Table of Contents

Original Articles

Thrombotic Events in Covid-19: Incidence and their Association with Lab Parameters, Vaccination Status and Mortality

Pooja Prakash Heda1*, Ali Jafer Nejim Al-Hilly2

Pages: 1-10
  • Abstract
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  • Background & Objectives: Major arterial or venous thrombotic complications occur frequently with COVID-19. This risk seems to be present despite no known underlying thrombophilia and even adequate anticoagulation does not diminish its risk. Whilst pulmonary embolism may seem to be the most common thrombotic complication, others may also occur. A vaccination link to thrombotic events in COVID-19 has not been studied to the best of our knowledge.

    Methods: In this retrospective cross-sectional study we determined the incidence of total thrombotic events, individual Venous Thromboembolisms (VTE) and Arterial Thromboembolisms (ATE) that occurred in patients requiring ICU admission for COVID-19 in one of Bahrain’s main COVID ICU facilities for a period of 6 months. We also aim to determine mortality rate in this group of patients, links with specific baseline characteristics, laboratory parameters and patient vaccination status.

    Results: We studied 1597 patients over 6 months, 6% of patients were found to have VTE or ATE with a cumulative incidence of 6.5% thrombotic events. Elevated D dimer >1 was associated with an increased risk of thrombosis and an increased risk of mortality. There was a higher risk of thrombotic events in unvaccinated individuals. All-cause mortality in COVID-19 patients complicated with thrombosis and mortality solely secondary to thrombotic event were both significantly higher in unvaccinated individuals.

    Conclusions: Based on the findings of this study, unvaccinated individuals are at significantly higher risk of developing thrombotic events. This will assist in enabling physicians to lower their threshold of diagnosing such events. The urgency of lab parameters the swift management of other risk factors and the importance of vaccination against COVID-19 can be further studied.

    Keywords: COVID-19, Venous Thromboembolisms, Arterial Thromboembolisms, Mortality, D dimer, Vaccination status

Effect of COVID-19 Vaccine on Menstrual Cycles

Nada Abdulfattah Abdulaal1,*, Nahid Kamal2

Pages: 11-18
  • Abstract
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  • Background: A worldwide increase in menstrual abnormalities was reported post Coronavirus disease (COVID-19) vaccinations. The study aimed to investigate the prevalence and impact of the menstrual abnormalities post COVID-19 vaccinations in Bahrain. The study also looked at the variations after first, second and third dose of vaccination.

    Methods: The survey was sent to the participants who had received the COVID-19 vaccinations (n=1000) via social media as well as printed copies; 343 responses were received. Participants who had a history of irregular menstruation prior to COVID-19, were on hormonal or non-hormonal medications, gynaecological and non-gynaecological diseases were excluded from the study.

    Results: The findings indicated that 62.5% of the participants reported menstrual abnormalities after COVID-19 vaccinations manifested as changes in frequency, length and quantity of menstruation. Majority of the participants had Sinopharm for their first and second doses (62.8% and 58.5% respectively) while majority of the participants had Pfizer as third or booster dose (88.4%); however, was no significant effect of the type of vaccine on the menstrual changes. 46.8% of the participants reported that their daily life activities were affected and about 5.8 % participants were prescribed medications to regulate their menstruation.

    Conclusion: The study indicated that there is a temporary effect of COVID-19 vaccination on menstrual cycle about which the women needs to be counselled and informed.

    Keywords: COVID-19 vaccination, menstrual abnormality, variation in menstruation

Knowledge and Practice of Immunization Among Primary Health Care Nurses in Bahrain

Fatema Saleem1*, Aalaa Ahmed1, Eman Sayed Faisal1, Khatoon Abdulhadi1, Dr Afaf Mirza2

Pages: 19-26
  • Abstract
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  • Background & Objectives: Nurses play an important role in delivering and advocating for vaccines in the healthcare system. Our goal was to assess the nurses’ knowledge of vaccine administration, their immunization practice, knowledge of precautions and contraindications to vaccines, and practices towards them in primary health centers in Bahrain.

    Methods: We conducted an observational cross-sectional study using a self-administered questionnaire. All nurses practicing in the primary health centers in Bahrain were invited to participate in the study. The questionnaire contained several statements regarding general knowledge and practice of vaccines administration and contraindications. Written consent obtained from all participants prior to study.

    Results: Overall knowledge of vaccine administration, practice of immunization and practice towards precautions and contraindications to vaccines were satisfactory. Although, certain areas of gaps exist. The least satisfactory result was observed in the knowledge of vaccine precautions and contraindications.

    Conclusion: Our study showed good immunization practice in Bahrain. However, there is a need for improvement in the area of knowledge regarding precautions and contraindications of vaccines.

