffered

from MAS and being infant of diabetic

mother (IDM). Seventy eight percent of

the neonates received oxygen through

nasal cannula, while 20.0% were only

had incubator oxygen, and 2.0% did not

receive oxygen therapy.

Table 1: Distribution of the neonates with respiratory distress according to their demographic and

clinical characteristics. Data shown are frequency; n (%) or range (mean ± SD). Respiratory

distress syndrome = RDS, Meconium aspiration syndrome (MAS), and, Infant of diabetic mother

(IDM).

Characteristic n (%) or range (mean ± SD)

Gestational age (weeks) 33 – 38 (35.16 ± 1.78)

Birth weight (kg) 0.6 - 3.7 (2.30 ± 0.73)

Gender: Male/Female 19 (38%)/31 (62%)

Diagnosis:

RDS

35 (70%)

Pneumonia 9 (18%)

MAS

IDM

3 (6%)

3 (6%)

Oxygen Therapy:

Nasal cannula

Incubator oxygen

Not received

39 (78%)

10 (20%)

1 (2%)



2015 2015

Table 2 shows statistical significant

differences of respiratory rates comparing

the three positions along the time points

investigated. Respiratory rate decreased

gradually in each position which was best

observed in Semi-Fowler position.

Table 3 shows statistical significant

difference in oxygen saturation among

the three body positions along their five

time points, with the best improvement

observed in Semi-Fowler position.

Table 2: Mean value of respiratory rate in relation to the body positions along the follow-up time

points in the investigated neonates with respiratory distress. Data shown are mean ± SD and t and

F values (and their respective p values).

Respiratory Rate Positions

F (p) Supine Prone Semi-Fowler

Baseline 64.77 ± 5.64 60.10 ± 5.17 55.91 ± 5.78 32.050 (0.001)

After 30 minutes 64.57 ± 2.43 59.24 ± 5.88 54.60 ± 5.21 55.225 (0.001)

t (p) 0.355 (0.724) 1.477 (0.146) 3.862 (0.001)

After 60 minutes 62.54 ± 4.66 57.56 ± 7.57 52.30 ± 5.73 35.151 (0.001)

t (p) 3.670 (0.001) 3.918 (0.001) 7.349 (0.001)

After 90 minutes 62.83 ± 4.00 55.17 ± 7.36 51.89 ± 5.50 47.070 (0.001)

t (p) 3.225 (0.002) 9.300 (0.001) 6.053 (0.001)

After 120 minutes 62.36 ± 4.29 56.56 ± 7.05 49.11 ± 6.33 61.188 (0.001)

t (p) 3.130 (0.003) 7.435 (0.001) 9.967 (0.001)

Table 3: Mean value of oxygen saturation measured by pulse oximetry in relation to the body

positions along the follow-up time points in the investigated neonates with respiratory distress.

Data shown are mean ± SD, and, t and F values (and their respective p values).

Oxygen Saturation

(mmHg)

Positions F (p)

Supine Prone Semi-Fowler

Baseline 92.73 ± 3.81 96.34 ± 1.85 96.67 ± 2.26 31.030 (0.001)

After 30 minutes 92.73 ± 3.75 96.36 ± 1.96 97.08 ± 1.73 39.047 (0.001)

t (p) 0.000 (1.000) 0.051 (0.960) 1.936 (0.059)

After 60 minutes 92.91 ± 3.97 96.75 ± 1.47 97.22 ± 1.80 39.717 (0.001)

t (p) 0.344 (0.733) 1.425 (0.161) 2.241 (0.030)

After 90 minutes 94.57 ± 3.07 97.17 ± 1.78 98.23 ± 0.76 40.514 (0.001)

t (p) 4.472 (0.001) 3.157 (0.003) 4.616 (0.001)

After 120 minutes 95.59 ± 2.34 97.78 ± 0.77 98.74 ± 0.74 59.034 (0.001)

t (p) 5.320 (0.001) 5.391 (0.001) 7.182 (0.001)

Discussion

Body position may play an important role

in improving gas exchange in the

neonates with respiratory distress(10)

and

stimulate normal physiological

ventilation, perfusion and ventilation

perfusion matching in the lungs - all are

subjected to gravity and body position(11)

.

Respiratory stability is difficult for

newborn because their respiratory



2015 2015

muscles, alveolar sacs, airway stability,

and CNS control are underdeveloped,

where higher respiratory rates may be

associated with stress, excitement, or

respiratory compromise, while a lower

normal respiratory rate may be associated

with calming or quiet sleep(12)

. The

results of the present study showed a

significant decrease in respiratory rate in

the studied three positions. The best

improvement seen in Semi-Fowler

position compared to the other two

positions. The prone position

spontaneously decreases high respiratory

rate. Prone position was found to

significantly improve in respiratory rate

compared to supine in patients with lung

disease(13)

.

Most neonatal intensive care units define

normal oxygen saturation as 90 - 98%,

while many neonatal intensive care units

set oxygen alarms at 88%(14)

. The present

study revealed that oxygen saturation of

the respiratory distressed newborn was

improved in all positions applied.

However, Semi-Fowler position was

superior in achieving maximum oxygen

saturation vs. the other two positions

(supine and prone).

The lung‘s own weight lower the

diaphragm and induce alveolar expansion

that increase tidal volume and lung

capacities in Semi-Fowler position.

Agreeing with us Semi-Fowler’s

positioning improves tidal volume and

oxygenation in mechanically ventilated

patients(15)

. However, Martha (2005)

found that prone positioning did not

significantly reduce ventilator-free days

or improve oxygenation in pediatric

patients with acute lung injury(16)

. Early

prone positioning in pediatric patients

with acute lung injury demonstrated

improvements in oxygenation without

serious iatrogenic injury after prone

positioning(17)

. Similarly, maximum

oxygen saturation was achieved when

neonates with RD were placed in Semi-

Fowler's position after 120 minute. At

tighter time frames (0, 15 and 30

minutes), there was no statistically

significant relationship between

oxygenation level and respiration with

changing position of patients with

unilateral lung pathology(18)

. The present

study showed a lower oxygen saturation

level in the supine position vs. the other

two positions which may be due to

forcing the abdominal organs against the

diaphragm(19,20)

.

Conclusion

Neonate body positioning can improve

oxygenation and respiratory rate in cases

of respiratory distress. In comparison,

Semi-Fowler position was superior in

attaining maximum oxygen saturation vs.

each of the supine and prone positioning.

However, the duration required to

achieve maximum oxygen saturation in

the three positions was the same; 120

minutes.

Limitations of the Study

During intervention, some neonates

were taken for clinical

investigations that disturbed data

collection.

Some neonates were discharged in

the second day of enrollment in the

study leading to their exclusion

from the study.

During the intervention, nurses

happened to do suction or inserting

new i.v. line to the neonates that

disturbed data collection.



2015 2015

Semi-Fowler position induced very

acute improvement in the target

measurement that we could not

catch a baseline for them as

compared to the other two

positionings.

Conflict of Interest: The authors

declared no conflict of interests.

Authors’ Contributions

Mohammed Sh. El Farargy participated

in the sequence alignment and drafted the

manuscript, participated in the design of

the study. Hamed M El-sharkawy

participated in the idea and the design of

the study. Marwa Abd-El-Wahab

performed the statistical analysis, and

participated in the sequence alignment.

All authors read and approved the final

manuscript.

Acknowledgement

The authors acknowledge the substantial

contributions of Dr. Neama Soliman,

Department of Microbiology, Faculty of

Medicine, Tanta University, Tanta,

Egypt, in conception and design of the

study, and, analysis and interpretation of

data.

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SQ, Liu L, Huang YZ, Guo FM, Yang

Y, Qiu HB. The effect of prone

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2. Sud S, Friedrich JO, Adhikari NK,

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2015 2015

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Marini JJ. Prone position in acute

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preterm infants. J Obstet Gynecol

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Mercadante D, Matassa P, Pedotti A,

Colnaghi M, Dellacà RL, Mosca F.

Positional effects on lung mechanics

of ventilated preterm infants with

acute and chronic lung disease.

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Hey E. Pulse oximetry, severe

retinopathy, and outcome at one year

in babies of less than 28 weeks

gestation. Arch Dis Child Fetal

Neonatal Ed., 2001;84(2):F106-10.

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Comparison of Effect of Semi-

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LD, Wypij D, Shih MC, Thompson

JE, Grant MJ, Barr FE, Cvijanovich

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MA, Arnold JH. Effect of prone

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41.



2015 2015

Alduraywish et al - Correlation among the glycemic control and lipogram ………..


2015

Original Article

Correlation among the Glycemic Control and Lipogram Indices

with Chronic Complications in Saudi Diabetic Patients: Al-Jouf

Status

Abdulrahman Abdulwahab Alduraywish1*

, Farhan Musafiq AlAnazi2, Mohammed

Abdulaziz Alharbi2, Faisal Musaad Al-rasheed

2, and, Louai T. Alaithan

2

Department of Internal Medicine1, College of Medicine

2, Aljouf University, Sakaka,

Saudi Arabia. *Correspondent author: [email protected].

Abstract

Background: Diabetes mellitus (DM) is a group of metabolic disorders that constitutes

a major public health problem in Sakaka, Al-Jouf and Saudi Arabia as a whole. Poor

glycemic control and dyslipidemia represent the major link between diabetes and its

complications. Hypothesis and Aim: We hypothesized that serum lipid profile would

be invaluable assessment and a reflection of the quality of glycemic control in the local

diabetic patients and that they would correlate with disease duration and occurrence of

diabetic complications. Material and Methods: A retrospective hospital records-based

cross-sectional descriptive study was conducted on eligible valid 126 diabetic patient

files of both types I and II from both genders followed up at the Diabetes Care Unit of

Prince Motaeb Ben Abdul Aziz General Hospital. Results: The glycemic control and

serum lipid indices showed bad disease management that correlated a high prevalence

of complications at their worst grade of myocardial infarction and diabetic foot and

gangrene particularly in type II diabetes and at longer disease duration. Conclusion:

Glycemic control and serum lipid indices of local diabetic patients showed

dyslipidemia and bad disease control as reflected on prevalence of the advanced disease

complications; necessitating better disease prevention and control strategies.

Alduraywish AA, AlAnazi FM, Alharbi MA, Al-rasheed FM, and, Alaithan LT.

Correlation among the glycemic control and lipogram indices with chronic

complications in Saudi diabetic patients: Al-Jouf Status. AUMJ, 2015 September

1; 2(3): 9 - 24.

Keywords: Diabetes, A-Jouf, Sakaka, Saudi Arabia, Glycemic control, Lipogram,

Diabetic complications, Disease duration.

Introduction

Saudi Arabia is a community thrilled by

sudden social and economical changes,

leading to a sharp increase in the

prevalence of abnormal glucose

metabolism. Abnormal glucose

metabolism has reached an epidemic

level in this society, where half of adults

and older are affected(1)

. The rapid

outbreak of diabetes mellitus (DM) type-

2 (DM2) is one of the largest public

health problems around the globe, and

became the epicenters of cardiometabolic

disorders owing to the change in lifestyle

and diet preference besides genetic

predisposition in developing nations(2)

.

Lipids parameters significantly associate

the anthropometric measures and glucose



2015

in Saudi school adolescents, where

elevated triglycerides level was most

predictive of elevated glucose(3,4)

.

The different components of diabetic

complications are interdependent of each

other, rendering the disease difficult to

diagnose and control with a complicated

pathogenesis because of the

heterogeneous, polygenic, and

multifactorial nature of the disease(5)

. DM

is associated with a high risk of

cardiovascular disease due to

dyslipidemia comprising a high

triacylglycerols, a low high-density

lipoprotein cholesterol (HDL-Ch) and an

increased concentration of small dense

low-density lipoprotein cholesterol

(LDL-Ch) particles. The management of

diabetic dyslipidemia, as a modifiable

risk factor, is an important element in the

multifactorial approach to prevent

cardiovascular disease (CVD),

development of myocardial infarction

(MI) and other complications. LDL-Ch

levels in patients with diabetes are

comparable to those found in the rest of

the population, while concentration of

small dense LDL-Ch is increased in

diabetics. The elevated level of total

cholesterol, triglycerides and LDL-Ch

and, lowered HDL-Ch are the predictable

risk factor for coronary artery disease

(CAD) in DM2(6)

. The risk of death due

to heart disease and stroke is up to four

times higher in individuals with diabetes

compared to non-diabetics. Glycemic

control through combined adherence to

therapy, diabetes self-management

education, diet control and exercise is the

major element against that risk(7)

.

Diabetic dyslipidemia is a cluster of

potentially atherogenic lipid and

lipoprotein abnormalities that are

metabolically interrelated. A fundamental

defect is an overproduction of large very

low-density lipoprotein (VLDL) particles,

which initiates a sequence of lipoprotein

changes, resulting in higher levels of

remnant particles, smaller LDL, and

lower levels of HDL-Ch. Unfortunately,

such atherogenic lipid abnormalities

precede the diagnosis of type II diabetes

by several years(8)

. In this regard,

increased free fatty acid flux secondary to

insulin resistance is a major culprit. The

availability of multiple lipid-lowering

drugs and supplements should enable

patients to achieve target lipid levels(9)

.

The primary serum lipid control target is

an LDL-Ch <100 mg/dL (<70 mg/dL in

very high-risk patients). To achieve

serum lipid control targets, attention

should be directed first toward non-

pharmacologic therapeutic interventions

to control dyslipidemia, such as diet,

exercise, smoking cessation, weight loss,

and glycemic control. The lipid lowering

statin therapy is recommended for most

subjects(10)

.

