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Multiple choice questions in medical schools

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Letters to the Editor
Need for non-invasive pain reduction 1993; 91: 379-382.
Thyroid surgery experience of King
strategies in neonates.
Saud Hospital, Unaizah, Al-Qassim.
Sir,
Sir,
The pain perception in neonates has been clearly
described.1,2 During the intensive care of neonates, Over a period of 5 years, 70 patients underwent
they are exposed to many procedures, including thyroid gland surgery in King Saud Hospital,
intubation, IV access, central line placement, chest Unaizah, Al-Qassim. Eighty five percent of the
tube insertion, lumber puncture, catheterization, patient were females. Thyroid carcinoma occurred in
suprapubic aspiration etc. These procedures are 7% of the patients. Fifty percent of the studied group
associated with pain and stress. However, no clear of patients presented clinically with multinodular
guidelines are available for alleviating the distress by goiter. FNAC was useful in determining the
premedication during such procedures. Researchers diagnosis, when performed, but the false negative
are looking for methods to minimize the pain and results were of high incidence. Thyroid surgeries
distress in neonates during these procedures. were safely and successfully performed in our
Examples include the use of thiopental as hospital and operative complications were not more
premedication before intubation,3 local anesthetics than complication rates in higher centers.
before heel prick 4 and lumber puncture.5 Thyroid enlargement is usually due to a variety of
The goal is to choose a method of analgesia that is underlying pathologic conditions either neoplastic or
non-invasive and less painful. An intramuscular non-neoplastic. Clinical distinction between these
injection before an elective procedure is not two pathologies is not usually possible. Several
acceptable. Similarly, patch therapy with local diagnostic modalities have been used such as thyroid
anesthetics or premedication will be a problem in function tests, scintigraphy and ultrasonography.
acute situations, such as immediate intravenous Although these modalities can help in the detection
access or emergency intubation. There exists an of cold nodules, still they are not diagnostic. Fine
urgent need for randomized control trials on this needle aspiration of thyroid nodules has
issue. The questions are: what type of drug revolutionized the diagnostic approach to nodular
(analgesic, sedative or anesthetics) should be used in goiters and is widely used in identifying malignant
what procedures, what should be the mode of nodules and selecting patients for surgery. It was
administration (IM, IV, ET or non-invasive), and also helpful in limiting the number of surgical
what should be the dose adjusted for gestational age. explorations for histologic examination in patients
We look forward to have some answers in near who would need only medical treatment, thyroid
future. enlargement with either a solitary nodule, multiple
Shabih Manzar nodules or diffuse enlargement is a common
King Faisal University & presentation in the outpatient clinic in our hospital.
King Fahd University Hospital This prompted us to study the correlation between
PO Box 40211 FNAC results with histopathologic examination.
Al-Khobar 31952 Also to study the most common thyroid pathologies
Kingdom of Saudi Arabia encountered in Al-Qassim area and the sectors of
population frequently affected.
King Saud Hospital is a secondary referral hospital
References for the population of Unaizah and the surrounding
districts of Qassim area. The data of patients who
1. Anand KJS. The biology of pain perception in newborn have undergone thyroid surgeries for different
infant. In: Tyler DC, Krane EJ, eds. Advances in pain thyroid pathologies during the period October 94 to
research and therapy: Pediatric Pain. New York, NY: October 99 were collected and included in this study.
Raven Press; 1990: 113-122. Records of 70 patients with thyroid enlargements
2. Fitzgerald M, Millard C, MacIntosh N. Hyperalgesia in were retrospectively reviewed. The collected data
premature infants. Lancet 1988; 1: 292.
3. Bhutada A, Sahni R, Rastogi S, Wung JT. Randomised included patient’s age, sex, nationality, clinical
controlled trial of thiopental for intubation in neonates. Arch presentation, investigations carried out, surgical
Dis Child Fetal Neonatal Ed 2000; 82: F34-F37. procedures, post operative course including operative
4. Barker DP, Rutter N. Lignocaine ointment and anesthesia in complications and histopathological diagnosis.
preterm infants. Arch Dis Child Fetal Neonatal Ed 1995; 72:
F203-F204. Special interest for correlation between the results of
5. Pinheiro JMB, Furdon S, Ochoa LF. Role of local FNAC and histopathological diagnosis was included
anesthesia during lumber puncture in neonates. Pediatrics in our study.