    Keywords: Bahrain, Knowledge, Immunization, Primary health care, Nurses

Incidence and Factors Related to Endodontic Flare Up - A 1-year Retrospective Study

Jawaher Almudahki*, Rawan Khaled Hassan, Emad Alagamawy

Pages: 27-31
  • Abstract
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  • Background: Endodontic flare up is a common complication of endodontic treatment that results from acute exacerbation of pulpal and peri-radicular pathosis; leading to unscheduled emergency visits that is disturbing for both clinicians and patients. Flare up causes are multifactorial that includes microbial, host, chemical and mechanical factors.

    Objective: The aim of this retrospective study was to evaluate the incidence and identify risk factors of flare up in a multispecialty dental and maxillofacial center over a period of one year from February 2019 to February 2020.

    Methods: Data was collected from 323 teeth belonging to 272 patients that completed their root canal treatment on multiple sessions during the evaluation period. The samples were classified based on inclusion criteria and variables according to teeth type; age; sex; pulpal and periapical pathosis; presence of intracanal medication between visits; and absence of coronal seal.

    Results: The incidence of flare up was 122(38%), the evaluated variables did not show statistical significance in any of the evaluated parameters.

    Conclusion: The incidence of flare up is widely diverse and may be due to a variety of reasons; and therefore, the management of flare up in each dental facility is different and varies according to their setup; number of clinicians and specialists available. Continuous training and skills improvement for clinician in charge of managing emergency patients with flare up is highly recommended.

    Keywords: Dental Emergencies; Flare up; Infection; Inflammation; Risk factors; Root canal treatment

Review Articles

Anti-NMDA Receptor Encephalitis in Children: Report of Four Cases from Bahrain

Alia Khalil Ebrahim Ali Mohamed1,*, Ayman Khalil Ebrahim Ali2

Pages: 32-37
  • Abstract
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  • Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a newly described subtype of limbic encephalitis. This disease is probably the commonest autoimmune encephalitis predominantly affecting children and young adults. It has a higher incidence among young females. Patients manifest with a constellation of symptoms including psychosis, dyskinesia, and seizures. Antibodies against NR1/NR2 heteromers of the NMDAR glutamate receptor mediate this type of encephalitis. Patients with anti-NMDAR encephalitis might have underlying tumors, which are typically teratomas. Exploring for occult tumor and resection is crucial in management. First-tier immunotherapy include steroids, intravenous immunoglobulin and plasma exchange, while rituximab and cyclophosphamide are frequently used as second-tier immunotherapy. Around 80% of patients achieve almost complete recovery, however some patients suffer from cognitive deficits or death. Early diagnosis and prompt treatment can lead to better recovery and outcome. The unique feature of this disease reflects the intimate relationship between psychiatry and neurology. In this article, we describe the clinical phenotype and outcome of four affected children from Bahrain.

    Keywords: Anti-NMDAR encephalitis, Limbic encephalitis, Epilepsy, Psychosis, Dyskinesia, Immunotherapy

Case Reports

IgA Crescentic Nephropathy Post COVID-19 Infection: A Case Report

Ahmed Moustafa Ibrahim Elsayed1,*, Hajar Abdulla Alahmadi2, Nuria Perez Romano3

Pages: 38-43
  • Abstract
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  • Background: Since the Coronavirus Disease 2019 (COVID-19) outbreak, individuals affected by COVID19 may be at risk of acquiring certain forms of glomerular disease. Several biopsy researches reveal that acute tubular injury, as well as glomerular nephropathy were common histological findings. However, to our knowledge, there is limited data regarding de novo diagnosis of IgA vasculitis in an adult following a COVID-19 infection.

    Case presentation: In the present case report, we document a 24-year-old Bahraini woman with new onset hypertension, microhematuria, proteinuria and decreased renal function after she recovered from COVID-19 infection. Renal biopsy after COVID-19 infection was performed and revealed IgA nephropathy without any evidence of COVID-19 infection. After a regimen of immunosuppression and angiotensin converting enzyme inhibitor therapy, the patient recovered and remained stable upon follow-up.

    Conclusions: When dealing with patient with COVID-19 infection and kidney involvement, it is vital to evaluate the underlying glomerular disease aggravation as well as virus-induced consequences. A kidney biopsy may be necessary to roll out rapidly progressive glomerular disease (RPGN).

    Keywords: COVID-19, microscopic hematuria, IgA nephropathy, acute kidney injury, case report.