The nature of the glycemic control as

reflected on lipid profile in DM1 and

DM2 patients from Sakaka City, the

northern Al-Jouf area, Saudi Arabia was

not previously assessed to predicate

diabetic complications. These two indices

reflect adherence of both patients and

physicians to the guidelines of the

Ministry of Health for the management of

diabetes. We hypothesized that serum

lipid profile would be invaluable

assessment of the diabetic disease status

in an area famous for general population

unhealthy over-feeding and sedentary

lifestyle that was not previously assessed.

For that we planned the present hospital

records-based retrospective cross-

sectional study to test the extent of such

control and correlation among parameters

- particularly the diabetic complications.



2015

Materials and Methods

The present hospital records-based

retrospective cross-sectional study

reviewed 126 diabetic patients' files valid

for anonymously collection of target data

that included: Patient’s age in years, type

of diabetes (1 vs. 2) and medication (oral

hypoglycemics vs. insulin), disease

duration in years, fasting blood glucose in

mg/dL, HbA1c %, serum total

triacylglycerols in mg/dL, serum total

cholesterol, HDL- and LDL-Ch in

mg/dL, presence and nature of diabetes

complication. Permission for conducting

the study was ensured from both the

Ethical Committees of Aljouf University

College of Medicine and Prince Motaeb

Ben Abdul Aziz General Hospital. The

study was conducted during March, 2015

at the Records Section of the Diabetes

Care Unit of Prince Motaeb Ben Abdul

Aziz General Hospital, Sakaka, Al-Jouf,

Saudi Arabia.

These parameters were statistically

analyzed for their correlation (non-

parametric Spearman's analysis) amongst

each other within the whole group of

enrolled patients and within each of their

sub-grouping; DM1 vs. DM2 sub-

grouping, and recent (≤3 years) vs.

advanced (>3 years) disease duration

subgrouping. Unpaired one-tailed

Student’s “t” was used to test the

significance of differences for each

parameter between these two subgroups.

Data were presented as n, Range, Median,

Mean ± SDM and SEM and were

presented in tables and figures. For

statistical purpose, diabetic complications

were scored as follow: Diabetic

ketoacidosis = 1, microvascular

neuropathy = 2, retinopathy (eye) = 3,

Macrovascular (CAD, CVA, peripheral

vascular diseases) = 4 and Diabetic foot =

5.

The statistical analyses and data

presentation were conducted using the

Prism 6.0 Statistics Software package

(GraphPad Software, Inc, San Diego, CA,

USA). We wished to correlate the

glycemic control and lipid profile indices

also with body mass index and daily

habits (smoking, alcoholism and physical

activity) and other common and expected

ophthalmic, nephropathic and erectile

diabetic complications of patients.

However, the deficient recording of such

data (only one patient had BMI recorded)

hindered us doing it.

Results

This study included 126 diabetic patients

followed up at the Diabetes Care Unit at

Prince Motaeb Ben Abdul Aziz General

Hospital, Sakaka, Al-Jouf, Saudi Arabia

(Figure 1). Their age ranged from 15 to

85 years (Median = 50 and Mean ± SDM

= 50.16 ± 11.27 years). Female

constituted almost half of the study

participants (49.206%; n = 62) and the

remaining were males (50.794%; n = 64).

DM1 constituted 16.667% (n = 21; 7

males and 14 females) and were treated

with insulin, and the remaining patients

(83.333%; n = 105; 57 males and 48

females) suffered DM2 and were on oral

hypoglycemic medications.

Their disease duration ranged from 2

weeks to 42 years (Median = 7 and Mean

± SDM = 8.825 ± 8.473 years). Their

serum fasting blood glucose level ranged

from 69 - 380 mg/dL (Median = 169.5 and

Mean ± SDM = 187.7 ± 70.04 mg/dL).

Their HBA1c ranged from 4.2 - 13.6%

(Median = 7.6 and Mean ± SDM = 7.748

± 1.52%). Their serum total cholesterol

concentration ranged from 114 - 262

mg/dL (Median = 183 and Mean ± SDM =

183.5 ± 35.82 mg/dL). Their serum HDL-

Ch concentration ranged from 19 - 97.4



2015

mg/dL (Median = 39.8 and Mean ± SDM

= 42.05 ± 12.2 mg/dL). Their serum LDL-

Ch concentration ranged from 35.4 - 178.9

mg/dL (Median = 98.5 and Mean ± SDM

= 101.5 ± 31.34 mg/dL). Their serum

triacylglycerols level ranged from 49 -

456 mg/dL (Median = 167.5 and Mean ±

SDM = 178.4 ± 70.84 mg/dL). Only 31

patients were recorded to have

complications that ranged from numbness

to diabetic foot and gangrene, where

majority of complicated cases suffered

myocardial infarction (n = 27; 87.097%)

and complications happened mainly in

DM2 patients (n = 21; 67.742%).

A g e , Y

D D , Y

F B G , mg /d

L

H b A 1 c %

T o tal-C

h , mg /d

L

H D L -Ch , m

g /dL

L D L -Ch , m

g /dL

T o tal T

A G s , mg /d

L

C o mp lic

a t ion s

0

1 0

2 0

3 0

4 0

5 0

5 0

1 0 0

1 5 0

2 0 0

2 5 0

3 0 0

3 5 0

4 0 0

4 5 0

5 0 0

Pa

ra

me

ter

Figure 1: Scattergram of the main findings of the diabetic participants of the cross-

sectional retrospective study conducted on patients records reserved at the Diabetes

Care Unit of Prince Motaeb Ben Abdul Aziz General Hospital, Sakaka, Al-Jouf, Saudi

Arabia - during March, 2015. Disease duration (DD), fasting blood glucose (FBG), total

(T-Ch), HDL- (HDL-Ch) and LDL-cholesterol (LDL-Ch), triacylglycerols (TAGs) and

presence of diabetic complications (Compl.). Y = year.

Correlation analysis (Non-parametric

Pearson’s r/p values) among all

parameters investigated in the study

patients as one group revealed

positive/negative significant correlation

between: Patients' age vs. each of disease

duration (0.611/0.001) and total TAGs

(0.226/0.006); disease duration vs.

complications (0.497/0.002); fasting blood

glucose vs. each of HbA1c (0.599/0.001),

total cholesterol (0.203/0.011), HDL-Ch

(0.325/0.001), and LDL-Ch (0.178/0.023);

HbA1c vs. each of HDL-Ch (0.269/0.001)

and total TAGs (-0.179/0.022); total

cholesterol vs. each of HDL-Ch

(0.212/0.009), LDL-Ch (0.752/0.001) and

total TAGs (0.176/0.025); HDL-Ch vs.

each of LDL-Ch (0.164/0.034), total

TAGs (-0.242/0.003), and disease

complications (-0.355/0.025). Other

correlations were non-significant.



2015

When patients were subdivided as DM1

and DM2, the following were the

characteristics of DM1 subgroup (Table

1). Their age ranged from 15 to 85 years

(Median = 44 and Mean ± SDM = 51.81

± 20.45 years). Their disease duration

ranged from 2 weeks to 42 years (Median

= 9 and Mean ± SDM = 15.05 ± 14.91

years). Their serum fasting blood glucose

level ranged from 115 - 335 mg/dL


± 67.85 mg/dL). Their HbA1c ranged

from 4.2 - 12% (Median = 7.6 and Mean

± SDM = 7.562 ± 1.753%). Their serum

total cholesterol concentration ranged

from 128 - 241 mg/dL (Median = 185 and

Mean ± SDM = 189.7 ± 35.03 mg/dL).

Their serum HDL-Ch concentration

ranged from 24.34 - 97.4 mg/dL (Median

= 39.8 and Mean ± SDM = 43.86 ± 15.84

mg/dL). Their serum LDL-Ch

concentration ranged from 36.80 - 161

mg/dL (Median = 94.50 and Mean ±

SDM = 98.95 ± 37 mg/dL). Their serum

triacylglycerols level ranged from 70 -

369 mg/dL (Median = 153 and Mean ±

SDM = 180 ± 85.28 mg/dL). Only 8

patients were recorded to have

complications that ranged from numbness

to diabetic foot and gangrene where

majority were diabetic foot and gangrene

(n = 5; 62.5%).

Table 1: Main findings of the type I diabetic participants of the cross-sectional

retrospective study conducted on patients records reserved at the Diabetes Care Unit of

Prince Motaeb Ben Abdul Aziz General Hospital, Sakaka, Al-Jouf, Saudi Arabia -

during March, 2015. For abbreviations, see Figure 1. T-TAGs = total TAGs. Cp =

Complications.

Age, Y DD, Y

FBG,

mg/DL HbA1c%

T-Ch,

mg/dL

HDL-Ch,

mg/dL

LDL-Ch,

mg/dL

T-TAGs,

mg/dL Cp

n 21 21 21 21 21 21 21 21 8

Range 15 - 85 0.042 -

42 115 - 335 4.2 - 12 128 - 241 24.34 - 97.4 36.8 - 161 70 - 369 1 - 5

Mean 51.81 15.05 197.2 7.562 189.7 43.86 98.95 180.0 4.000

SDM 20.45 14.91 67.85 1.753 35.03 15.84 37.00 85.28 1.604

SEM 4.463 3.255 14.81 0.383 7.645 3.457 8.073 18.61 0.567




patients with DM1 revealed



duration (r = 0.796/0.001) and

complications (0.870/0.006); disease

duration vs. complication (0.851/0.009);

fasting blood glucose vs. HbA1c

(0.708/0.001); total cholesterol vs. LDL-

Ch (0.670/0.001); and LDL-Ch vs.

disease complications (-0.546/0.039).

Other correlations were non-significant.

When patients were subdivided as DM1

and DM2, the following were the

characteristics of DM2 group (Table 2).

Their age ranged from 30 to 75 years


± 8.465 years). Their disease duration

ranged from 2 weeks to 26 years (Median

= 7 and Mean ± SDM = 7.581 ± 5.842

years). Their serum fasting blood glucose



± 70.63 mg/dL). Their HBA1c ranged



2015

from 5.1 - 13.6% (Median = 7.6 and

Mean ± SDM = 7.785 ± 1.476%). Their

serum total cholesterol concentration

ranged from 114 - 262 mg/dL (Median =

182 and Mean ± SDM = 182.2 ± 30.02

mg/dL). Their serum HDL-Ch

concentration ranged from 19 - 96.5

mg/dL (Median = 39.45 and Mean ±

SDM = 41.69 ± 11.38 mg/dL). Their

serum LDL-Ch concentration ranged

from 35.4 - 178.9 mg/dL (Median =

98.85 and Mean ± SDM = 102 ± 30.25

mg/dL). Their serum triacylglycerols


(Median = 170 and Mean ± SDM = 178 ±

68.06 mg/dL). Only 23 patients were

recorded to have complications that

ranged from numbness to diabetic foot

and gangrene where majority of these

complications were myocardial infarction

(n = 19; 82.609%).

Table 2: Main findings of the type II diabetic participants of the cross-sectional

retrospective study conducted on patients records reserved at the Diabetes Care Unit of

Prince Motaeb Ben Abdul Aziz General Hospital, Sakaka, Al-Jouf, Saudi Arabia -

during March, 2015. For abbreviations, see Figure 1 and Table 1.

Age, Y DD, Y

FBG,

mg/dL HbA1c%

T-Ch,

mg/dL

HDL-Ch,

mg/dL

LDL-Ch,

mg/dL

T-TAGs,

mg/dL Cp

n 105 105 105 105 105 104 104 105 23

Range 30 - 75

0.042 -

26 69 - 380

5.10 -

13.60 114 - 262 19.0 - 96.5 35.4 - 178.9 49 - 456 2 - 5

Mean 49.83 7.581 185.8 7.785 182.2 41.69 102.0 178.0 3.957

SDM 8.465 5.842 70.63 1.476 36.02 11.38 30.25 68.06 0.562

SEM 0.826 0.570 6.893 0.144 3.515 1.116 2.966 6.642 0.109




patients with DM2 revealed



duration (0.465/0.001) and TAGs

(0.213/0.015); fasting blood glucose vs.

each of HbA1c (0.583/0.001), total

cholesterol (0.164/0.05), HDL-Ch

(0.382/0.001), and LDL-Ch

(0.207/0.018); HbA1c vs. each of HDL-

Ch (0.305/0.001), and TAGs (-

0.185/0.03); total cholesterol vs. each of

HDL-Ch (0.228/0.01), LDL-Ch

(0.775/0.001) and TAGs (0.234/0.01);

and HDL-Ch vs. TAGs (-0.252/0.005).

Other correlations were non-significant.

When means ± SDM of both DM1 and 2

subgroups were compared for all

parameters investigated using unpaired

two-tailed Student’s “t” test, there were

non-significant differences among the

two subgroups except for the disease

duration (p<0.034).

When patients were stratified for the

disease duration, advanced diabetes (>3

years duration; Table 3) was recorded in

68.254% of patients (n = 86). 52 patients

were males (60.465%) and 34 were

females (39.535%). 14 patients belonged

to DM1 (16.279%) and 72 patients were

DM2 (83.721%). There were 30

complicated diabetes; majority were

myocardial infarction (n = 19; 63.333%)

followed by diabetic foot (n = 7; 23.333).

Therefore, 96.774% of patients with the



2015

overall and the worst diabetic

complication lied within the advanced

diabetic subgroup. Correlation analysis

(Non-parametric Pearson’s r/p values)

within this advanced diabetic group of

patients revealed positive/negative

significant correlation between: Patients'

age vs. each of disease duration

(0.613/0.001), TAGs (0.218/0.022), and

complications (0.318/0.047); disease

duration vs. each of HDL-Ch (-

0.186/0.044), and complications

(0.511/0.002); fasting blood glucose vs.

each of HbA1c (0.540/0.001), total

cholesterol (0.207/0.028), and HDL-Ch

(0.285/0.004); total cholesterol vs. each of

HDL-Ch (0.209/0.027), and LDL-Ch

(0.751/0.001); and HDL-Ch vs. each of

TAGs (-0.237/0.014), and complications

(-0.349/0.029). Other correlations were

non-significant.

