Invitro Effect of Bulkfill and Incremental Application Techniques with Different Composite Filling Materials on Marginal Microleakage

Objective: To assess the in vitro effect of bulkfill and incremental application techniques on the microleakage of class II dental cavities filled with three different bulkfill composite materials at occlusal and cervical margins. Methods: Standardized class II cavities were prepared on 120 human premolar teeth extracted for orthodontic treatment, which were randomly divided into two main groups of 60 teeth, corresponding to the two application techniques. Each group wasthen sub-dividedrandomly into three sub-groups based on the type of bulkfill restorative materials as follows: Tetric®N-Ceram BulkFill, Filtek™BulkFill flowable restorative material and X-trafil®BulkFill. All cavities were prepared and etched, and the corresponding self-etch bond adhesive systems were applied. A stereomicroscope was used to assess microleakage after thermocycling and immersion of the specimens in 0.1% methylene blue for 24 hours. Mann-Whitney U test was then used to analyze data. Results: No statistically significant difference was found in the marginal microleakage between the incremental and bulkfill techniques using the three types of composite materials at both occlusal and cervical margins. The X-trafil®BulkFill showed the lowest score of microleakage with both application techniques compared to other bulkfill composite materials. Conclusion: Both incremental and bulkfill application techniques using Tetric®N-Ceram BulkFill, Filtek™BulkFill flowable restorative material and X-trafil®BulkFill composite materials have a comparable effect on the marginal microleakage at occlusal and cervical margins of human teeth extracted from dental clinics in Sana’a city. Further studies are recommended to assess the clinical success of bulkfill composite materials using SEM or confocal microscope.

Effect of Chronic Khat Chewing on Intima-Media Thickness of Common Carotid Arteries in Yemeni volunteers

Objective: To assess the changes occurring in both common carotid arteries (CCAs) intima-media thickness (IMT) in Yemeni chronic khat chewers using B-mode ultrasonography. Methods: This cross-sectional study was conducted among 195 participants (103 regular khat chewers and 92 non-khat chewers) conveniently selected at the Radiology Department of the University of Science and Technology Hospital (USTH) in Sana’a from August 2017 to August 2018. Data about gender, age, BMI, chewing khat and the period of chewing were collected from participants using a structured questionnaire. B-mode ultrasonography of bilateral CCAs was then performed to measure the IMT. Data were analyzed using suitable statistical tests, and P-values <0.05 were considered statistically significant. Results: The majority of participants with CCA-IMT were males (91.8%) and aged 27 years or younger (59.0%), with a mean age of 27.9 ± 6.8 years. Khat chewers constituted more than half of patients with CCA-IMT. There was no statistically significant difference in the mean values of RT CCA-IMT and LT CCA-IMT between khat chewers and non-khat chewers. The CCA-MIT was significantly higher among male khat chewers compared to male non-chewers (P = 0.004). However, there was no statistically significant difference between khat chewers and non-chewers with respect to the age of 20 years or older (P = 0.301) and BMI of 18.5 kg/m2 or higher (P = 0.888). Age showed a significant positive correlation with RT CCA-IMT (r = 0.380; P < 0.001) and LT CCA-IMT (r = 0.458; P < 0.001) in Khat chewers. In contrast, age showed a significant positive correlation with LT CCA-IMT only in non-khat chewers (r = 0.236; P = 0.024). On the other hand, BMI showed a significant positive correlation with LT CCA-IMT (r = 0.254; P = 0.010) among khat chewers, but no significant correlation was found in CCA-IMT of both sides among non-khat chewers. Among khat chewers, there was a significant positive correlation with RT CCA-IMT (r = 0.273; P = 0.005) and LT CCA-IMT(r = 0.194; P = 0.049). Conclusion: Khat chewing does not lead to a significant difference in CCA-IMT among Yemeni chewers compared to non-chewers. However, the period of chewing may slightly affect the CCA-IMT among khat chewers. Age has a significant positive correlation with CCA-IMT in khat chewers and LT CCA-MIT in non-khat chewers, which could help to determine the contribution of different predisposing factors to atherosclerosis. A significant positive correlation can be found between BMI and LT CCA-MIT among khat chewers. Keywords: Khat Chewing, Intima media thickness, Carotid, Yemen