Rituximab Therapy in Polymyositis-associated Severe Dysphagia: A Case Report

Fajer Altamimi1*, Donncha O’Gradaigh2, Claire Sheehy3

Pages: 44-48
  • Abstract
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  • Polymyositis is one of the inflammatory myopathies. It is a chronic autoimmune disease that usually involves the proximal muscles. It is caused by an inflammatory infiltrate of the skeletal muscle. Notably, dysphagia occurs in one-third of the patients. Traditional treatment with steroids and immune modulators has been reported to have varied outcomes and recurrent symptomatic flares. The dysphagia which occurs in such myopathies may be one of the recurrent and severe symptoms of myopathies, often associated with considerable mortality and morbidity. Dysphagia, an often-noted clinical presentation of polymyositis (PM) /dermatomyositis (DM) can be the initial sign of idiopathic inflammatory myopathies. It can cause considerable morbidity in patients such as reduced pharyngeal contractility, hypomotility of the esophagus, cricopharyngeal dysfunction, and decreased laryngeal elevation. Here is a case of severe dysphagia in a patient with muscle and skin involvement in PM. Steroids are the first line of treatment for patients with myositis and the same was adopted initially for the current case. Rituximab was used after unsuccessful attempts with other recommended first-line treatments. Reversal of dysphagia and overall improvement were achieved with the use of rituximab and intravenous immunoglobulins. The patient demonstrated significant improvement in swallowing, with reasonable improvement, following which the percutaneous endoscopic gastrostomy (PEG) tube was removed. After 15 months, the patient showed 100% resolution of all symptoms and was advised to stop all medications. Therefore, we suggest that this combination may be considered in cases with dysphagia flares in DM, where traditional treatment options have shown no benefit.

    Keywords: Deglutition Disorders, Dysphagia, Muscular Diseases, Myopathy, Polymyositis, Rituximab

A Case of Latent Syphilis in Pregnancy Masked by Beçhet’s Disease

Aseel Ahmed Hussain1*, Anga Adnan Badawi2, Nayla Jamal Bushaqer3

Pages: 49-53
  • Abstract
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  • Syphilis in pregnancy is a worrisome topic due to its fetal consequences. The diagnosis and management of such a case might be intriguing when overlapped with Behçet’s disease, an inflammatory disease involving multiple organ systems. This case presents a 35-year-old pregnant female, a known case of Behçet’s disease and hypothyroidism, presenting at 33 weeks to the emergency department at Bahrain Defense Force (BDF) hospital with vaginal leaking and a solitary oral ulcer. As per the guidelines of the ministry of health, she underwent perinatal screening and was found to be positive for the venereal disease research laboratory (VDRL) test and was diagnosed with latent syphilis. The diagnosis of latent syphilis in a known case of Behçet’s disease presenting with a solitary oral ulcer is unpredictable. The importance of perinatal screening is emphasized in this case report.

    Keywords: Latent Syphilis, Behçet’s disease, Pregnancy

Small Bowel Volvulus: A Rare Case Report

Abdul Jabbar, Mohamed Fatema*

Pages: 54-56
  • Abstract
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  • Adult small intestinal volvulus is a rare entity and even more rarely, the ileum undergoes torsion without known predisposing factors. This presents as an acute abdomen. Although a rare condition, it should be kept in mind in cases of abdominal pain with or without intestinal obstruction. Since there is no specific laboratory or routine radiological finding in these cases, a CT scan abdomen is the investigation of choice. Small intestinal volvulus exits as two types according to etiology. Emergency surgical intervention is the treatment of choice. Delay and missed diagnosis have serious consequences with increased morbidity and mortality due to bowel ischemia. Here we report a case of a 32-year-old male having no predisposing factors presenting with abdominal pain, nausea, and vomiting. Physical examination and investigations were unremarkable. The patient was managed by urgent surgical intervention after having confirmed the diagnosis peroperatively as small bowel volvulus.

    Keywords: Abdominal pain, Small bowel volvulus, Intestinal obstruction, Midgut volvulus, Bowel necrosis, Whirlpool sign.

Management of Acute Massive Pulmonary Embolism During Pharmaco-mechanical Thrombectomy for Acute DVT: A Case Report

Mehtash Butt1,*, Rashad Al Qasim2, Dhafer M Kamal3

Pages: 57-61
  • Abstract
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  • This case report describes an incident of MPE during lower limb endovascular pharmaco-mechanical thrombectomy under sedation, which was immediately identified and promptly managed with cardiopulmonary resuscitation. After return of spontaneous circulation, ECMO was initiated, as her haemodynamics were unstable, and MPE was diagnosed based on transoesophageal echocardiography findings. During intensive care unit stay, she was successfully weaned off from ECMO and ventilatory support. However, the patient developed right-sided body weakness. Echocardiography showed a patent foramen ovale, and stroke due to paradoxical embolism was diagnosed. She was transferred to the ward in a stable condition and later discharged home.

    Abbreviations: MPE: Massive pulmonary embolism, ECMO: extracorporeal membrane oxygenation.

    Keywords: MPE: Massive pulmonary embolism, ECMO: extracorporeal membrane oxygenation, PFO: patent foramen ovale, PMT: pharmaco-mechanical thrombectomy, Sedation