Table 3: Main findings of the advanced diabetic participants (disease duration >3

years) of the cross-sectional retrospective study conducted on patients records reserved

at the Diabetes Care Unit of Prince Motaeb Ben Abdul Aziz General Hospital, Sakaka,

Al-Jouf, Saudi Arabia - during March, 2015. For abbreviations, see Figure 1 and Table

1.

Age, Y DD, Y

FBG,

mg/dL HbA1c%

T-Ch,

mg/dL

HDL-Ch,

mg/dL

LDL-Ch,

mg/dL

T-TAGs,

mg/dL Cp

n 86 86 86 86 86 86 86 86 30

Range 15 - 85 3.5 - 42 69 - 380 4.2 13.6 115 - 262 24.3 - 97.4 35.4 - 178.9 49 - 456 1 - 5

Mean 52.87 12.25 187.9 7.674 182.6 41.76 99.28 182.0 3.967

SDM 11.74 8.224 73.69 1.518 35.94 11.53 31.82 71.58 0.928

SEM 1.265 0.887 7.946 0.164 3.876 1.243 3.431 7.719 0.169

When patients were stratified for the

disease duration, recent diabetes (≤3

years duration; Table 4) was recorded in

31.746% of patients (n = 40). 12 patients

were males (30%) and 28 were females

(70%). 7 patients belonged to DM1

(17.5%) and 33 patients were DM2

(82.5%).

Table 4: Main findings of the recent diabetic participants (disease duration ≤3 years) of

the cross-sectional retrospective study conducted on patients records reserved at the

Diabetes Care Unit of Prince Motaeb Ben Abdul Aziz General Hospital, Sakaka, Al-

Jouf, Saudi Arabia - during March, 2015. For abbreviations, see Figure 1 and Table 1.

Age, Y DD, Y FBG, mg/dL HbA1c%

T-Ch, mg/dL

HDL-Ch, mg/dL

LDL-Ch, mg/dL

T-TAGs, mg/dL Cp

n 40 40 40 40 40 39 39 40 1

Range 30 - 56 0.042 - 3 85 - 335 5.8 - 12 114 - 245 19 - 96.5 41.3 - 161 70 - 407 4

Mean 44.33 1.460 187.3 7.905 185.4 42.70 106.3 170.6 4

SDM 7.491 1.084 62.35 1.532 35.95 13.69 30.08 69.46 0.0

SEM 1.185 0.171 9.859 0.2422 5.684 2.192 4.816 10.98 0.0



2015

There was only one case of complicated

diabetes with myocardial infarction in a

DM2 patient. Correlation analysis (Non-

parametric Pearson’s r/p values) within

this recent diabetic group of patients

revealed positive/negative significant

correlation between: Patients' age vs.

disease duration (0.411/0.004); fasting

blood glucose vs. each of HbA1c

(0.742/0.001), HDL-Ch (0.431/0.003),

and LDL-Ch (0.283/0.04); HbA1c vs.

each of total cholesterol (0.317/0.023),

HDL-Ch (0.518/0.001), and LDL-Ch

(0.331/0.02); total cholesterol vs. LDL-

Ch (0.736/0.001). Other correlations were

non-significant.

When means ± SDM of both recent and

advanced diabetic subgroups were

compared for all parameters investigated

using unpaired two-tailed Student’s “t”,

there were non-significant differences

among the two subgroups except for each

of patients age and prevalence of

complications (p<0.001 for each).

Discussion

Our findings showed a complication rate

of 24.603% among our patients that

ranged from numbness to diabetic foot

and gangrene. Majority of complicated

cases suffered myocardial infarction (n =

27; 87.097%) and complications

happened mainly in DM2 patients (n =

21; 67.742%). This could be due to

several reasons including uncontrolled

blood sugar due mainly to patient

incompliance and unawareness of danger

of diabetic complication. In a Saudi study

conducted at AL-AHSA, a higher rate of

complication was reported that reached

72.72% of the studied diabetic

subjects(11)

. Deficient recoding could be

one cause of our lower arte. Diabetic

complications are aggressive and

progressive and careful monitoring and

proper institution of management

protocols should be implemented to

identify diabetic patients at high risk for

complications. Reviewing 1,952 DM2

patients followed-up at Security Forces

Hospital, Riyadh, Saudi Arabia from

January 1989 to December 2004, there

were 626 (32.1%) patients (294 (47%)

were males) who developed diabetic

nephropathy. Concomitant diabetic

complications included cataract (38.2%),

acute coronary syndrome (36.1%),

peripheral neuropathy (24.9%),

myocardial infarction (24.1%),

background retinopathy (22.4%), stroke

(17.6%), proliferative retinopathy

(11.7%), foot infection (7.3%), limb

amputation (3.7%) and blindness (3%).

Hypertension was documented in 577

(92.2%) patients, dyslipidemia in 266

(42.5%) and mortality from all causes in

86 (13.7%)(12)

.

We found a direct correlation between

HbA1c and FBG, as well as with lipid

profile. The median of HbA1c slightly

increased similar to FBG. Cholesterol

level is at upper normal to slightly

increased similar to LDL-Ch. Median of

TG is increased with a positive

correlation with blood sugar. HDL-Ch

ranged from decreased to lower normal

with a negative correlation with FBG

status. Levels of HbA1c, FBG and LDL-

Ch did not differ significantly between

males and females. Female patients

showed significantly higher cholesterol

and HDL-Ch but significantly lower TG

levels as compared to males. As

expected, HbA1c and FBG correlated

highly significantly. Both HbA1c and

FBG exhibited direct correlations with

cholesterol, TG and LDL-Ch and inverse

correlation with HDL-Ch. There was a

linear relationship between HbA1c and

dyslipidemia. The levels of serum



2015

cholesterol and TG were significantly

higher and of HDL significantly lower in

patients with worse glycemic control as

compared to patients with good glycemic

control(13)

.

Our DM1 results showed a median

HbA1c of 7.6 for duration of the disease

around 9 years. In general, the median of

lipid profile was almost normal.

Complications prevailed in 38% of the

patients. Reportedly, DM1 adolescents

from Jeddah, Saudi Arabia showed

HbA1c level of 8.8%, acute

complications included ketoacidosis in

65.4% of patients, and hypoglycemic

attacks in 68.9%, whereas, long-term

complications included retinopathy

(4.4%), microalbuminuria (16.2%), and

dyslipidemia (8.3%) with evidence of

autoimmune diseases(14)

. In an Iranian

study, diabetes complications were

evident amongst 67.2% of the patients(15)

.

The prevalence of diabetic microvascular

nephropathy, retinopathy and neuropathy

scored 9.5 - 12.5% in a Qatari study(16)

. In

an Indian study, retinopathy was

diagnosed in 32.5%, nephropathy was

present in 30.2%, peripheral neuropathy

was present in 26.8%, coronary heart

disease was present in 25.8% and

peripheral vascular disease was present in

28% of the patients (17)

. Rate of our

cardiovascular complications is very

close to such reports. However, because

of the very deficient data recording, the

details of individual complication were

difficult to dissect. Moreover, our low

complication rates could be reasoned to

the close to normal median of HbA1c and

relative durations of disease in our

patients.

Increased urbanization in the developing

world parallels a rising burden of chronic

diseases. Developing countries account

for ∼ 80% of global cardiovascular (CV)

deaths with a high prevalence of CV risk

factors (hypertension, DM, dyslipidemia,

obesity, smoking and abdominal

obesity(18)

. Diabetes is a potent risk factor

for ischemic heart disease death in young

people, particularly young women(19)

.

Cardiovascular disease (CVD) constitutes

one of the major causes of deaths and

disabilities. Over the last decade Saudi

Arabia has a witnessed significant rise in

CVD-related deaths. Smoking, high-fat,

low-fiber dietary intake, lack of exercise,

sedentary life, high blood cholesterol and

glucose levels were reported as frequent

CVD-risk factors among Saudis. The

prevalence of dyslipidemia, in particular,

indicates that treatment should be

directed at reducing the disorder with

statins as lipid-modifying agents and

therapeutic lifestyle changes particularly

to individuals with diabetes aged 40-75

years and with LDL-Ch 70-189

mg/dL(20)

. Nevertheless, statins usage

should be cautious since some of them

are diabetogenic in high risk groups(21)

.

Risk of diabetic cardiometabolic diseases

correlates body fat distribution. However,

indices involving abdominal obesity and

dyslipidemia are clinically significant

than body mass and body adiposity

indices in DM2 Saudi patients(3,4)

.

Dyslipidemia, a known cardiovascular

risk factor, is extremely common among

Saudis, both adults and children. DM was

the single most significant predictor of

mortality. Among Saudi patients with

heart failure, 82.9% exhibited low HDL-

cholesterol level, 35.2% had

hypertriglyceridemia, 27.8% showed

atherogenic dyslipidemia and 9.2% had

hypercholesterolemia. However, only low

levels of HDL-cholesterol contributed to

significant mortality risk(22)

. Saudi

National Atrial Fibrillation Survey

showed that the cardiovascular risk



2015

profile included smoking 92 (23.5%),

hypertension 253 (63.25%), diabetes 192

(48%), as well as dyslipidemia 173 (44%)

and indicated a relatively young patients

with higher rates of diabetes and

rheumatic heart disease than the

international profile(23)

. Among Saudi

acute coronary syndromes, 72% were

either overweight or obese, 57% were

diabetic, 56.6 were hypertensive, and

42% were dyslipidemic. Increasing BMI

was significantly associated with

diabetes, hypertension, and

hyperlipidemia. Overweight and obese

patients were significantly younger than

the normal-weight group(24)

. There is a

high prevalence of DM young Saudi

population with acute coronary

syndrome(25)

.

Dyslipidemia is a significant predictor of

cardiovascular events and mortality in

diabetes patients. Dyslipidemia among

DM2 Saudi males (higher cholesterol and

triglyceride) were higher than females

(higher HDL-Ch) imparting a significant

risk factor of low glycemic control into

cardiovascular events. Control of

hyperglycemia and other CVD risk factor

appears to be suboptimal in Saudi

Arabia(26)

. Almost two-thirds of statin-

treated dyslipidemic patients in the

United Arab Emirates, Saudi Arabia,

Lebanon and Jordan had inadequately

controlled lipid levels. Factors

independently associated with LDL-Ch

levels not being targeted for management

include lifestyle choices, and control of

diabetes mellitus(27)

.

Hypertriglyceridemia are associated with

chronic kidney disease, but not

retinopathy in subjects with DM2,

independently of statin treatment(28)

.

Coronary artery disease and diabetic

nephropathy, which are thought to share

pathogenic mechanisms, remain the most

common causes of mortality in DM1. In

adults with DM1, fasting triglyceride

independently predicted cardiorenal

disease over 6 years(29)

.

Erectile dysfunction (ED) is more

common in men with diabetes.

Dependent on the selected population,

age, DM type and duration, the

prevalence of diabetic ED (DED) varies

from 32 to 90%. In 12-30% of men ED is

the first sign of diabetes, diagnosed later.

Today men with diabetes live longer than

ever, and develop more late diabetic

complications(30,31)

. Unfortunately, we

could not find any detail regarding

erectile dysfunction for our male patient.

Deficient recording and/or fear of social

stigmatization are possible factors.

Saudi National Diabetes Registry-Based

Study revealed 10.8%, overall prevalence

of diabetic nephropathy. The strongest

impact was for age and diabetes duration

(3.7% in patients aged 25-44 years and a

duration of >5 years and 21.8% in

patients ≥ 65 years with a diabetes

duration of ≥ 15 years). Diabetes

duration, retinopathy, neuropathy,

hypertension, age >45 years,

hyperlipidemia, male gender, smoking,

and chronologically, poor glycemic

control have significantly high risk for

diabetic nephropathy(32)

. Among 2535

DM2 patients at 24 sites in 13 countries -

including Saudi Arabia - with an average

duration of 14 years, 1891 patients

kidney disease and 1218 with retinopathy

were reported. Diabetic kidney disease is

associated worldwide with higher levels

of plasma triglycerides and lower levels

of high-density lipoprotein cholesterol

among patients with good control of low-

density lipoprotein cholesterol(33)

.

Shockingly, even under best clinical

settings a great majority of Bangladeshi

adults with DM2 have uncontrolled



2015

diabetes and a high prevalence of risk

factors that might contribute to early

development of complications. Only

28.7% of the participants achieved targets

for HbA1c. The overall prevalence of

hypertension, obesity and dyslipidemia

was 57.5%, 62.6% and 72.7%,

respectively. Eye problems were the most

common complication (68.9%) followed

by chronic kidney diseases (21.3%) and

cardiovascular diseases (11.8%). There

were significant associations between the

complications and age, duration of

diabetes and duration of hypertension.

Early screening of high risk groups and

proper management of diabetes is

recommended to avoid early

complication(34)

.

Diabetic foot is one of the most morbid

complications of diabetes mellitus. This

is also a frequent cause of hospitalization

and disability. Most of the patients with

diabetic foot ulcers living in developing

countries present to healthcare facilities

fairly late with advanced foot ulcers

because of poor economic status,

inadequate knowledge of self-care, socio-

cultural reasons and poor and inadequate

diabetes healthcare. Our results showed

complication rate for all patients as 24%,

where 16% of them suffered foot

gangrene. In a cross-sectional study of

newly diagnosed DM patients, Kolkata,

India, diabetic foot ulcers were found in

4.54%. It was pathogenetically either

neuro- (46.06%), ischemic (19.74%) or

neuro-ischemic (34.2%)(35)

. Diabetic

retinopathy is the lead among causes of

blindness in North America. Glucose-

induced endothelial injury is the most

important cause of diabetic retinopathy

and other vascular complications(36)

.

