Objective: Circumcision is one of the most frequently performed elective procedures in male. In general, post circumcision complications are minor and treatable but complications requiring expert intervention are seen when the circumcision is perrformed by inexperienced/untrained person and in non-sterile setting and inadequate equipments. Materials and Methods: From March 2008 to May 2012, 59 patients with circumcision related complications were received at age range of 6 months to 5 years with a mean age of 2.4 years. The most common complication was urethra-cutaneous fistulae in 18 patients, followed by meatal stenosis in 9, bleeding in 6, incomplete circumcision in 6, buried penis in 5, glanular injury in 4, skin bridge in 4, complete amputation of phallus 3, hole in the prepuce in 3 patients and one patient with coronal constriction and fistula. Results: Urethral fistulae were closed in all 18 patients with recurrence in 16%. Two patients with extensive bleeding required blood transfusion and all 6 children required hematoma evacuation under general anesthesia in the operating room. The circumcision was revised in those with an incomplete procedure, a hole in prepuce, burried penis and residual skin bridge. Meatotomy was the procedure of choice in 6 of 9 patients with meatal stenosis, but in the remainder meatal dilatation was efffective. Glanular injuries were managed conservatively. A short residual after glanular injury needed grafting. Conclusion: Circumcision is considered a simple and minor surgical procedure, yet it needs to be performed competently by only medically qualified and trained personnel and with a great care.

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Saudi Arabia has witnessed a significant improvement in its health indicators. The kingdom has spent generously on the curative health services and established hundreds of hospitals and primary health care centers. However, we believe that this huge health expenditures and the presence of curative services is not the only reason for this improvement. Public health services have also had a significant impact on people's health and that this improvement is due to a combination of public health programs such as immunization, environmental sanitation and health education with good formulation of sound health policies and health delivery systems. It is noted that health plans and expenditure in the health system are concentrating on the curative aspects and there is a significant weaknesses in public health services. Additionally, most jobs are allocated for curative care and there is scarcity of job titles related to public health in the health structure, such as public health officers, public health inspectors and public health specialists. A suggested body namely, Ministry of public health, will work to confirm that all issues related to health of the public in every aspect of daily life in the kingdom are within the genuine interest of all policy makers.

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Background: Hyperuricemia is a term given to serum uric acid levels higher than 7.0 mg/dL; asymptomatic hyperuricemia may precede gouty attacks with several years. This progression is variable from a person-to-person and may not even develop. Owing to this, there is a great controversy in whether to treat asymptomatic hyperuricemia or not. Objective: The objective of the following study is to determine the treatment habits of asymptomatic hyperuricemia in Makkah Region, Kingdom of Saudi Arabia. Materials and Methods: This survey was carried out using a structured questionnaire that was answered through face-to-face interviews with 104 physicians who diagnose and treat hyperuricemia. The data was collected on the second half of 2012. The specialties included in the study were general practitioners, family physicians, orthopedicians and rheumatologists. Results: Half of the doctors in our study (50.9%) chose to observe and follow asymptomatic hyperuricemic patients and 84% depend on the serum uric acid levels to help them decide when to start their treatment, 53% asked about co-morbid diseases as renal stones, diabetes mellitus and ischemic heart disease whereas 49% asked about family history. When doctors are to start the treatment, 84.1% will start with allopurinol and 42.5% will advise on the change of dietary and life-style habits. Conclusions: The results showed that the doctors in Makkah Region depend on the serum uric acid levels to decide when to start the treatment, not abiding by the international guidelines. They still chose the life-style and dietary modification, as well as starting treatment with allopurinol with a starting dose of 100 mg/dL daily.

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Objectives: The objective of the following study is to find out the effects of two different pushing techniques in the second stage of labor on postpartum maternal fatigue and APGAR score of neonates in Saudi females, as very few such studies are available in these patients. Hence this study was carried out in this population to see the results and to do a comparison with other studies in literature as well as to find out how we can make labor awareness in our females. Design: Quasi experimental study. Settings: It was carried out in two hospitals in the eastern province of Saudi Arabia from 1 January, 2011 up to 31 December, 2011. One hundred Saudi women who fulfilled criterion were included in the study. They were randomized and the results seen. Results: There was a significant difference in postpartum fatigue within 60 min and 24 h in two groups as P = 0.001, P < 0.001 respectively. There was a significant difference of APGAR score of newborn in both groups, i.e., P < 0.001. Conclusion: It is concluded that physiological pushing technique has a better outcome with regard to postpartum maternal fatigue and neonatal APGAR score when compared to directed pushing during the second stage of labor.

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The presence of a granulomatous reaction in association with a breast carcinoma is a rare phenomenon. We present two cases of breast carcinoma, invasive ductal and invasive lobular carcinoma in which a non-caseating granulomatous response was present within the stroma of the breast carcinoma, followed by a discussion of its pathogenesis and practical significance.