Ethical Evaluation of Pharmaceutical Marketing in Sana’a City, Yemen

Objectives: To evaluate the ethics of pharmaceutical marketing practices in Sana’a city, Yemen. Methods: A cross-sectional study was conducted among 400 physicians and 50 pharmaceutical companies in the period from March to August 2018. Data about pharmaceutical marketing ethics were collected from physicians and pharmaceutical companies using two types of self-administrated, structured questionnaires. Data were analyzed with appropriate statistical tests using IBM SPSS Statistics, version 21.0. Results: The majority of physicians (60.0%) agreed that medical samples had been used most frequently as a promotional tool for pharmaceutical marketing, followed by gifts (14.0%). More than half of physicians were satisfied with the way of pharmaceutical marketing in Yemen. Personal relationships and medical samples and gifts were the factors affecting their prescriptions, being reported by about a third of physicians each. Meanwhile, most physicians (44.0%) preferred medical conferences and exhibitions as a promotional benefit to be gotten for prescribing the company’s products. The majority of physicians (62.0%) agreed that the availability of medical samples affect their prescriptions, and about 28.2% of physicians reported that all medical samples are used by their patients. Most physicians (37.0%) perceived that only 50% of medical representatives respond well to their queries related to marketed drugs, and 41.5% of physicians agreed that global companies are more compliant with ethical marketing. About 60% of the physicians reported not facing unethical promotions, and the majority (54.0%) agreed that unethical pharmaceutical marketing is the responsibility of companies, physicians, and representatives. There was a statistically significant difference in the proportion of drug prescriptions affected by medical representative visits and availability of medical samples on prescription in relation to the work experience of physicians. On the other hand, there was a statistically significant difference in facing an unethical promotion offered by companies for prescribing their products and the attribution of unethical pharmaceutical marketing in relation to the type of medical profession of physicians. Conclusions: Pharmaceutical marketing in Yemen still depends on traditional tools, with the lack of ethical guidelines or codes for pharmaceutical marketing in the country. Work experience and medical profession of physicians can significantly affect pharmaceutical marketing. The spread of unethical marketing is the responsibility of pharmaceutical companies, physicians and medical representatives. Therefore, it is recommended to develop well-defined and updated ethical standards and national guidelines for pharmaceutical marketing by the Ministry of Public Health and Population. Furthermore, official campaigns should be regularly carried out to control and restrict unethical promotion. Further studies on the ethics of pharmaceutical marketing are also recommended. Pharmaceutical companies should continuously train their medical representatives and provide physicians with the latest medical knowledge about new drugs. Keywords: Pharmaceutical marketing, Ethics, IFPMA guidelines, Sana’a

Common Autoimmune Diseases among Yemeni Patients in Sana’a City, Yemen

Objective: To determine the most common autoimmune diseases (ADs) among Yemeni patients in Sana’a city. Methods: This cross-sectional study was conducted in six health facilities in Sana’a city from January 2014 to July 2017. It prospectively recruited 131 patients with ADs and retrospectively included 1786 records of patients with ADs, totaling the sample size to 1917. Data about gender and age of prospective patients and as well as the gender, age and the type of AD from patients’ records were collected using a pre-designed data collection sheet. Sera from patients’ sera were investigated for autoantibodies to diagnose ADs using immunological techniques. Data were then analyzed and expressed using descriptive statistics. Results: The majority of approximately two-thirds of patients with ADs attending the health facilities or record-retrieved were females, with a mean age of 32.35 ± 13.72 years (range: 1–89). Approximately half of the patients had a single type of either systemic or organ-specific ADs, while less than 1% had concurrent ADs. Rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) were the most frequent systemic ADs, being higher among females than males with male:female ratios of 1:4, 1:6 and 1:7, respectively. On the other hand, autoimmune hepatitis (AIH), Graves’ disease, Hashimoto's disease and celiac disease (CD) were the most frequent organ-specific ADs. AIH was higher among males than females with a male:female ratio of 2:1, while Graves’ and Hashimoto's diseases and CD were higher among females with a male:female ratio of 1:2–1:5. The most frequent concurrence between ADs was between SLE and RA (55.6%) as well as AIH and AIG (16.7%), being higher among females than males with male:female ratios of 1:9 and 1:2, respectively. SLE and AIH were equally concurrent between males and females, while the concurrence of other types of ADs was observed among females only. Conclusions: AIH, RA and SLE are the most frequent ADs among Yemeni patients with a steady rise in the frequency of ADs over the period 2014-2017 in Sana'a city. Systemic and organ-specific ADs are comparably equal in distribution and concurrently present among approximately 1.0% of cases, with predominance among females compared to males. Population-based studies for the assessment of incidence/prevalence of ADs and the environmental factors associated with the trending increase in the prevalence of ADs in Yemen are issues for further studies. Keywords: Autoimmune diseases, Autoimmune hepatitis, Rheumatoid arthritis, Systemic lupus erythematosus, Yemen