DM2 is characterized by hyperglycemia,

dyslipidemia and disturbed liver function

compared to non-diabetes Saudi

participants(37)

. There is significant

suboptimal adherence with American

Diabetes Association standards

(diagnostic, medication and outcomes) of

diabetic care among patients with DM2

treated at a primary care center in Saudi

Arabia. Only 7.2% had glycemic control

in addition to controlled blood pressure

and targeted LDL-Ch level(38)

.

Investigating Prescription Practice for

Diabetes Management among a Female

Population in Primary Health Care,

Riyadh, Saudi Arabia, Alhreashy and

Mobierek reported the deficiency in

management of dyslipidemia among

diabetic patients(39)

. However, DM and its

complications are linked to

environmental, clinical, and genetic

factors. Hence, a number of gene

polymorphisms – for, e.g., ApoC3, TGF-

β1, IL-10, solute carrier family 30

member 8 (SLC30A8), Src-homology-2

B adaptor protein 1 (SH2B1), hepatic

nuclear factor-1 alpha (HNF1a),

Paraoxonase 1, Apolipoprotein E, insulin

receptor substrate-1, vitamin D receptor,

C5L2 gene, ACE I/D and MTHFR, TLR5

gene, WFS1, JAZF1, SLC30A8,

CDKN2A/B, TCF7L2, KCNQ1,

HMG20A, HNF4A and DUSP9, NPC1

gene, and KCNJ11 KATP channel subunit

were significantly connected to diabetes

and its complications in that

popupation(3,4,40-54)

.

It is essential to detect early, monitor and

manage proteinuria, hypertension and

dyslipidemia and to have good glycemic

control to prevent diabetes

complications(55)

. The glycemic control in

DM2 Saudi patients significantly

improves diabetic related

dyslipidemia(56)

. In DM1, diabetic

microvascular complications can be

controlled with tight glycemic therapy,

dyslipidemia management and blood



2015

pressure control along with renal function

monitoring, lifestyle changes, including

smoking cessation and low-protein diet.

Screening for subclinical complications

and early interventions with intensive

therapy is the need of the hour(57)

.

Conclusion

Giving the modest increases in the

glycemic control and lipogram indices and

the relative short disease duration among

Al-Jouf DM patients investigated,

dyslipidemia and the suboptimal disease

control were reflected on high prevalence

of the advanced disease complications.

This necessitates better disease prevention

and control strategies, and, more

elaborative prospective studies

considering the very deficient recording

system available.


The study experienced very deficient

patient information archiving.

Although there are hundreds of

thousands diabetics in the area, we

could not retrieve except very limited

number of usable filed information

that limits the merit of the study as

being representative.

We missed very beneficial correlation

analyses and presented some

apparently biased correlation results

due to such bad data filing.



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KH, Youssef AM, Al-Batel A,

Alotaibi MS, Al-Gamdi AA.

Epidemiology of abnormal glucose

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epidemic: SAUDI-DM study:

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Farghaly et al - Experimental Diabetic Nephropathy: TGF-beta vs. Kidney………..


2015

Original Article

Experimental Diabetic Nephropathy: TGF-beta vs. Kidney Injury

Molecule-1 and Apoptotic Biomarkers

Omar A. M. Farghaly1*

, Hosny A. Hasan2, Mohamed A. Abd-Alaziz

1, Hisham H.

Taha1

Departments of Biochemistry, 1Faculty of pharmacy, Al-Azhar University, Assiut

Branch, and, 2Faculty of Medicine, Assiut University, Assiut, Egypt.

*Correspondent author: [email protected]

Abstract

Background: Diabetic nephropathy (DN) is serious complication of diabetes mellitus

and is the major cause of end stage renal disease. Early diagnosis of DN provides a

potential for protective interventions. Study Aims: We firstly evaluated the

relationship of kidney injury molecule-1 (kim-1) with traditional kidney injury

markers. Kim-1 was also correlated with some DN pathogenic mediators namely; TGF-

β, caspase-3 and oxidative stress. Materials & Methods: Diabetes was induced in rats

following i.p. injection of alloxan monohydrate 150 mg/kg body weight. Investigations

were done on kidney tissues, urine and serum at 14, 28 and 42 days post induction.

Kim-1 was estimated by ELISA, TGF-β was semi-quantitatively detected by western

blotting, caspase-3 mRNA expression was estimated by Rt-PCR, and other parameters

were assayed colorimetrically. Results: Results revealed that, urinary kim-1 showed a

significant increase in all diabetic groups earlier than the significant increases in

traditional markers of DN (Albumin-creatinine ratio & serum creatinine) compared to

control group. Also, there were marked elevation in TGF-β protein, caspase-3 mRNA

expression and oxidative stress indices (malondialdehyde, nitric oxide and reduced

glutathione) and a marked decrease in the anti-oxidant GSH in all diabetic groups

compared to control group. Conclusion: Urinary Kim-1 is an invaluable non-invasive

biomarker for early detection of DN, and, paralleled the increases in TGF-β protein and

caspase-3 mRNA expression and oxidative stress indices as known pathogenetic

mediators in DN. Farghaly OAM, Hasan HA, Abd-Alaziz MA, Taha HH. Some

Biochemical Features of Diabetic Nephropathy Induced In Rats. AUMJ, 2015

September 1; 2(3): 25 - 38.

Keywords: Diabetic Nephropathy, Kidney injury molecule-1, TGF-β, Caspase-3,

Oxidative stress.

Introduction

Diabetic nephropathy (DN) is a serious

complication of diabetes mellitus (DM)

and the most common cause of end stage

renal disease (ESRD)(1)

.The exact

pathogenesis of DN is complex and not

fully understood(2)

. Uncontrolled

hyperglycemia plays a central role in the

pathogenesis of DN through inducing

secretion of cytokines and growth factors,

oxidative stress and lipid peroxidation,

abnormal glycosylation and inflammatory

elements(3)

. The early diagnosis of DN is

clearly beneficial through early nephro-

protective intervention. Routinely tests;

albuminuria and elevations of serum



2015

creatinine and blood urea nitrogen

diagnose DN after significant decline in

glomerular filtration rate (GFR)(4)

. This is

because such tests have moderate

specificity and sensitivity at early stage of

the disease(5)

. Furthermore, DM patients

may experience renal pathological

alterations and significant marked decline

in kidney function despite absence of

albuminuria(6)

. Kidney injury molecule-1

(kim-1) was previously shown to be a

sensitive, specific, and early non-invasive

urinary marker for acute kidney injury

induced by various nephro-toxicants such

as cadmium, chromium, cisplatin,

gentamycin, arsenic, and folic acid in

animal models(7-9)

, and human cases that

included urinary tract infection,

angiographic procedure, renal cell

carcinoma, obstruction-induced kidney

injury and in contract-induced

nephropathy(10-12)

. Kim-1 is a type 1 104

kDa transmembrane glycoprotein

containing in its extracellular portion a 6-

cysteine immunoglobulin-like domain

and a Thr/Ser-pro rich domain

characteristic of mucin-like o-

glycosylated protein with possible

signaling function. Metalloproteinases

cleave the protein and the soluble 90 kDa

kim-1 appears in urine(13-16)

. KIM-1 have

a central role in the removal of dead cells

and other debris from the tubular

lumen(17)

.

Transforming growth factor beta (TGF-β)

family comprises a group of cytokines

which are key regulator of extracellular

matrix (ECM) homeostasis. Its

overexpression indicate tissue fibrosis

and organ failure(18)

. Hyperglycemia,

hypertension, activations of renin-

angiotensin system and increases intra-

glomerular pressure that associate DN

induce TGF-β production in kidney and

in cultured mesangial or tubular cells(19)

.

Caspases (cysteinyl aspartate-specific

proteases), a group of cysteine proteases,

play a main role in the initiation and

execution of apoptosis(20)

. Among those,

caspase-3 is the most commonly involved

executive caspase in different cell types

including renal tissues(21)

. Hyperglycemia

and induces oxidative stress and

inflammation active caspase-3(22)

. These

pathogenetic condition also increases

Bax/Bcl-2 ratio, associated with

cytochrome c release from mitochondria

and subsequently the proapoptotic

caspase-3(23)

. Within renal cells, a balance

between pro- and anti-oxidant effectors is

critical. Although reactive

oxygen/nitrogen species (ROS) have

important functions in normal cellular

signaling and regulation, their excess

induces oxidative damage to lipids,

proteins and DNA leading to apoptosis

and renal injury(24)

. Hyperglycemia,

through formation of advanced glycation

end products (AGEs) and the

mitochondrial dysfunction, induces

oxidative stress and production of ROS

with subsequent cell death and decline in

renal functions(25)

.

It is clear that there is a need for

evaluation of a more sensitive, specific,

and early markers for diagnosis of DN. In

the current study, we evaluated

alterations in urinary level of kim-1 in

associated with alloxan-induced DN in

rats as compared to the traditional

markers of acute kidney injury

(albuminuria, serum creatinine and blood

urea nitrogen), and their correlation with

established DN pathogenetic effector,

namely, TGF-β, oxidative stress (GSH,

NO., and MDA) and caspase-3 - at

protein and mRNA expression levels and

serum, urine and tissue content level. The

role of kim-1 in apoptosis and fibrosis of

DN is poorly understood so we focused



2015

on checking its correlation with renal

apoptosis and fibrosis.


Reagents: Rabbit anti-TGF-β primary

antibody was obtained from abcam®

company (cat# AB66043, Cambridge,

UK). Alkaline phosphatase anti-rabbit

antibody was obtained from Santa Cruz

Co. (cat# sc-2057, Texas, USA). Alkaline

phosphatase labeled secondary anti-

mouse antibody was obtained from

Novus Co. (cat#NB7524, Littleton,

USA). Anti-β-actin primary antibody was

obtained from Novus Co. (cat# NB600-

501, Littleton, USA). Total RNA was

extracted from renal tissues by using total

RNA purification kit obtained from Jena

Bioscience GmbH (Cat# pp-210S, Jena,

Germany). The extracted RNA was

reverse transcribed into complementary

deoxyribonucleic acid (cDNA) using

Thermo Fisher Scientific Revert Aid TM

(cat# k1691, Waltham, MA, USA).

cDNA was amplified by PCR using

MyTaqTMMix obtained from BIOLINE

(cat# BIO-25041, Sydney, Australia).

Purified and validated gene-specific

primers of caspase-3 were obtained from

Vivantis Technologies (Selangor,

Malaysia; Table 1). Urinary kim-1 was

determined by ELISA assay obtained

from Glory Science Co. Ltd (cat# 20241,

Hangzhou, China). Serum and urine

creatinine content was colorimetrically

assayed by kinetic procedure (cat# 15014,

Human Diagnostic, Wiesbaden,

Germany). Blood urea nitrogen (BUN)

was colorimetrically assayed (Randox

Laboratories Ltd, cat# UR1068, County

Antrim, UK). Urinary albumin was

detected by using a commercially

available kit by turbidimetric (cat#

31924, BioSystems S.A., Barcelona,

Spain). Analytical grade alloxan

monohydrate was purchased from Oxford

Co. (cat# A-00446, Maharashtra, India).

All other chemicals and solvents used in

this study were of analytical grade and

were obtained either from Sigma

Chemical Co. or other Commercial

suppliers.

The experimental DN Model: Forty adult

male Wister albino rats with initial body

weight 185 ± 15 g were used. Rats were

obtained and maintained in the animal

house of Faculty of Medicine, Assiut

University under standard laboratory

conditions (12/12 hrs light/dark cycle, 21

± 2 ºC with relative humidity of 55% and

were allowed free access to standard rat

pellets and tap water. All animals

received professional humane care in

compliance with the International Ethical

Guidelines for Animal Care (US Naval

Medical Research Center, Unit No.3,

Abbaseya, Cairo, Egypt) accredited by

the Association for Assessment and

Accreditation of Laboratory Animal Care

International. Rats were randomly

divided into four groups of ten rats each.

Diabetes was induced in thirty 18-hrs

fasting rats by i/p injection of single dose

of alloxan monohydrate (150 mg/kg body

weight) freshly dissolved in 0.9% normal

saline(26)

. Healthy control rats received

the vehicle. To guard against drug-

induced hypoglycemia, alloxan treated

animals were allowed to drink 5%

glucose solution during the first 24 hrs

post-injection(27,28)

. Three days after

alloxan injection, diabetes was confirmed

by the presence of fasting hyperglycemia

(≥200 mg/dL) and glucosuria to exclude

resistant animals. Diabetic rats were

sacrificed under light diethylether

anesthesia at 14 (along with normal

controls), 28 or 42 days DM post-

induction. This protocol induces early

stage diabetic nephropathy(29)

.



2015

Table 1: Primer sequences for rat casapse-3 and control house-keeping β-actin used for

Rt-PCR analysis of their mRNA expression in alloxan-induced diabetic nephropathy in

rats.

Primer Primer sequence

Caspase-3

(product length

is 639 bases)

Forward primer:5´-GGAGCTTGGAACGCGAAGAA-3´

Reverse primer: 5´-TAGTAACCGGGTGCGGTAGA-3´

Gene bank accession number giǀ52138591ǀNM_012922.2

β-Actin

(product length

is 243 bases)

Forward primer:5´-CCACCATGTACCCAGGCATT-3´

Reverse primer: 5´-ACGCAGCTCAGTAACAGTCC-3´

Gene bank accession number giǀ402744873ǀNM_031144.3

Sample Collection and Investigations:

One day before the end of the

experimental period, food-fasting animals

from each group were kept individually

in metabolic cages for 24-hrs urine

collection. Urine volume was measured, a

specimen was centrifuged at 600×g for 15

min and supernatant was aliquot frozen.