1088 Saudi Medical Journal 2000; Vol. 21 (11)

 Letters to the Editor
During the period of 5 years from October 94 to The correlation rate between histopathology and
October 99, 70 patients underwent thyroid gland FNAC was 75%, which is consistent with the results
surgery in our unit. Of these 49 patients were of other centers. In a study carried out by Lowhagen
Saudi’s and they form the basis of this report. Sixty et al, for 3500 patients undergone FNAC, false
patients (85%) were females with a mean age of 33.6 negative results was less than 2%. Another study
years at presentation (range 14-59 years). The mean carried out by Christensen et al, to correlate FNAC
age at presentation for males was 34.3 years (range and scintigraphy, they confirmed that cases which
19-63 years). The clinical presentations and were hot in the scan were benign in FNAC. It has
indications for surgery are goiter in 66 patients and 4 been suggested that all patients with solitary thyroid
with toxic manifestations without palpable neck nodule should have FNAC as their initial
swelling. The investigations carried out to the investigation and that thyroid scan is not required. It
studied group of patients were thyroid function tests is also concluded that FNAC is an efficient method
in 49 cases, scintigraphy in 13 cases, ultrasonography for detecting cancer in patients who have a cold
in 6 cases, FNAC in 33 cases, while 5 patients did nodule on the thyroid scan. Thyroid scan is of value
not undergo any special investigations. in the follow up of patients who have had thyroid
FNAC results were conclusive in 25 out of 33 cysts aspirated.
samples collected. It gave the results of colloid It was found that multinodular goiter was the most
goiter in 7 cases, negative for malignancy in 10, prevalent pathology encountered in our area (33 out
follicular adenoma in 2, Hurthle’s change in 1, of 70 cases). Two cases presented with multinodular
benign follicular cells in 4, malignant cells in 1 and goiter were diagnosed as papillary carcinoma on a
was not conclusive in 8 cases. The thyroid background of multinodular goiter. The pathology of
pathologies of the studied cases were nodular goiter multinodular goiter can not be diagnosed with
in 33 cases, toxic goiter in 8, Hashimoto thyroiditis in confidence without surgery and pathology since most
4, follicular adenoma in 13, papillary carcinoma in 5, cases present clinically as a solitary thyroid nodule,
simple diffuse goiter in 6 and a hemorrhagic cyst in 1 which is in fact the more easily palpable of a
case. multinodular goiter.
It was noticed that two cases of multinodular Thyroid surgeries were carried out safely in our
goiter were associated with Hashimoto thyroiditis. hospital by a team of experienced surgeons without
Other cases of multinodular goiter showed foci of exceeding the morbidity or complication rates of
thyrotoxic changes. A fourth case of multinodular higher centers.3 Limitation of facilities did not
goiter showed follicular adenoma. prevent successful thyroid surgeries to be carried out
Post operative complications (morbidity rate) was in our hospital. Limited facilities such as lack of
6 out of 70 patients (8.5%) which were thyroid scan, lack of ultrasonic probe for thyroid
hypothyroidism in 1 case, hypoparathyroidism in 2, gland examination, even thyroid function tests which
recurrent laryngeal nerve injury in 1 and hoarseness were not available for most of the times. These did
of voice in 2 cases. Operative mortality was nil in
this group of patients. not prevent us from asking for these investigations
From our experience in King Saud Hospital in from King Fahad Hospital in Buraidah, since a good
Unaizah, we have found that patients with thyroid number of patients still prefer to be operated in our
enlargements are coming to ask for medical advice hospital in the same district where they used to live.
mostly for fear of cancer or for unsightly swellings.
Reassurance and surgery were usually needed. We Khalid A. Bakhsh
do agree for the attitude of surgeons practicing in our Hany M. Galal
area to handle most thyroid swellings surgically, Sawsan A. Lutfi
particularly those presenting as solitary thyroid Department of Surgery
nodules. Although malignancy was diagnosed only King Saud Hospital
in 5 out of 70 cases in our study (7%) which is lower PO Box 3175
than the rates of malignancy reported in higher Unaizah
centers in Buraidah and Riyadh areas, we still Al-Qassim
recommend that all thyroid swellings should be
handled surgically. Reviewing the results of our
preoperative investigations, we found that thyroid References
function tests were conclusive in 49 cases,
scintigraphy was conclusive in 11 out of 13 cases 1. Ali Elhamel. The pattern of thyroid disease in a closed
while ultrasound was conclusive in 5 out of 6 cases. community of 1 1/2 million people. Saudi Medical Journal
1988; 9: 481-484.
FNAC was conclusive in 25 out of 33 cases (75%) 2. Al-Tameem MM. Thyroid malignancy in 2 general hospitals
which is nearly similar to reports coming from higher in Riyadh. Saudi Medical Journal 1987; 8: 67-72.
centers. 3. Al-Tameem MM. The pattern of surgically treated thyroid