Association of Serum Complement Components (C3 and C4) with Disease Activity in Yemeni Bronchial Asthmatic Patients

Objective: To assess the role of the complement components (C3 and C4) in the pathogenesis and severity of bronchial asthma (BA) among Yemeni patients. Methods: This cross-sectional, clinic-based study was conducted in Sana’a city, Yemen in the period from March to June 2012. It included 100 BA patients, where demographic and clinical data were collected using a pre-designed, structured questionnaire. Blood samples then collected by venipuncture, and sera were then separated and tested for the levels of C3 and C4 by immunoturbidimetry assay. Data were analyzed using suitable statistical tests using IBM SPSS Statistics, version Results: Of 100 patients, 53% were males and 29% were older than 40 years. The mean age of patients was 34.7± 17.5 years (range: 6–80). The majority of patients had active asthma (81.0%) and experienced asthma for more than two years (66.0%). Dyspnea (81.0%) and cough (65.0%) were the most frequent clinical features, while edema (11.0%) was the least frequent clinical feature among asthmatic patients. The mean level of serum C3 among BA patients was elevated (127.9 ± 21.3 mg/dL) and was significantly higher among females, patients aged 40 years or older and those with active BA, but there was no statistically significant difference with respect to the duration of asthma. In contrast, the mean level of serum C4 was normal (27.6 ± 8.8 mg/dL) but was significantly higher among patients aged 40 years or older and those having asthma for more than two years. Wheezing was significantly associated with the mean level of serum C3 among BA patients. Similarly, the mean level of serum C4 was significantly higher among patients having cough. Conclusions: The majority of Yemeni patients with BA have elevated levels of serum C3, which can be significantly higher in females, patients older than 40 years and those with active asthma. On the other hand, the levels of serum C4 are normal among the majority of Yemeni patients with BA, but these can be elevated among those with severe clinical features or long-term asthma. Keywords: Active asthma, Bronchial asthma, Complement, C3, C4, Yemen

Thalassemia Phenotypes and Associated Mortality among Yemeni Patients: A Single-Center Retrospective Analysis

Objective: To retrospectively analyze thalassemia phenotypes and associated mortality among Yemeni patients seeking healthcare in Sana’a city, Yemen. Methods: This retrospective, cross-sectional study was conducted in the medical center of Yemen Society for Thalassemia and Genetic Blood Disorders (YSTGBD) in Sana'a city from January 2010 to December 2016. Data about gender, age, governorate of origin, type of thalassemia and thalassemia-related mortality were retrieved from the records of 496 thalassemia patients. Data were then entered into an Excel spreadsheet, cross-checked for accuracy and presented as frequencies and proportions. Factors associated with deaths among thalassemia patients were analyzed using chi-square or Fisher’s exact tests. Results: A total number of 496 patients attended the medical center of YSTGBD in Sana’a city in the period from January 2010 to December 2016. The majority of thalassemia patients were males (57.9%), and approximately half of the patients were aged 10 years or younger with a comparable proportion to those older than 10 years. Most thalassemia patients had β-thalassemia (92.7%), while 7.3% had α-thalassemia. The majority of patients were from Hajjah governorate (16.5%) followed by those from Sana'a (13.1%) and Amran (11.9%), while lower proportions ranging from 0.2% to 8.1% were recorded for patients from other governorates. Thirty out of the total attending thalassemia patients died, and mortality was significantly associated with recurrent transfusions of whole blood but not with the gender and age of the patients or thalassemia phenotype. Conclusions: The majority of thalassemia patients seeking healthcare in Sana’a city suffer from thalassemia, where males represent more than half of them and the patients are almost equally distributed in relation to the cut-off age of 10 years. The mortality incidence among Yemeni thalassemia patients seeking healthcare is lower than that reported elsewhere in the world, and mortality was significantly associated with recurrent blood transfusions. Further studies to identify the genetic abnormalities associated with thalassemia are recommended together with the need for the launch of a national center for counseling, research and supervision of voluntary activities related to thalassemia and genetic blood disorders in Yemen. Keywords: Thalassemia, Phenotype, Mortality, Yemen