At each time point, blood samples

withdraw through the retro-orbital plexus

using un-heparinized micro-capillaries

under anesthesia, blood was allowed clot

at room temperature, centrifuged at

600×g for 15 min to recover serum

separation that was aliquot frozen. Both

kidneys were isolated immediately after

sacrificing, washed with ice cold isotonic

saline, blot dried and divided into pieces,

and flash-frozen in liquid nitrogen and

stored at -80 °C.

TGF-β protein expression by western

blotting: Kidney tissue was homogenized

in 1.5 mL ice-cold lysis buffer containing

protease inhibitors by Glass-Col

Homogenizer, centrifuges at to 600×g for

15 min sediment debris. 50 µg protein

amount of homogenate supernatant were

denatured by boiling in 2% sodium

dodecyl sulfate (SDS) and 5% 2-

mercaptoethanol for 5 minutes and

loaded in each lane(30)

. 12% SDS-

polyacrylamide gel (SDS-PAGE) was

electrophoresed at 100 volts for 120

minutes. The protein was semidry

transferred onto nitrocellulose membrane

(T-77 ECL, Amersham Biosciences) for

120 minutes. The membrane was

blocked by 5% defatted milk dissolved in

TBST buffer for 60 minutes and was

incubated with the primary polyclonal

anti-TGF-β (at dilution 1:500) overnight.

Then was incubated with 1:5000 diluted

polyclonal goat anti-rabbit

immunoglobulin conjugated to alkaline

phosphatase in 10× diluted blocking

buffer. The bands of the proteins were

detected by using 5-bromo-4-chloro-3-

indoryl phosphate/nitroblue tetrazolium

detection system and Tris-HCl

buffer/magnesium chloride. These

incubations also included primary and

secondary specific antibodies against β-

actin for load control at dilution 1:5000

for both primary and secondary

antibodies.

Caspase-3/β-actin mRNA expression by

Rt-PCR: to maximized mRNA quality,

flash freezing and treatment of all utensils

with 0.1% diethylpyrocarbonate-treated

water was done before autoclaving. As

instructed, the extracted RNA was

quantified at 260/280 nm and was

reversing transcribed into cDNAs. The

resulting cDNA was amplified by PCR

using specific primers. A total 20 μL



2015

reaction mix contained 2 μL Rt, 2.5 U

Taq DNA polymerase, 20 μM/L dNTP,

0.1 μM/L primer and 1× Taq DNA

polymerase buffer. Using Biometra

thermal cycler, the amplification

condition was composed of a

predenaturation at 94 ºC for 4 minutes,

denature at 94 ºC for 30 seconds,

annealing at 55 ºC for 30 seconds, and

extension at 72 ºC for 1 minutes, for 30

cycles followed by incubated at 72 ºC for

4 minutes then cooling at 4 ºC. PCR

products were resolved on 1.5% (v/v)

agarose/ethidium bromide gel.

Biochemical Analysis: Urinary kim-1,

serum and urine creatinine content, serum

BUN level, urine albumin content were

quantitatively assayed according to the

kit manufacturer instructions. Kidney

tissue homogenate content of reduced

glutathione (GSH) was determined by

Ellman assay method(31)

and of

malondialdehyde (MDA) was determined

by Uchiyama and Mihara method(32)

.

Figure 1: A representative western blot analysis of TGF-β (upper panels) vs. β-actin (lower

panels) protein expression in rat kidney tissue homogenate from normal control, and 14, 28 and

42 days time point of alloxan-induced diabetic nephropathy rats (n = 8 for each group).

Kidney contents of nitric oxide (NO.)

were calculated as total nitrites(33)

. Urine

albumin-creatinine ratio (ACR) was

calculated.

Statistical analysis: Data were expressed

as the mean ± SEM. Variables were

compared using one way analysis of

variance (ANOVA) followed by Tukey's

post test. p˂0.05 was considered



2015

significant. All statistical analysis was

conducted with GraphPad Prism (version

5, GraphPad software, California, USA).

Results

The results showed an over expression of

TGF-β vs. β-actin protein in kidney tissue

of alloxan treated rats after 42 days

(Figure 1 lane 4) as compared to shorter

time points vs. healthy control (Figure 1).

Our result showed marked increase in

mRNA expression of caspase 3 vs. β-

actin after 42 days in alloxan-treated

group as compared to earlier time points

(Figure 2).

Figure 2: A representative Rt-PCR analysis of caspase-3 (upper panels) vs. β-actin (lower panels)

mRNA expression in rat kidney tissue homogenate from normal control, and 14, 28 and 42 days

time point of alloxan-induced diabetic nephropathy rats (n = 8 for each group).

Results showed that urinary kim-1 was

significantly increased in all diabetic

groups compared to normal controls with

undetectable level. Increases in urinary

ACR at 14 days after induction of DM

was non-significant but was significantly

increased at 28 and 42 days time points.

Serum creatinine level was only

significantly increased at the latest time

point in group 4. However, our results

showed a significant increase in serum

BUN in all diabetic groups compared to

the control non-diabetic group (Table 2).

Our results revealed significant decreases

in kidney tissue contents of GSH in all

diabetic groups compared to control group

and significant increases in contents of

each of MDA and NO. in all diabetic



2015

groups compared to normal controls (Table 2).

Table 2: Effect of alloxan-induced diabetic nephropathy (DN) in rats on urinary kim-1 (Uk-1),

urinary albumin-creatinine ratio (ACR), serum creatinine (SC), blood urea nitrogen (BUN), and

wet kidney tissue content of nitric oxide (NO.), malondialdehyde (MDA) and reduced

glutathione (GSH) at 14, 28 and 42 days post induction. Data shown are mean ± SEM. n = 8 per

each group.

DN at 42 days DN at 28 days DN at 14 days Controls Parameters

128.3 ± 4.0×××•••ₒₒₒ 90.5 ± 2.8•••ₒₒₒ 30.94 ± 4.5ₒₒₒ 0.085 ± 0.017 Uk-1 (ng/L)

2698 ± 178.35×××•••ₒₒₒ 1248.9 ± 117.4•••ₒₒₒ 557.8 ± 126.17 342.5 ± 31.3 ACR (mg/gm)

0.68 ± 0.0124×××•••ₒₒₒ 0.51 ± 0.008 0.49 ± 0.014 0.48 ± 0.011 SC (mg/dL)

94.4 ± 1.28×××•••ₒₒₒ 71 ± 0.80•••ₒₒₒ 54.0 ± 1.9ₒₒₒ 25.13 ± 1.125 BUN (mg/dL)

4.14 ± 0.17×××•••ₒₒₒ 3.14 ± 0.10•••ₒₒₒ 2.40 ± 0.09ₒ 1.78 ± 0.08 NO. (mM/gm)

90.59 ± 2.1×××•••ₒₒₒ 63.43 ± 1.7•ₒₒₒ 44.78 ± 1.05ₒₒ 30.13 ± 1.02 MDA (nM/gm)

29 ± 1.70×××•••ₒₒₒ 45.9 ± 1.4••ₒₒₒ 67.44 ± 1.3ₒ 89.73 ± 0.86 GSH (mg/gm)

º, •, and

× indicate significant change vs. each of normal control, 14 days DM, 28 days

DM, and 42 days DM, respectively. º, •, and

× = P<0.05, ºº,

••, and

×× = P<0.01, and, ººº,

•••, and

××× = P<0.001.

Discussion

Diabetes is experimentally inducible

alloxan and could be modeled as type 1

or type 2 according to the dose(34,35)

. The

toxic action of alloxan on pancreatic β-

cells involve oxidation of essential

sulfhydryl groups, inhibition of

glucokinase, generation of free radicals

and disturbance in intracellular calcium

homeostasis(36)

. In this diabetic model,

DN occurs within 14 days of

induction(29)

. Our results showed that,

urinary kim-1 was detected in very low

amount in normal control rats but showed

a marked elevation in diabetic rats at all

time points investigated. Such kim-1

increases preceded the significant

elevations in traditionally kidney injury

biomarkers, namely; albuminuria and

serum creatinine when renal injury is

established histopathologically. These

markers are neither universal urinary

biomarker nor do they reflect a final

common pathway for renal expression of

injury(37)

. Urinary kim-1 concentration

continued to be high after elevation of

urinary albumin and serum creatinine.

Reportedly, the ischemia-reperfusion

model of kidney injury caused a

significant increase of urinary kim-1

without significant changes in plasma

creatinine or urinary albumin(38,39)

.

In the current study, we found that the

significant elevation of urinary albumin

excretion began at 28 days of induction

of DM. Although, micro-albuminuria is

used for the early diagnosis of DN, it is

also found in apparently healthy

individuals and about 1∕3 of diabetic

patients suffering from kidney disease in

the absence of albuminuria(40,41)

. In

addition, moderate increases in albumin

excretion are associated with a variety of

other conditions, including obesity,

posture, exercise, diet, smoking, gender,

puberty, infection, and inflammation(42)

.

Therefore, the absence of albuminuria or

its progression to proteinuria does not

signify that an individual patient is safe

from a progressive decline in GFR.

Actually, 10-25% of normoalbuminuric



2015

diabetic patients shows progressively

declining GFR(43)

.

Our results revealed that serum creatinine

showed a non-significant increase at the

short and intermediate time points post

induction of DM that became significant

only at the latest time point of 42 days

post-induction compared to normal

controls. Serum creatinine is a poor

marker of kidney dysfunction as changes

in its levels are neither sensitive nor

specific in response to slight GFR

alterations and become significantly

higher only when the renal functions are

declined to 50% of its capacity.

Moreover, serum creatinine level is

influenced by other factors, which are not

directly related to kidney damage,

namely; age, gender, body mass, and

dehydration and nutritional status(39, 44-47)

.

Considering BUN, our results showed a

significant increase in diabetic rats at all

time points investigated vs. non-diabetic

controls. These results are similar to

previous results showed by Sharma et

al(48)

. The observed uremia in the present

study may be attributed to increased

protein degradation in diabetes as well as

increased facilitated urea reabsorption in

the kidney. Urea serum level is inversely

related to GFR, but several factors affect

its production and clearance, limiting its

reliability. Urea production is inconstant

and values can be altered by changes in

circulating volume, protein intake, liver

function and gastrointestinal bleeding.

Moreover, rate of renal clearance of urea

is not constant since 40 - 50% of filtrated

urea may be reabsorbed in the tubules(49)

.

In the current study we investigated

implication of TGF-β as fibrogenic

effector in renal injury secondary to

diabetes. Our results revealed a

significant up-regulation of renal tissue

TGF-β protein expression in all diabetic

groups compared to control group

paralleling early increases in urinary kim-

1 excretion. Kim-1 is thought to be

involved in the development of interstitial

fibrosis since kim-1-positive atrophic

tubules are surrounded by fibrosis and

inflammation(50-52)

. Our results are

consistent with previous studies

demonstrating increases in TGF-β

expression in diabetic kidney in relation

to glomerular and tubule-interstitial

damage(53-56)

. Such results could be

explained on the basis that hyperglycemia

stimulates expression of TGF-β in

mesangial cells and TGF-β receptor

(TGF-βR) in podocytes - possibly

completeing a paracrine fibrogenic loop.

Activation of TGF-β/Smad signaling in

podocytes may induce collagen ӏV,

connective tissue growth factor and

vascular endothelial growth factor

overexpression, leading to glomerular

basement membrane thickening and

mesangial matrix expansion, culminating

in diabetic glomerulosclerosis(57)

. TGF-β

also decreases matrix degradation by

inhibiting proteases and by activating

protease inhibitors such as plasminogen

activator inhibitor-1. In addition, TGF-β

promotes cell-matrix interactions by up-

regulating integrin(58)

. The detrimental

role of TGF-β∕Smad signaling pathways

in the pathogenesis of DN was further

confirmed when treatment with anti-

TGF-β antibody was shown to reduce

renal fibrosis and albuminuria through

inhibition(59)

.

Cell loss by apoptosis participates in

pathogenesis of DN. The present study

further revealed that there was a marked

elevation of kidney tissue caspase-3

mRNA expression in diabetic rats at all

time points compared to the control

group. This result paralleled increases in

tissue oxidative stress biomarkers (MDA,



2015

GSH and NO.). While there were a

marked elevation in renal MDA and NO.,

GSH content was significantly reduced in

diabetic rats at all time points compared

to normal controls they also paralleled

increases in urinary kim-1 levels. These

results are consistent with previous

studies(60-62)

. Hyperglycemia increases

Bax/Bcl-2 ratio associated with

cytochrome c release from mitochondria

and subsequent activation of caspase-3

and ROS-dependant apoptosis(23,63-68)

.

Kim-1 specifically bind

phosphatidylserine on the apoptotic cell

surface and transform tubular epithelial

cells into semiprofessional phagocytes to

clear apoptotic and necrotic cell debris

from the tubular lumen(17,64)

. Increased

MDA level in plasma, serum, and many

other tissues has been reported in diabetic

cases(69,70)

.

Our results showed a significance

decrease in renal tissue GSH content in

diabetic rats at all time points post

induction compared to control group.

These results were in agreement with

previous results(67,71-77)

. GSH is the most

abundant non-protein thiol that defense

against oxidative stress. It is a biomarker

of redox imbalance at cellular level(74-77)

.

NO. has multiple vascular functions,

namely; a vasodilator, anti-inflammatory,

anti-thrombotic, and proliferative

activities. Biological unavailability of

NO. in the kidney play a role in the

pathophysiology of the development and

progression of DN. Increases NO. in the

kidney may contribute to the glomerular

hypertension, hyperfiltration, and

microalbuminuria(78)

. Hyperglycemia

increases NO.(79)

. Our results, showed a

significance increase of renal tissue NO.

content in diabetic rat at all time points

post induction compared to the control

group. These results are similar to those

of Sharma et al, Chiarelli et al and Noh

et al(80-82)

.