Saudi Medical Journal 2000; Vol. 21 (11) 1089

 Letters to the Editor
disease in two general hospitals in Riyadh. Saudi Medical rapidly expand our global marketing activities.” The
Journal 1987; 8: 61-66. DISA S-Flex coronary stent is a new generation
4. device, designed using extensive computer aided
Salah Kona. The surgery of goiter in Riyadh Armed Forces
Hospital. Saudi Medical Journal 1988; 9: 617-621. modeling technology to minimize restenosis by
5. Mofti AB. Experience with thyroid surgery in the Security reducing the degree of vessel-wall injury during and
Forces Hospital, Riyadh. Saudi Medical Journal 1991; 12: after stent implantation. A 10%-20% incidence of
504-506. restenosis, causing instent arterial narrowing remains
the major negative side-effect of stenting. All major
stent companies are racing to find a solution to
restenosis.
Starke pointed out that preliminary clinical
outcomes have shown excellent primary results. The
Biomedical Engineering Company unique S-Flex linkage provides unusually high
announces its DISA S-Flex Coronary flexibility for easy delivery and low-injury vessel-
wall conformity, while the 8-cell structure provides
stent, Africa’s first CE marked heart more circumferential support than existing 6-cell
implant stents. Based on a large body of independent, recent
research, the developers believe that this combination
Sir, is the key to a less restenotic implant.
Dr Basil Levetan, the Director of the Cardiac
The Biomedical Engineering Company (BEC), a Catheterization Laboratory at Groote Schuur Hospital
South African developer of cardiovascular products, in Cape Town adds: “Over the last year my
is on the verge of a worldwide breakthrough after experiences with the DISA S-Flex coronary stent
announcing international approval for its new have been very favorable. It is easy to deliver and
generation coronary stent. The development of the has produced excellent angiographic results.”
precise, laser-sculpted implant which is used to open BEC continues to develop innovative medical
and maintain blood flow in the coronary arteries, devices for the minimally-invasive treatment of
builds on a long tradition of heart research in the vascular disease. BEC will release its peripheral
Western Cape, home of the world’s first heart stent in the first quarter of 2001.
transplant. In October 1999, BEC received venture funding
BEC, founded in 1998 by South African from Catlyst Innovation Incubator (Pty) Ltd.
biomedical engineers, has received Class III CE Catalyst invests in early-stage life-science
Mark approval for its DISA S-Flex coronary stent. businesses. Starke noted: “It’s been a tremendous
Dr Gregory Starke, CEO of BEC, says: “Although a boost working together with the internationally
number of international distributorships have already experienced Catalyst team in fast-tracking BEC’s
been established by our distribution partner, DISA growth.”
Vascular, this exciting development now allows us to Gregory Starke