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Slipped capital femoral epiphysis (SCFE) is an adolescent hip disorder of increasing prevalence, particularly within patients aged younger than 10 years. When present in these younger patients, SCFE is usually associated with metabolic abnormality or endocrinopathy. We present a case of a 5-year-old boy with idiopathic SCFE who underwent staged bilateral pinning in situ using a uniquely modified smooth wire for fixation across the physis. He eventually required bilateral screw revision after outgrowing the initial screws. At follow-up 3 years later, the patient was pain free with satisfactory hardware placement. He will be closely monitored, as he will likely need further surgical revision once he outgrows the second set of fixation screws.

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Acute generalized exanthematous pustulosis (AGEP) is an acute febrile drug eruption characterized by sudden occurrence of numerous, non-follicular, pinhead-sized pustules. This usually occurs 3-5 days after the commencement of treatment. Development of pustular eruptions in patient with plaque psoriasis raises the differential diagnosis of AGEP versus pustular psoriasis of the Von Zumbusch type. Herein, we report a 56-year-old male who came into hospital with history of vomiting fresh blood. The patient was then admitted for management of hematemesis. He is a known case of psoriasis vulgaris, which was still present during admission. During admission, the patient developed pustular skin eruptions associated with fever 4 days after using clindamycin and ceftriaxone. Laboratory investigations revealed leukocytosis and neutrophilia. Histopathological examination showed sub-corneal neutrophilic collection and eosinophils in the papillary dermis. The pustular eruption disappeared completely within ten days after stopping clindamycin and ceftriaxone, confirming the diagnosis of AGEP.

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Background: Both genetic and environmental factors play major roles in the development of inflammatory bowel disease (IBD). Recent studies have identified a number of genetic susceptibility loci for Crohn's disease (CD) and ulcerative colitis (UC). Objectives: The present study aimed at examining the association of nine polymorphisms in four different genes with the development of CD and UC in a sample of Saudi patients with IBD. Materials and Methods: All gene polymorphisms were identified by polymerase chain reaction and by direct sequencing. Allele and genotype frequencies of polymorphisms of NOD2/CARD15 (R702W, G908R, L1007finsC), Toll-like receptor 4 (TLR4) (D299G, T399I), OCTN promoter (C1672, G207C) and DLG5 (G113A, C4136A) genes were determined in Saudi subjects with CD (51), UC (26) and in 75 normal controls. Results: Out of the nine polymorphisms studied in four loci, only two polymorphisms in two different loci were found to have increased in patients compared with the control subjects. The CT genotype of TLR4 T3991 was over represented in patients with CD or UC compared to that in controls (odds ratios [OR], 5.63:95% confident interval [CI], 1.19-26.69; P = 0.03). In addition, the GA genotype of DLG5 G113A was over represented in patients with CD or UC compared with that in controls (OR, 4.72:95% CI 2.30-9.66; P = 0.0001). However, there were no significant associations found between all other polymorphisms studied and the susceptibility of CD or UC found in the Saudi population. Conclusion: Our finding indicates that association of IBD with nine gene polymorphisms was only significant in two of these polymorphic variants.

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Metaplastic breast carcinomas (MBC) are rare primary breast malignancies characterized by the co-existence of carcinoma with non-epithelial cellular elements. They can be classified as monophasic spindle cell (sarcomatoid) carcinoma, biphasic carcinosarcoma, adenocarcinoma with divergent stromal differentiation (osseous, chondroid and rarely rhabdoid) as well as adenosquamous and pure squamous cell carcinomas. Nearly all reports portrait women in their forties or older, yet younger affected females in their twenties have been reported. The usual presentation included firm painless breast mass ranging between 1.4 and 14 cm in diameter, with no evidence of loco-regional or distal metastasis. Mammary osteosarcomas are aggressive tumors with a propensity for blood-borne rather than lymphatic spread. Metastatic disease expected to develop at a mean of 10.5 and 14.5 months from the initial diagnosis and demise followed within 20 months of the onset of metastasis. MBC remains a rare entity with poor response to both chemo-radiotherapy, histological diagnosis is challenging yet it is the main stay in outlining the management. The surgical option remains the only successful current treatment in the form of simple Mastectomy to achieve negative margins sparing the patients axillary node dissection.

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Central venous line catheterization is the main route for therapeutic intervention in critically ill patients. Despite the relatively common complications, the femoral vein is a standard route for catheterization. This is a case report of a rare preventable complication of migration of the guide wire and catheter from the femoral vein through the systemic circulation in a 75-year-old critically ill man in a university hospital in Saudi Arabia.

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Objective: The aim of this retrospective study is to analyse the outcome of 4 different methods in management of hepatic hydatid disease. Patients and Methods: The study was carried out in the Military Hospital, Riyadh: 110 patients were included; 37 were treated medically; 26 patients were subjected to percutaneous drainage via ultrasound guidance. Fifty patients required surgical treatment, while the remaining 10 patients were managed endoscopically. Results: The study showed different responses of the 4 methods applied. Conclusion: This retrospective analysis revealed that percutaneous draiange of the hydrated cysts achieved the best yield among all other methods.

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