Conclusion

Urinary kim-1 was significant elevated

before significant elevation of

albuminuria, and serum creatinine and the

elevation of urinary kim-1 continued after

progression of alloxan-induced DN in

rats where such traditional biomarkers

started to increase. Urinary kim-1 could

serve an earlier biomarker function for

DN. Pathogenetic overexpression of

TGF-β and caspase-3 and oxidative stress

(MDA and NO. increases and GSH

decreases) paralleled the increases in

urinary kim-1 production. Future

molecular studies could further dissect

the role of kim-1 in pathogenesis and

diagnosis of DN.


The animal model used is type 1 DM.

We wished to include type 2 DM, too

that would be done in a future study.

Urinary kim-1 as early marker of DN

was compared to traditional markers

only of kidney dysfunction and not

other biomarkers such as β2-

micglobulin and N-acetyl-β-D-

glucosaminidase.



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Almarshad et al - The nephroprotective effect of Zingiber officinale extract against…..


2015

Original Article

The Nephroprotective Effect of Zingiber Officinale Extract Against

Azathioprine-Induced Renal Damage: An Experimental

Histopathological Study

Hassan Aqla Almarshad*, Ahmed Abd El-Hafez Tantawy and Talal Afet Alenazi

Department of Clinical Laboratory Science, College of Applied Medical Sciences,

Aljouf University, Sakaka, KSA. *Correspondent author: [email protected]

Abstract

Background: Ginger extract is protective in various cytotoxic models. The

immunosuppressive azathioprine prevents graft rejection albeit with a non-prefect

clinical profile. The histopathological nephroprotective effect of ginger extract in

azathioprine-induced nephrotoxicity was scarcely studied. Aims: The present study

aimed at describing the histopathological changes in the kidneys after oral

administration of azathioprine and the possible potential nephroprotective effect of co-

treatment with dried juice of ginger rhizome in Guinea pigs. Materials and Methods:

Sixteen adult male Guinea pigs were randomly divided into four groups, four guinea

pigs in each. Normal control group (G1) fed normal diet and received vehicle solution

daily (1 mL distilled water). Ginger extract treated group (G2) received dried juice of

ginger at 50 mg/kg body weight (BW) dissolved in distilled water once orally daily for

a period of 5 days. Azathioprine treated group (G3) received azathioprine with at 50

mg/kg BW once daily orally for a period of 5 days. Ginger plus azathioprine treated

group (G4) received ginger extract + azathioprine as described for 5 days. Results: The

microscopic examination of the kidneys of guinea pigs of both normal control and

ginger extract treated groups revealed normal histological structures of the renal

tubules and glomeruli. Kidneys of guinea pig treated with azathioprine revealed

tubulointerstitial nephritis characterized by focal mononuclear inflammatory cellular

infiltration of interstitial tissues together with necrosis and degeneration of the renal

tubules. Cystic dilatation of some renal tubules together with luminal hyaline casts was

also observed. In ginger + azathioprine treated group, the histopathological

examination of the kidneys showed partial improvement of the microscopic picture of

the renal tissue where renal tubular degenerative changes was only recorded

microscopic lesion. Conclusion: Azathioprine induced tubulointerstitial nephritis in

guinea pigs at the used dosage and ginger extract had nephroprotective effect and

ameliorated most of the azathioprine-induced acute renal damages. Almarshad HA,

Tantawy AA-E, Alenazi TA. The nephroprotective effect of Zingiber officinale

extract against Azathioprine-induced renal damage: An experimental

histopathological study. AUMJ, 2015 September 1; 2(3): 39 - 46.

Keywords: Nephroprotective, Zingiber officinale, Nephrotoxicity, Renal damage,

Azathioprine, Histopathology.



2015

Introduction

The use of botanical natural products and

their active principles in therapy of

numerous diseases has been on the

increase. The main effective component

in such plants are their natural

antioxidants that protect against cytotoxic

oxidative stress and cellular damage(1-3)

.

Ginger rhizome, Zingiber officinale, is

one of the most commonly used botanical

natural product around the world. The

gingerol was identified as the major

active component in the fresh ginger

rhizome(3,4)

. These polyphenols and

flavonoids found in ginger extract are

responsible its cytoprotective

activities(2,4)

. In addition to its antioxidant

activities, ginger extract has many

pharmacological effects including

antitumor, hepatoprotective, anti-arthritic

and anti-inflammatory effects(5-7)

.

Zerumbone, the active compound of Z.

zerumbet rhizome was used for protection

against cisplatin-induced kidney

dysfunction by preventing lipid

peroxidation and preserving antioxidant(8-

10). In addition coadministration of

Zingiber officinale extract prevented

gentamycin nephrotoxicity and reduced

the severity of tubular damage caused by

gentamicin(11,12)

.

Azathioprine is one of the common

immunosuppressants used for therapy of

hematological malignancies,

inflammatory bowel disease, autoimmune

conditions and to avoid organ rejection

following transplantation(13)

. However, its

use has been complicated by a high

incidence of serious adverse reactions

such as mylosuppression, hepatotoxicity,

pancreatitis, atrial fibrillation and

gastrointestinal disturbances(14-17)

.

Although the occurrence of azathioprine

nephrotoxicity was less common than

that of hepatotoxicity as reported by Raza

et al (2003), Wu et al (2006), Ruiz-

Clavijo et al (2013) and Cho et al

(2014)(18-21)

, some studies have

recognized that administration of

azathioprine induced nephrotoxicity(22,23)

,

and renal tissue damage that cause

rapidly progressive renal failure in a

patient with Wegener's

granulomatosis(24)

.

The present study was carried out to

describe the histopathological changes in

Guinea pig kidneys after oral

administration of azathioprine and the

possible nephro-ameliorative effect of

coadministration of ginger extract.


Experimental animals: Adult male

Guinea pigs were obtained from local

market. They were kept under

observation for two weeks before the

onset of the experiment to exclude any

current infection. The animals were kept

at room temperature and exposed to

natural daily light-dark cycles. Guinea

pigs were fed ad libitum and clean water

was continuously available. The study

was approved by the Departmental

Scientific Committee and was performed

in compliance with relevant standards

laws and Institutional Ethical Guidelines

and in accordance with the

recommendations for the proper care and

use of laboratory animals stated by

National Committee of Bioethics (NCBE)

and Aljouf University Bioethics

Committee Guidelines.

Preparation of ginger extracts: Ginger

was prepared and extracted as reported by

Almarshad (2014)(25)

. A 0.5 kg of fresh

ginger rhizomes (Zingiber officinale L.)

was obtained from local market, washed

with water, sliced, and pressed by an

electric press to recover its juice. The

liquid juice obtained was evaporated



2015

under reduced pressure at 70 °C. The

yield of the dried powder obtained was

50 mg/mL of the juice.

Experimental design: Sixteen adult male

Guinea pigs with body weight (BW)

range of 0.8 - 1.2 Kg were randomly

assigned to each of four groups (four

guinea pigs in each). Normal control

group (G1) was fed normal diet and

received 1 mL of distilled water as the

vehicle. Ginger treated group (G2)

received dried ginger juice powder orally

daily for a period of 5 days at a dose of

50 mg/kg BW dissolved in 1 mL distilled

water. Azathioprine-induced renal

damage group (G3) received azathioprine

(ImuranTM

, GlaxoSmithKline, Canada) at

a dose of 50 mg/kg BW dissolved in 1

mL distilled water once daily orally for a

period of 5 days. Ginger + Azathioprine

treated group (G4) received dried ginger

juice powder together with azathioprine

as described for G2 and G3. All animals

were kept under observation for recording

of any clinical signs and mortality rates.

Histopathological specimens: At the end

of the experiment, Guinea pigs in all

groups were anesthetized with

chloroform and then sacrificed by

decapitation. Post mortem examination of

guinea pigs was carried out and any

abnormal gross renal lesions were

recorded. For microscopic examination,

small tissue specimens were collected

from kidneys of guinea pigs in all groups

and immediately fixed in 10% neutral

buffered formalin. After proper fixation,

the fixed specimens were dehydrated in

ascending strengths of ethyl alcohol,

cleared in xylene, embedded in paraffin

wax and then 5 mm tissue-paraffin

sections were prepared and stained with

H&E(25)

.

Results

The microscopic examination of the

kidneys of Guinea pigs in both normal

control group and ginger treated group

revealed normal histological structures of

the renal tubules and glomeruli (Figure

1A & B). In Ginger plus azathioprine

treated group, the histopathological

examination of the kidneys showed only

focal areas of cloudy swelling and

hydropic degeneration of some renal

tubular epithelium (Figure 1C). In

contrast, the examined kidneys of animals

treated with azathioprine alone revealed

definite tubulointerstitial nephritis

characterized by presence of multiple

areas of interstitial edema infiltrated with

inflammatory cells particularly

lymphocytes, plasma cells, macrophages

and few neutrophils with slight

proliferation of few interstitial fibroblasts

(Figure 1D). Degeneration of the lining

epithelium of renal tubules in the form of

cloudy swelling and hydropic

degeneration was noticed (Figure 1E).

Hyaline casts in the lumens of some

tubules were observed in the most

examined kidneys of Guinea pigs (Figure

1F). Necrosis of some renal tubular

epithelium was also recorded in the same

group (Figure 1G). Moreover, focal areas

of calcification were also seen in

examined kidney of one animal treated

with azathioprine alone (Figure 1H).

Discussion

Azathioprine is the pro-drug of 6-

mercaptopurine synthesized by attaching

an imidazole ring to the sulfur atom at 6th

position of 6-mercaptopurine. The

success in the field of kidney

transplantation in 1962 broadened its

clinical applications thereafter upon the

advent of immunosuppression drugs(27)

.



2015

Figure 1: Representative micrographs of kidneys of Guinea pigs in control group showing

normal renal tubules and glomeruli (A). Kidneys of Guinea pigs given ginger extract showing

congestion of intertubular blood vessels (B). Kidneys of Guinea pigs treated with azathioprine

plus ginger extract showing cloudy swelling of epithelial cells lining some renal tubules (C).

Kidneys of Guinea pigs treated with azathioprine alone showing interstitial inflammatory edema

(D), hydropic degeneration of renal tubular epithelium (E), hyaline casts in the lumens of some

dilated renal tubules (F), necrosis of tubular epithelium (G) and focal calcification (H). H & E

stain X 200..



2015

A wide range of adverse reactions of

azathioprine manifesting from trivial

gastrointestinal discomfort to life-

threatening myelosuppression or

anaphylactic shock has been

described(28,29)

. Conversely, a few

information about nephrotoxicity of

azathioprine was recorded(22,23,30)

. The

present study is first carried out to

investigate the possible azathioprine-

induced renal damage and its

amelioration by cotreatment with ginger

extract in experimental animal model.

In the present study, the histopathological

examination of kidneys showed that

administration of azathioprine induces

renal damages in the form of

tubulointerstitial nephritis characterized

by inflammatory edema of the

interstitium, severe tubular degeneration

and necrosis with cystic dilatation of

some renal tubules. These microscopic

changes were also described by Shin et al

(2006) who detected tubulointerstitial

nephritis by renal biopsy at the end of the

course of azathioprine treatment(30)

.

Although interstitial nephritis can be a

primary cause of renal failure, it usually

follows glomerular injury, which

probably initiates secondary interstitial

disease as a consequence of persistent

proteinuria(31)

. This tubulointerstitial

nephritis may be the final common

pathway to renal failure(32)

.

In this investigation, the tubulointerstitial

lesions were characterized by multiple

areas of mononuclear cellular infiltration

particularly lymphocytes. These

microscopic changes suggest immune

mediated mechanisms of renal injury and

this may initiate tubular injury or amplify

the damage. This opinion was supported

by previous experimental studies where

induction of acute interstitial nephritis

involved either cell-mediated immunity

or antibody-mediated immunity(33,34)

. In

the present study, the microscopic

examination of the kidneys in ginger plus

azathioprine group revealed that the

extract was able to cause partial recovery

of the renal damages in azathioprine

treated group where only focal areas of

tubular degenerative changes in the form

of cloudy swelling were seen. This result

indicated that extract of ginger had

nephroprotective effects and preventing

the renal damages-induced by

azathioprine. The recorded results were

supported by those mentioned by Uz et al

(2009) who demonstrated reduced

histological features in the kidney of

ischemia/reperfusion rats by dietary

ginger supplementation(34)

and Al-Qattan

et al (2008) and Ramudu et al (2011) who

concluded that ginger successfully

reduced the progression of nephropathy

in streptozotocin-induced diabetic

rats(36,37)

.

Conclusion

The results of this study showed that

administration of azathioprine induced

interstitial nephritis in Guinea pigs and

co-treatment with ginger extract induced

an ameliorative effect on such

nephrotoxicity.


An elemental spectroscopy analysis of

the ginger Zingiber officinale aqueous

extraction was not performed to

ensure the composition and the purity

of the compound.

The sample size was limited and did

not allow the construction of a dose-

response curve for each of

azathioprine and ginger extract due to

cost constraints.





2015

Acknowledgment

We wish to thank Mr. Hafiz Qum from

Department of Clinical Laboratory

Science, College of Applied Medical

Science at Aljouf University, Sakaka,

Saudi Arabia, for his valuable technical

assistance during the preparation of this

study.

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Mohamed et al - Serum Progesterone and Estradiol Levels and the Mast Cells ……


2015

Original Article

Serum Progesterone and Estradiol Levels and the Mast Cells Count

in Skin Tags among Healthy Pregnant and Non-Pregnant Women: Correlation with Age of Pregnancy and Phases of the Menstrual

Cycle

Alaa A. Mohamed1*

, Abd El-Aziz El-Rifaie2, Yasser Gohary

2, Khalid A. El-Nesr

3, and

Ahmed Abd-Eltawab4.