1090 Saudi Medical Journal 2000; Vol. 21 (11)

Correspondence
Biomedical Engineering Company were known diabetics. Following was the pattern of
Cape Town admissions in our patients based on the indication for
South Africa that particular admission (Table 1). It is clear from
Pattern of admission in diabetics of the data that acute complications (hypoglycemia,
hyperglycemia, ketoacidosis) were responsible for
Najran 166 episodes of admissions (19%) where as chronic
complications were responsible for 314 (37%), 287
Sir, patients (34%) were admitted for a concomitant
hypertension and 86 patients (10%) were admitted
We read with interest the article on common causes for other medical illness. Hypertension with other
of admission in diabetics.1 With obesity and diabetes macrovascular complication were responsible for
reaching epidemic proportions in Saudi Arabia2,3 and 67% of our admissions. We fully agree with the
a continued trend of its increase, it is quite important authors that the risk factors for macrovascular
to know more about this disease in this particular complications are smoking, hyperlipidemia,
community.4 Knowledge about the magnitude of hypertension, obesity and smoking almost all of them
disease, level of education in diabetic subjects, reversible or controllable. Control of these factors
pattern of admissions, availability of medical help, may lead to a drastic reduction in hospital admissions
quality of available care, motivation of patient for and probably a reduction in morbidity. However
treatment and available family and social support is most of such a control will be achieved by patient
important to look into the multiple variables relevant education which has to be on a mass scale and which
in proper care. We are actively collecting data in this needs a strong commitment by health authorities.
regard and we would like to share our experience We believe that health education should be part of
with the authors and other colleagues involved in the every doctor-patient encounter, but it is our personal
care of diabetic subjects in the Kingdom. experience that it alone is not enough. Unless a
Najan General Hospital is a Ministry of Health national level health education program is not taken
hospital with its well-defined catchment area. All
patients seen in primary care centers attached to it are up, things might not change at ground level. A
referred to hospital for care. During the year 1420 healthy, lean, non-smoker, jogger, whose diet
(1999) we admitted a total of 2461 patients to our consists of balanced diet rather than kabsa and
medical department comprising of 1452 males and mandi, has to be projected as a national hero to infuse
1009 females (male: female ratio of 1.4:1). A total of a concept of healthy lifestyle into the young
480 males and 373 females were identified to have generation. Saudi sportsmen could be ideal
diabetes. This comprised of 33% male admissions candidates for such an exercise.
and 37% female admissions. Just 12 patients
(<0.5%) were diagnosed for the first time, others Latif A. Khan, Sarosh A. Khan

Table 1 - The pattern of admissions in our patients based on the indication for that particular admission.

Disease entity Male (%) Female (%) Total (%) (Nearest whole
number)

Ischemic heart disease Angina/MI/arrhymias 149 (31) 76 (20) 225 (26)

Hypertension 145 (30) 142 (38) 287 (34)
Strokes 29 (6) 18 (5) 47 (5)
Infections (lung/kidney) 28 (6) 27 (7) 55 (6)
Diabetic foot ulcer 18 (4) X 18 (2)
Diabetic ketoacidosis 5 (2) 6 (2) 11 (1)
Hypoglycemia 9 (2) 4 (1) 13 (1.5)
Hyperglycemia 62 (13) 80 (21) 142 (17)
Diabetic renal disease 12 (2.5) 12 (3) 24 (3)
Miscellaneous 23 (5) 8 (2) 31 (4)
Total 480 (56) 373 (44) 853 (100)

X=Zero

Saudi Medical Journal 2000; Vol. 21 (11) 1091

 Correspondence
Husni Al-Hateeti incedence and perinatal loss in diabetics at the
Najran General Hospital, Najran Riyadh Armed Forces Hospital (RAFH). Of the
Kingdom of Saudi Arabia 44307 mothers delivered between 1994 and 1999,
References 236 (5%) were labelled as gestational diabetic, 730/
2316 (31.5%) required insulin treatment.
1. Akbar D, Al-Gamdi A. Common causes of admission in The incidence of GDM at RAFH ranged between
diabetics. Saudi Medical Journal 2000; 21: 539-542. 3% and 7% with an overall incidence of 5% while
2. Khan LA. A diabetes mellitus - an evolving epidemic the incidence of true diabetes on insulin varied
(editorial). The Practitioner East Mediterrean Edition 1999;
10: 1, 3. between 0.5% in 1994 and 2% in 1998, because most
3. Ahmed M. An epidemic of obesity in the Kingdom of Saudi of previously labelled gestational diabetics were
Arabia. Annals of Saudi Medicine 1997; 17: 667-668. classified as true diabetics and required insulin
4. Alzaid A. A time to declare war on diabetes (editorial). therapy from the beginning of their pregnancy. The
Annals of Saudi Medicine 1997; 17: 154-155. perinatal mortality rate for gestational diabetics was
twice (24% per thousand) the overall PMR while
PMR for established diabetics was 4 times the overall
rate.
This data supports the view of the author1 that
diabetes in pregnancy is still a major cause of
perinatal loss. This data illustrates our concern
Reply from the Author regarding screening and management of diabetes
mellitus in pregnancy whether gestational or
I am grateful to each of the authors for their interest established diabetes. Regular follow up and close
in my article and in the care of diabetic subjects in monitoring of blood sugar level in pregnancy and
the Kingdom. I totally agree with them, diabetes is management on outpatient basis is the cornerstone of
reaching epidemic proportion in Saudi Arabia. We successful outcome. There is still a lot which needs
need more studies from different regions of the to be done to reduce the PMR in diabetics to its
Kingdom in addition to our studies to show the similar level in normal population.
magnitude of the problem we are facing and to
augment the role of health education and social Ratib Mesleh
support all over the Kingdom. This will not only Department of Obstetrics and Gynecology
decrease the rate of admissions of diabetics but also Riyadh Armed Forces Hospital
reduce their morbidity, mortality and cost. PO Box 7897
Daad H. Akbar Table 1 - Comparative table, incidence and perinatal mortality in
diabetics (RAFH 1994-1999).
King Abdul Aziz University Hospital
Jeddah
Kingdom of Saudi Arabia
Year 94 95 96 97 98 99 Total

Total mothers 7003 7246 7711 7590 6897 7860 44307

Total infants 7082 7331 7801 7679 6990 7961 44844

Diabetes and perinatal loss, a
Overall perinatal 12.5 14 12 13 13 14 13
continuing problem mortality rate

Gestational diabetes 394 365 477 541 216 323 2316

Sir, mellitus

Incidence (%) 6 5 6 7 3 4 5
I have read with great interest the article titled
“Diabetes and perinatal loss, a continuing problem.” 1 Perinatal death 9 9 9 11 10 8 56
The Perinatal Mortality Rate (PMR) in the abstract
Perinatal mortality rate 23 25 19 20 46 25 24
was calculated as a percent when it should have been per thousand
calculated as per thousand as shown in Table 3 of the
article.1 The Cesarean Section (CS) rate was 5 times True diabetic on insulin 34 33 40 48 130 53 338
higher in the cases than in the controls. In our Incidence (%) 0.5 0.5 0.5 1 2 1 1
institution the CS rate of 13% for Gestational
Perinatal deaths 5 3 5 3 2 2 20
Diabetes Mellitus (GDM) on diet was similar to other
obstetric population (12%), but CS on GDM Perinatal mortality rate 147 91 125 62.5 15 38 59
requiring insulin was twice the controls (26% vs. per thousand
12%). 2 The table shows a comparative data,