1Biochemistry Department, Faculty of Medicine, Beni-Suef University, Beni-Suef,

Egypt, and, Pathology department, College of Medicine, Aljouf University, Sakaka,

Saudi Arabia. Departments of 2Dermatology and

3Pathology, Faculties of Medicine and

Postgraduate for Advanced Sciences, Beni-Suef University, Beni-Suef University,

Beni-Suef, Egypt. 4Physiology Department, Faculty of Medicine, Beni-Suef University,

Beni-Suef, Egypt, and College of Medicine, Aljouf University, Sakaka, Saudi Arabia. *Correspondent author: [email protected]

Abstract

Background: Skin tags (STs) are common benign skin tumors usually occurring on the

neck and major flexors of elder people. STs are histologically composed of loose

collagen fibers and dilated capillaries enclosed in a hyperplastic epidermis. Objectives:

We aimed at investigating the possible correlation between each of serum level of

progesterone and estradiol with mast cells count (MCC) in STs among healthy

pregnant and non-pregnant females to check for their possible pathogenetic roles.

Participants and Methods: Thirty participants with STs comprised two groups (15

non-pregnant and 15 pregnant). One skin tag biopsy from each participant was

histopathologically examined for mast cell count that was correlated with serum

progesterone and serum estradiol measured using specific ELISA kits. Results: A

statistically significant correlation between MCC and serum estradiol was detected in

both of the study groups. There was no statistically significant correlation between

MCC and serum progesterone in both of the studied groups. MCC in STs was

statistically higher in the pregnant than the non-pregnant group. Conclusion: There

may be possible interaction of both mast cell and estradiol and both could be involved

in the pathogenesis of STs. Mohamed AA, El-Rifaie A-E, Gohary Y, El-Nesr KhA,

Abd Eltawab A. Serum Progesterone and Estradiol Levels and the Mast Cells

Count in Skin Tags among healthy Pregnant and Non-Pregnant Women:

Correlation with Age of Pregnancy and Phases of the Menstrual Cycle. AUMJ,

2015 September 1; 2(3): 47 - 56.

Keywords: Skin tags, Pregnant, Non-Pregnant, Mast cells, Estradiol, Progesterone,

Pathogenesis.

Introduction

Skin tags (STs) or acrochordons are

benign connective tissue tumors of the

dermis that present as small, soft, usually

skin-colored or tan or brown, round or

oval, pedunculated papilloma (polyp). It

is usually constricted at the base and may

vary in size from >1 mm to as large as 10

mm, occurring in the middle aged and



2015

elderly. They often develop in areas of

skin friction and are particularly found in

obese persons. The most frequent sites

are the neck and axillae, but any skin

fold, including the groin could be

involved(1)

. STs are cutaneous findings

frequently associated with obesity and

dyslipidemia(2)

. Histopathologically, STs

are polypoid lesions with loose to dense

fibro-vascular core together with an

overlying mildly acanthotic epidermis(3)

.

Mast cell count (MCC) increases in

number in many skin diseases(4)

. In

addition of being able to mediate

immediate hypersensitivity, mast cells are

known to have effects on T and B cells,

keratinocytes, fibroblasts, Langerhans

cells and endothelial cells, through an

array of cytokines, chemokines, and

growth factors they produce. The

presence of mast cells in STs could play a

role in fibroblast proliferation and

collagen deposition, as well as acanthosis

of the epidermis(5)

. Mast cell activation

can be achieved through IgE receptor,

and several alternative mechanisms have

been described. Among the latter, female

sex hormones; estradiol and

progesterone, have been proposed to

activate human mast cell. These

mechanisms culminate in altering the

activity of the effector calcium channels

involved in normal stimulus-secretion

coupling to IgE(6)

. This activation caused

influx of extracellular Ca2+

which causes

subsequent release of both preformed

(granule-derived) mediators and newly

generated autacoids and cytokines(7)

.

Estrogens, C-18 steroids, are synthesized

from the precursor cholesterol in the

ovary and to a lesser extent in peripheral

tissues, where aromatase converts

androstenedione into estradiol. The latter

becomes the only source in

postmenopausal women. While

aromatase enzyme is present in the

ovarian theca cells, bone, brain, and skin,

the majority of peripheral production of

estrogen occurs in the skin(8)

. The skin

constitutes the largest non-reproductive

target on which estrogen acts(7)

.

Keratinocytes express both estrogen

receptors (Erα and Erβ). At normal

physiological range, estradiol binds Erβ

with high affinity to induce keratinocyte

proliferation(10)

. In addition, 17β-estradiol

has been shown to increase fibroblast

proliferation in human skin(11)

. Mast cells

express high-affinity estrogen receptors,

where 17β-estradiol augments secretion

of histamine and serotonin through

calcium influx(7,12)

.

Progesterone is a C-21 steroid hormone

involved in the female menstrual cycle,

pregnancy and embryogenesis.

Progesterone is produced in the ovaries

by the corpus luteum, the adrenal gland,

and, during pregnancy, in the placenta.

Progesterone is stored in adipose tissue. It

raises epidermal growth factor levels, a

factor often used to sustain and induce

proliferation of stem cells(13)

.

Based on the above mentioned

interactions between estradiol and

progesterone on one side and skin

components particularly mast cells on the

other side, we hypothesized that there

may be a relationship between serum

level of these two hormones and MCC in

the skin that could be pathogenetic in

STs.


Participants: thirty healthy women

(Group I of 15 non-pregnant and Group II

of 15 pregnant female) with STs were

enrolled through Beni-Suef Dermatology

Outpatient Clinic, Beni-Suef University

Hospital, Beni-Suef, Egypt in the period

from September 2013 to Marsh 2014. A



2015

written informed consent from each

participant was obtained. The study was

approved by the local Beni-Suef Faculty

of Medicine Committee for Ethics of

Scientific Conducts. The age of the non-

pregnant participants ranged from 15 to

55 years and pregnant participants' age

range was 19 - 36 years. Diabetic

patients, patients with concurrent allergic

or fungal or bacterial dermatitis were

excluded. In addition, patients with

chronic skin disease as psoriasis were

also excluded.

Skin tag biopsy collection,

histopathological preparation and mast

cell count: In each participant, one biopsy

was taken from filiform STs of the neck

with a size of ~2 mm width and ~5 mm

length. Collection and histopathological

processing of the biopsy followed

standard procedures. Briefly, after local

anesthesia injection with 1% xylocaine,

the skin tag was grasped with forceps and

cut at the base with sharp scissors.

Biopsies were fixed in 10% formalin

solution for 24 hours and paraffin blocks

were prepared as instructed(14)

. Four µm

thickness sections were cut close to the

middle of the biopsy and perpendicular to

the skin surface. Each section was stained

with hematoxylin and eosin and toluidine

blue-uranyl nitrate metachromatic

methods for mast cell count. Mast cells

stained with toluidine blue were counted

by image cytometry in ten different fields

of each section using an Olympus

microscope with magnification x1000,

three section were taken from each

biopsy were examined and the average

number of mast cells was calculated. All

mast cell profiles were counted by the

same experienced histopathologist.

Serum estradiol and progesterone: Serum

was recovered from blood sample

collected by venipunture after clotting

and centrifugation at room temperature

and aliquots were stored at -20 oC.

ELISA kits that utilize specific

polyclonal antibody and an estradiol or

progesterone-horseradish peroxidase

conjugate as competitive ligand and color

development system was used according

to the manufacturer specifications (cat#

EIA-2693 for estradiol, DRG

International, Inc., USA – with a

minimum detection limit of 9.7 pg/mL

for estradiol) and (cat# EIA-1561 for

progesterone, DRG International, Inc.,

USA – with a minimum detection limit

zero , the range of the assay is between 0

- 40 ng/mL for).

Statistics: Descriptive analysis of the

results in the form of percentage

distribution for qualitative data

(minimum, maximum, mean and standard

deviation) was done. For quantitative

data, Student’s “t” test was used to

compare the two groups. F-Test (One

way ANOVA) was used to compare

between means of three groups. P <0.05

was considered significant. We used

Statistical Package for Social Science

(SPSS) software version 17.

Results

Thirty participants with STs were

included in this study. 15 non-pregnant

participants; eight in follicular phase of

menstrual cycle (53.3%), four in luteal

phase of menstrual cycle (26.7%), two

using a combined contraceptive method

(estradiol and progestin) either as oral or

injection (13.3%), and one

postmenopausal (6.7%) at age ranging

from 15 to 55 years (mean = 39.2 years).

The control group was 15 pregnant

volunteers with age ranging from 19 to

36 years with mean age of 27.4 years.

Table 1 presents the levels of serum

progesterone and estradiol content and



2015

the MCC in non-pregnant and pregnant

females studied. Comparison between

MCC in skin tags of healthy non-

pregnant and pregnant women showed a

highly significant difference (P = 0.001;

Figure 1). Figure 2 presents a

representative microphotograph of skin

tag of each of the investigated healthy

non-pregnant and pregnant women

showing toluidine blue stained mast cells

to be more frequent in the pregnant

tissue. Table 2 presents the clinical

characteristics, MCC and serum

progesterone and estradiol levels in

individual pregnant and non-pregnant

healthy women investigated for skin tags.

Figure 1: Comparison between healthy non-

pregnant and pregnant women for the mast

cell count in their skin tags (Data shown are

Mean ± SEM).

Figure 2: A representative microphotograph of skin tag of each of the investigated healthy non-

pregnant (left side) and pregnant (right side) women showing toluidine blue stained mast cells to

be more frequent in the pregnant tissue (Arrow; x1000).

Table 1: Serum estradiol (pg/dL) and progesterone (ng/dL) contents and mast cell counts in non-

pregnant and pregnant females investigated for skin tags. Data shown are n, means, standard

deviation and standard errors.

groups n Mean Std. Deviation Std. Error Mean

MCC non pregnant 15 19.267 7.805 2.015

pregnant 15 30.867 11.470 2.962

Progesterone non pregnant 15 2.049 1.953 0.762

pregnant 15 63.160 19.760 5.102

Estradiol non pregnant 15 657.893 1327.916 342.866

pregnant 15 6716.067 4302.992 1111.028



2015

Table 2: Clinical characteristics, skin tag mast cell count (MCC) and serum progesterone

(ng/mL) and estradiol (pg/mL) levels in individual pregnant and non-pregnant healthy women

investigated for skin tags. Data shown are mast cell count in skin tag specimen, level of

progesterone and estradiol, and the phase of menstrual cycles (PMC), duration of pregnancy

(DP) for pregnant participants, contraceptive (CC) or postmenopausal (PM).

PMC, DP, CC or PM Estradiol Progesterone MCC No.

Follicular phase- day 16 2.42 0.31 33 1

Non-Pregnant


Follicular phase- day 4 754 0.1 20 3


Luteal phase- day 22 7.81 0.49 11 5


Oral contraceptive pills 3331 1.49 26 7

Luteal phase- day 32 139 8.61 29 8

Depoprovera 150 0.56 11 9


Postmenopausal 8.39 0.25 8 11

Follicular phase- day 1 7.2 13 4.52 17 12

Luteal phase- day 34 0.65 0.42 14 13

Luteal phase- day 20 8.35 0.1 20 14


Pregnant 39 week 5000 78 34 16

Pregnant

Pregnant 30 week 4089 4.8 32 17

Pregnant 34 week 12198 73 38 18

Pregnant 22 week 2131 54.6 33 19

Pregnant 24 week 12839 65 32 20

Pregnant 39 week 12350 76 26 21

Pregnant 38 week 11580 79 28 22

Pregnant 32 week 12564 69 14 23








In the non-pregnant group (Figure 3),

there was non-significant positive

correlation between MCC and serum

progesterone level (r = 0.100 and P =

0.725). However, there was a statistically

significance positive correlation found

between MCC and serum estradiol level

(r = 0.600 and P = 0.011).



2015

In the pregnant group (Figure 3), there

was non-significant positive correlation

between MCC and serum progesterone (r

= 0.200 and P = 0.424). However, MCC

correlated significantly negatively with

serum estradiol level in this group (r = -

0.500 and P = 0.020).

Figure 3: Correlation between skin tag mast cell count and each of serum progesterone (ng/mL)

and serum estradiol (pg/mL) in non-pregnant fertile women (Upper panels), and in pregnant

women (Lower panels) investigated for skin tags.

Results of correlation analysis between

week of pregnancy (reference range) and

MCC in the pregnant group revealed a

non-significant positive correlation (r =

0.300 and P = 0.338; Figure 4). There is

non-significant positive correlation

between the duration of the pregnancy in

weeks and the number of mast cells in

STs in pregnant group (r = 0.266 and P =

0.338).



2015

Figure 4: A non-significant positive correlation between week of pregnancy and mast cell count

in pregnant women investigated for skin tags.

Discussion

In our study we found positive significant

correlation between serum level of

estradiol and the mast cell count in both

groups. This agrees with previous studies

reporting sex hormones, estradiol and

progesterone, as modulators of the

activity of mast cells. And this may

suggest that MCC may be affected by

serum estradiol level and this may

explain our observation about the

increase of STs development in

pregnancy(11,15)

. Also correlation between

MCC and serum estradiol was

statistically significant in both pregnant

and non-pregnant group. This strengthens

the suggested effect of serum estradiol

level on MCC and its role in the

pathogenesis of STs. Support for such

possibility comes from studies revealing

the expression of estradiol and

progesterone receptors in human, mouse,

and rat mast cells(16-21)

. Moreover, Barky

et al. (2014) found higher estrogen

receptor ERβ significantly associated

female gender and obesity. Higher

estrogen receptor ERα significantly

associated loose collagen arrangement.

Both higher ERα and ERβ expression

significantly associated the presence

of mast cells and dilated blood vessels.