1092 Saudi Medical Journal 2000; Vol. 21 (11)

 Correspondence
Reply from the Author 4. Drexel G, Bichler A, Sailer S, Breier C, Lisch HJ,
Braunsteiner H et al. Prevention of perinatal mortality by
We thank Ratib Mesleh for the comments on the tight metabolic control in gestational diabetes. Diabetes Care
1988; 11: 761-768.
article “Diabetic and Perinatal loss, A continuing 5. Combs CA. Relationship of fetal macrosomia to maternal
problem” 1 and also the data on diabetes and postprandial glucose control during pregnancy. Diabetes
pregnancy from their institution that was presented. Care 1992; 15: 1251-1257.
We agree that perinatal mortality rate is and should
be calculated per thousand for international
comparison. Nonetheless, it is still acceptable if
percentage is used bearing in mind that both units are
easily convertible. The perinatal mortality rate for all Multiple choice questions in medical
diabetic patients in our study was about 5 times more schools
than that of non-diabetic controls1 while Dr Mesleh
quoted perinatal mortality rate for established Sir,
diabetics that was 4 times the overall rate. It is
pertinent to note here that our study included patients I sympathize with our Sudanese colleagues. The
with well controlled and uncontrolled blood sugars. problems reported by Ahmed et al1 during the
Several studies 3,4 have shown the effect of tight preparation; and validation of multiple choice
control of blood sugars during pregnancy on perinatal questions (MCQs) in Sudanese Medical Schools give
mortality. It is obvious therefore that one way of me a feeling of deja entendu. Issues related to MCQs
reducing perinatal mortality in diabetics whether have been a matter of debate amongst academic staff
gestational or established is maintaining euglycemic in all medical schools including at our medical
state throughout pregnancy. The increase is cesarean college. Although there is no single best answer to
section in our diabetic patients and Dr. Mesleh’s may each one of the problems raised, I would like to
be related among other things to the birth weight, comment on some of the observations reported.
which is significantly higher in diabetic patients as in Large number of students resulting in crowded
our study. However, Combs5 demonstrated in his examination rooms together with low student/
study that fetal macrosomia is related to postprandial invigilator ratios are known to be catalysators for
glucose levels. It may deduced then that maintaining students’ misconducting behavior during MCQ
a normal postprandial glucose level during pregnancy examinations. There is however a simple and
may result in the reduction of cesarean section inexpensive solution to circumvent this problem,
performed in diabetic patients. We agree that there is being the use of at least three versions of the same
still a lot to be done to reduce perinatal mortality rate MCQ paper in which the questions have been set in a
and the cesarean section in diabetics and the different order. In our experience, this obviously
cornerstone is maintaining a cuglycemic state discouraged students from ‘seeking help’ from their
throughout pregnancy. fellow students during the examination. I believe
that in an era where information technology in
Adekunle A. Dekunle education is ample, this remedial solution should be
A. Sobande realistic.
College of Medicine and Medical Sciences I do agree that writing of well-constructed MCQs
King Khalid University demands a lot of experience and that critical review
PO Box 641 of the MCQ paper is essential even after the
Abha examination. It was however not clear from the
Kingdom of Saudi Arabia authors’ report how this was or should be done. I
presume that they allude to the use of the optical
mark reader system which provides the ability of
reevaluation of each MCQ for indices such as
References discrimination and difficulty. Needless to say that
based on this fast and relatively inexpensive
1. Sobande AA, Al Bar H, Archibong EI. Diabetes and evaluation tool valuable questions can be selected for
perinatal loss, a continuing problem. Saudi Medical Journal storing in the question bank.
2000; 21: 161-163. I realize the need for essay questions as an
2. Mesleh R. Screening for gestational diabetes. Saudi assessment tool during the medical training. But as
Medical Journal 1999; 20: 482-483. correctly pointed out by the authors, it needs the
3. Thompson DM, Danscreau J, Creed M, Redell. Tight
glucose control results in normal perinatal outcome in 150 required English language skills which are often
patients with gestational diabetes. Obstet Gynecol 1994; 83: lacking in many medical students around the world.
362-365. As a result some of these essays end up in telegraphic