ERs may share in STs pathogenesis

through their effect on keratinocytes,

fibroblasts, and mast cells(22)

. This may

also explain why STs increase in size and

number in pregnant and obese females

and also obese males. Treatment of adult

ring doves with sex-specific gonadal

steroids testosterone or

dihydrotestosterone in the male, or

17beta-estradiol in the female results in

an increase in mast cell number, their

degranulation and release of mast cell

mediators in the medial habenular region

of the brain(23)

.

The mast cell is proposed to be associated

with the pathogenesis of STs in previous

study by Zaher et al. (2007). They found

that MCC in STs was significantly higher

than normal adjacent skin suggesting an

important role of mast cells in the

pathogenesis of skin tags(24)

. It was

observed that incidence of skin tags is

related to serum level of female sex

hormone(25)

. An increased incidence of

STs was observed in obese diabetic

patients. Increased peripheral

aromatization of androgens to estrogens

and hormonal imbalance accompanying



2015

obesity were suggested as causes(26)

.

Similar hormonal imbalance occurs in

obese males where blood levels of

increases in estrone, both free and total,

and estradiol directly proportionate with

body mass index(27)

. These high plasma

estrogen levels may not decrease even

after massive weight reduction(28)

.

Keratinocytes, fibroblasts and mast cells

are targets for estradiol that activates the

latter to secrete autacoids and cytokines

that regulates the first two types of

cells(10,24)

.

It was found that blocking androgen

receptors with sex hormone antagonists

in the testis of frog Rana esculenta causes

a significant increase in MCC, supporting

the involvement of androgens in mast cell

proliferation and/or differentiation(12)

. On

the contrary, it was found that

testosterone and tamoxifen have an

inhibitory effect on mast cell secretion of

histamine and serotonin in rats(29)

.

Androgen receptor is most closely related

to the progesterone receptor, and

progestins in higher dosages can block

the androgen receptor(11,13)

. The level

of estrogen receptors (both α and β) was

significantly higher in STs than in

controls suggesting the possible role

of estrogen receptors in etiogenesis

of STs(30)

.

In our study correlation between MCC

and serum progesterone in both pregnant

and non-pregnant groups was non-

significant that is agreement with(31)

. In

their study, Abdou et al. (2014)

demonstrated that the possible role

of mast cells in promoting fibrosis and its

role in facilitating the development

of STs and they reported that mast

cells may attract eosinophils to cooperate

in inducing more fibrosis in STs

development(32)

. Moreover, androgen

receptors were significantly higher in STs

than in controls suggesting a possible role

for androgens in etiogenesis of STs(30)

.

Progestins at high dosages can block the

androgen receptor(11,13)

.

Conclusion

There is possible association between

skin tags, MCC and serum estradiol level.

MCC is higher in STs of pregnant than

non-pregnant adult women. Serum

estradiol but not progesterone

significantly correlated MCC in adult

women studied - both pregnant and non-

pregnant. The number of mast cells in

skin tags did not correlate the duration of

the pregnancy in weeks.


The sample size was limited

particularly considering subgrouping

of participants enrolled along one year

due to infrequent admission of such

volunteering patients.

Due to the limited number of

participants per subgroup, the effect

of the used individual contraceptive

on the development of skin tags and

mast cell role could not be tested.



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with antiandrogenic properties".

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S. Effect of sex steroid hormones and

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Jänne OA. "Progestins can mimic,

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Theory and practice of histological

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T. Effect of 17 β estadiol and

phytoestrogen daidzein on the

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Abdelmajeed et al - Septic hip arthritis superimposed by Reactive Arthritis


2015 2015

Case Report

Septic Hip Arthritis Superimposed by Reactive Arthritis

Omaima Abdelmajeed1*

, Amar Ahamed Ibrahim2, Rabab Mahdi

3

Departments of Pediatrics1 and Orthopedic Surgery

2, Faculty of Medicine, Omdurman

Islamic University, and, Immunology Unit3, Mohammed A Hamid’s Teaching Hospital

for Pediatrics, Khartoum, Sudan. *Corresponding Author: [email protected]

Abstract

Septic hip arthritis is an easily missed diagnosis because of non-specific presentations.

We report a Sudanese 13-years-old boy who presented with polyarticular arthritis that

rendered him completely bed ridden. During investigations he was found to have right

septic hip arthritis caused by Proteus mirabilis secondary to a minor trauma, and the

polyarticular arthritis was just reactive arthritis. His reactive arthritis disappeared

completely after surgical debridement of the septic hip and intravenous amikacin.

Abdelmajeed O, Ibrahim AM, Mahdi R. Septic hip arthritis superimposed by

Reactive Arthritis. AUMJ, 2015 September 1; 2(3): 57 - 60.

Key Words: Septic arthritis, Reactive arthritis, Proteus mirabilis.

Introduction

Septic hip arthritis is a real clinical

problem because symptoms and signs of

arthritis in the form of swelling and

warmth are usually not that clear in case

of hip joint affection. This is because it is

a deeply seated joint and pain is usually

referred to other sites like knee joint or

the abdomen for example(1)

.Septic hip

arthritis in children is an orthopedic

emergency that has serious consequences

if not diagnosed promptly and treated

effectively(2)

. On the other hand, reactive

arthritis (ReA) is a non-infectious sterile

inflammation of the joint(3)

. ReA can be

polyarticular and prolonged and can be

severe to the extent of affecting daily

living activity(4)

.

Case Description

We report here a 13-year- old boy who

was previously healthy, shepherd. He had

history of trauma with mild superficial

abrasions after which he developed a

painful limp. He received oral non-

steroidal anti-inflammatory drugs

(NSAIDs) with mild improvement, but he

didn’t seek medical advice. After three

weeks he started to develop fever,

bilateral symmetrical painful swellings of

elbows, wrists, left metacarpophalangeal

joints. Also, he had painful swollen

fingers and right ankle joint with

significant tenderness and pain at the

Achilles’ tendon. This led to marked

limitation of movement to the degree that

he became completely dependent on his

parents to carry his daily activities. These

symptoms developed gradually over two

weeks.

Physical examination showed an unwell

and well grown child, febrile, in pain and

slightly pale. He had neither skin rash nor

palpable lymph nodes. Musculoskeletal

system examination (pGALS: pediatric

Gait, Arm, Leg and Spine examination)

revealed that the elbows, wrists,

metacarpophalangeal joints and right

ankle were swollen, warm, tender and

erythematous with significant affection of

joint movement when assessed.

Complete blood count (CBC) showed

neutrophilia with normocytic

normochromic anemia. Urine analysis

was clear. He had also raised

inflammatory markers (erythrocyte

sedimentation rate; ESR: 170 mm 1st hr

and C-reactive protein was high (CRP; 32



2015 2015

mg/L estimated in plasma using i-

CHROMATMTM

Reader). Tests for

rheumatoid factor, anti-cyclic citrullinated

peptide (anti-CCP) antibody and

antinuclear antibody were negative.

Human leukocyte antigen B27 (HLA-

B27) not done. Anti-streptolysin O (ASO)

titre and sputum for acid fast bacilli

(AFB) were negative. Brucella and HIV

screening were negative. Lactate

dehydrogenase (LDH) was slightly raised

(400 U/L) with normal uric acid level.

Blood culture was negative. Chest X ray

was normal. Screening X rays of the

joints apart from the right hip joint were

normal with the exception of effusions.

The right hip joint X ray revealed lytic

lesions of the right femoral head with

posterior dislocation (Figure 1).

Figure 1: A) Pelvis X ray film showing lytic lesions in the right femoral head with

posterior dislocation, and, B) Right ankle X ray film showing soft tissue swelling of the

metacarpophalangeal joints in a Sudanese 13-year- old boy with septic hip arthritis.

Figure 2: A) Removed right capital epiphysis, and, B) Pelvis X ray film after the

operation showing no capital epiphysis in a Sudanese 13-year-old boy with septic hip

arthritis.

An orthopedic surgeon was consulted, and

the diagnosis of septic hip arthritis was

proved. The patient was operated on

through a posterior approach of the hip

joint and pus collection was found along

with slipped capital epiphysis, fragile and

rough surface and devitalized tissues.

Drainage, debridement and removal of

capital epiphysis were done. Culture was

positive for Proteus mirabilis and the

patient was started on intravenous

amikacin 15 mg/kg/day for two weeks

according to sensitivity results, plus

NSAIDs. He showed dramatical

improvement within two weeks all the

joints become free regarding pain and

swelling and the patient was able to move

around freely carrying his daily tasks with

a mild limp due to shortening of his right

leg (Figure 2). The patient was planned

for hip replacement.

Discussion

Septic arthritis could be bacterial, fungal

or even due to mycobacterium, but

bacterial septic arthritis usually is severe

and destructive(5)

. In our patient the septic

arthritis was hip arthritis which is the



2015 2015

most difficult one to suspect and diagnose

since symptoms are usually non-specific

and not localized to the hip joint itself.

Our patient presented with hip joint

dislocation which is one of the unusual

presentations of septic hip arthritis(6)

.

Guidelines suggest improving the

diagnosis and early management of septic

arthritis by doing the following

investigations in all suspected cases:

CBC, ESR, CRP, and joint needle

aspiration and blood cultures. They also

suggest prompt use of intravenous

antibiotics(7)

. In the case of hip joint

involvement it should be drained via open

hip joint surgery(8)

, otherwise increased

pressure inside the joint can lead to a

vascular necrosis of the femoral head

secondary to impaired blood supply(9)

. As

in our patient, delayed presentation may

result in complete destruction of the

femoral head.

In our patient’s story, his parent didn’t

seek medical advice until he developed

polyarticular arthritis and dactylitis which

was severe enough to disturb the patient’s

and family’s life. ReA is used to describe

the development of sterile, non-infectious

inflammation of the joints secondary to

infection. It usually develops a few days

to weeks after an infection. The usual

presentation of ReA is asymmetric

oligoarthritis, often affecting the lower

extremities. However, upper extremities

can be affected in about 50% of patients

in the form polyarthritis of the small

joints(3)

. In the current case, he developed

bilateral arthritis of the upper limbs with

different degrees. Enthesitis is also one of

the features of ReA and swelling at the

heels is among the most characteristic

symptom of enthesitis(10)

. Our patient, he

developed painful swelling of his right

ankle joint with significant tenderness and

pain at the Achilles tendon with

restriction of joint movement secondary

to significant pain. Diagnosis of enthesitis

is usually clinically made but when

associated with arthritis it needs MRI to

be diagnosed (1)

.

Our patient also developed dactylitis of

the fingers of both hands which was more

prominent on his left hand. This is one of

the presenting features of ReA that cause

sausage shaped digits(11)

. ReA has usually

been described following urogenital

infection of which proteus species is one

of the common causative organisms.

Proteus mirabilis causes 90% of proteus

infections and can be considered a

community-acquired infection(12)

.

Although this patient had no urogenital

symptoms and his urine analysis was

clear, however, he needs urine culture,

nevertheless, the causative organism of

his septic hip arthritis was Proteus

mirabilis.

NSAIDs are used in management of

reactive arthritis - and sometimes steroids

can be used. Antibiotics are not routinely

prescribed unless there is an evidence of

an ongoing infection(13)

as the case in our

patient, where he partially responded to

NSAIDs, until the primary infection was

diagnosed and he received the appropriate

antibiotics according to culture and

sensitivity results.

Conclusion

Septic arthritis especially hip arthritis

should be part of septic screening in any

febrile child with no clear focus. This is

essential to avoid the devastating

consequences of delayed diagnosis as in

the case presented. It was a complicated

septic hip arthritis with reactive arthritis

in an atypical way as the only presenting

symptom that disappears completely after

surgical debridement and prompt use of

intravenous antibiotics.

Conflict of Interest

The authors declared no conflict of

interests.

References

1. Agarwal A, Aggarwal AN. Bone and

Joint Infections in Children: Septic

Arthritis. Indian J Pediatr., 2015 Jul

21 [Epub ahead of print].



2015 2015

2. Rutz E, Spoerri M. Septic arthritis of

the pediatric hip - A review of current

diagnostic approaches and therapeutic

concepts. Acta Orthop Belg., 2013;

79(2):123-34.

3. Leirisalo-Repo M. Reactive arthritis.

Scand J Rheumatol., 2005; 34:251-9.

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Leirisalo-Repo L. Reactive arthritis or

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5. Kaandorp CJ, KrijnenP, Moens HJ,

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6. Hua KS, Huang YY, Shen DL, Chang

IL, Chen SJ. Septic hip dislocation in

a child. Int Surg., 2009; 94(2):115-8.

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BSR & BHPR, BOA, RCGP and

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Rheumatology, 2006; 45(8): 1039-41.

8. Goldenberg DL, Cohen AS. Acute

infectious arthritis A review of

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infections (with emphasis on therapy

and prognosis). Am J Med., 1976; 60

(3):369-77.

9. Lee SC, Shim JS, Seo SW, Lee SS.

Prognostic factors of septic arthritis of

hip in infants and neonates: minimum

5-year follow-up. Clin Orthop Surg.,

2015; 7(1):110-9.

10. D'Agostino MA, Olivieri I. Enthesitis.

Best Pract Res Clin Rheumatol., 2006;

20(3):473-86.

11. Healy PJ, Helliwell PS. Dactylitis:

Pathogenesis and clinical

considerations. Curr Rheumatol Rep.,

2006; 8(5):338-41.

12. Luzzaro F, Brigante G, D'Andrea

MM, Pini B, Giani T, Mantengoli E,

et al. Spread of multidrug-resistant

Proteus mirabilis isolates producing an

AmpC-type beta-lactamase:

Epidemiology and clinical

management. Int J Antimicrob Agents,

2009; 33(4):328-33.

13. Barber CE, Kim J, Inman RD, Esdaile

JM, James MT. Antibiotics for

treatment of reactive arthritis: A

systematic review and meta-analysis. J

Rheumatol., 2013;40(6):916-28.

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