Saudi Medical Journal 2000; Vol. 21 (11) 1093

 Correspondence
style format which gives way to ambiguity and loss occasions may not discourage those who want to
of objectivity during interpretation and marking. “help” their colleagues by offering them some true
responses (especially in setting of crowed
Dirk Deleu examination rooms).
College of Medicine In the view of the MCQs paper we much
Sultan Qaboos University emphasize the construction of the questions which is
Oman the most critical factor in the final analysis of such
questions. Certainly, incorrectly or ambiguously
worded MCQs will not yield worthwhile results.
A good English language is an essential
Reply from the Author requirement for answering the essay questions. Lack
of language skills should not obviate the need of
We highly appreciate the valuable comments of Dr. these questions. We feel that English should be
Deleu that addressed vital points. MCQs have been meticulously taught in the preliminary year (which
taking a rapidly increasing place in the evaluation has been shortened to few months in most of our
programmes of medical school in the recent years. schools).
The disadvantages of MCQs are certainly out
weighted by the precision by which the factual Awad M. Ahmed
knowledge may be assessed by this technique which PO Box 102
have come to stay! Khartoum
Students misconducting behavior during MCQs Sudan
examination is a serious problem that not only
impairing the evaluation process but also can be References
considered as a predictor of future dishonest medical
practice. We strongly agree that the method 1. Ahmed AM, Hussein A, Ahmed NH, Elawad AM. Multiple
suggested by Dr Deleu would certainly discourage choice questions in Sudan Medical Schools: Teachers views.
this malbehaviour. But this method, in rare Saudi Medical Journal 2000; 21: 398-399.

1094 Saudi Medical Journal 2000; Vol. 21 (11)

Book Reviews
Dates in Medicine. A chronological comprehensive and interesting one.
Chapter 7 is devoted to the role of melatonin in
record of medical progress over three sleep and sleep disorders.
millennia. There were nine chapters covering sleep disorders
in neurodegenerative disorders, extrapyramidal
ANTON SEBASTIAN. 436pp. Price: U$ 58.00. disorders, dementia, stroke, epilepsy, headache, brain
Publisher: The Parthenon Publishing Group Lmt, injury, multiple sclerosis and neuromuscular
Lancaster, UK. ISBN: 1-85070-095-8. disorders. Chapter 9 is on motor disorders of sleep
such as sleep walking and nocturnal paroxysmal
This book provides a very brief overview of the dystonia and chapter 16 is on narcolepsy, idiopathic
progress of medicine from 800 BC to date. It hypersomnias and periodic hypersomnia.
contains a good overview and will be very useful for The text is outstanding and very useful for
somebody who wants to know the history of neurologists and sleep specialists. Other physicians
medicine. Unfortunately, there are no references, and such as pulmonarisits, psychiatrists and resident
I would like to see in this book such information to physicians will also find this book helpful. This
help others how to find more data if needed. book is an excellent buy especially for neurologists
In conclusion, I advise physicians or scientists who and sleep specialists.
are interested in the history of medicine to buy it, and
I also recommend that it should be made available in Nabil Biary
any medical library. Neurosciences Department
Riyadh Armed Forces Hospital
Saleh M. Al Deeb PO Box 7897
Neurosciences Department Riyadh 11159
Riyadh Armed Forces Hospital Kingdom of Saudi Arabia
PO Box 7897
Riyadh 11159
Kingdom of Saudi Arabia Mastering Documentation

DORIS WEINSTOCK, PETER, H. JOHNSON.

435pp. Price: US$: 42.95 Publisher: Springhouse
USA. Date of Publication: 1999. ISBN: 0-7506-
Sleep disorders and neurological 4073.
disorders
This book thoroughly reviews the many aspects of
ANTONIO CULEBRAS. 423pp. Publisher: the process of documentation. It is directed primarily
Marcel Dekker, Inc. USA. ISBN: 0-8247-76054-4 at nursing students but would serve as an excellent
reference book for any professional that wants to
Sleep is a fascinating topic. Neurologists are asked improve the documentation of care they have
to see large numbers of patients with sleep disorders rendered to a patient. Although professionals tend to
and the subspecialty of neurological sleep medicine view documentation as a necessity, our entire careers
has developed rapidly over the last three decades. can depend on the accuracy and completeness of
This multi-authorized comprehensive book is charting entries.
studying the sleep from the neurological perspective. In a practical way this book compares and
It focuses on the neurological mechanisms and contrasts the many different systems for
manifestations that underlie sleep and its disorders. documentation. One chapter focuses completely on
It covers the sleep manifestations, in common the medical-legal aspect of documentation and the
neurological disorders with illustrative cases and ethical implications. It is based on the American
extends into dimensions of pathophysiology, Nursing Association’s "Standards of Nursing
treatment and prevention. The book consists of 20 Practice" which are included as an Appendix. Three
chapters. The initial chapter covers the historical chapters are devoted to documentation in specific
perspective on sleep and man. The second chapter is settings: acute care, long-term care and home care.
on neurobiology and segmented neurology of sleep. These chapters are very comprehensive and focus
The third and fourth chapter provide important specifically on documenting the care given in each
information on sleep disorders in children and setting. This book could serve as a useful resource
pediatric sleep physiology and apnea syndrome. The for any hospital that is looking to develop new
chapter on dissociation of brain and mind such as documentation forms or updating forms that are
narcolepsy and phantom limb phenomenon is currently in use. It is abundant with examples of

Saudi Medical Journal 2000; Vol. 21 (11) 1095

 Book Reviews
forms ready to be adapted for use in any facility and structures: mesencephalic reticular formation for
there are special sections labeled "Better Charting" (EEG disynchronization), perilocus coeroleus for
that are full of practical tips. (marked atonia), peri-abducence RF for (REM),
Although this book has been written to meet Pontis oralis for (theta rhythm within hippocampus),
standards of documentation in the United States and peribrachial area and N coeroleus for (PGO), N.
the legal considerations are based on the U.S. legal giganto-cellularis for (myoclonic twitch) and
system, it would serve as an excellent resource for parabrachial neuclei for increased brain temperature,
nursing and medical students, nursing departments, cardiovascular and respiratory changes). 2) Role of
and as a library reference book in the Kingdom. nor-epinephrine, serotinin, 5 HT1 and 5 HT2
Mastering Documentation addresses with unique receptors, GABA, (inhibiting REM off neurons in LC
thoroughness the process of documentation for the and DRN), hormones like remin, GH, Prolactin and
new professional, and also has new ideas that will endogenous sleep substances in REM regulation and
impress even the seasoned professional. modulation. 3) Energy production in the limbic
cortex and in ponto - mesencephalic tegmentum
Ali Al Jumaiah during REM by functional brain mapping. 4)
Quality Assurance Department Influence of REM on sleep apnea syndrome, the
Riyadh Armed Forces Hospital function of REM across age and sex. 5) Neuronal
PO Box 7897 excitability and behavioral changes by REM sleep
Riyadh 11159 deprivation. 6) Reciprocal iteraction of NREM and
Kingdom of Saudi Arabia REM Sleep and its homeostatic regulation. 7) The
last topic hypothesises a neuronal dynamic in a
neuronal network model, where the author suggests
that REM Sleep is responsible for “dreaming” which
might contribute to the process of consolidation and
Rapid eye movement (REM) sleep maintenance of memories.
The book helps the understanding of the
BN Mallick, S Inoue. 421pp. Publisher: Marcel complicated subject like REM, it is an asset for the
Dekker Inc, USA. Date of Publication: 1999. basic neuroscience researchers and professionals
ISBN: 0-8247-0322-7 dealing with sleep laboratory and sleep disorders. On
the contrary, it does not throw much light on the
clinical aspects of REM. However, the writing style,
This is a multi author book covering extensively the mode of presentation and literature search are
phylogency, ontogenesis, physiology, pharmacology, excellent. Therefore, the book should be available in
molecular mechanisms and regulation of REM Sleep all medical libraries.
animals and humans.
In the beginning it describes the experiments Mohammad M. Kabiraj
related to the eyelid condition at birth with regard to Neurosciences Department
brain maturation and REM Sleep components: Riyadh Armed Forces Hospital
muscle atonia, Ponto Geniculo Occipital spike, EEG PO Box 7897
disynchronization. Later on, it explains: 1) Riyadh 11159
experimental evidence about the role of brain-stem Kingdom of Saudi Arabia

1096 Saudi Medical Journal 2000; Vol. 21 (11)

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