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Introduction Bacterial infections in CF patients are common and start early in life. The prognosis of the disease is substantially dependent on chronic respiratory infection and inflammation. Pseudomonas aeruginosa (PA) infection or chronic colonization have been established to cause a chronic decline in pulmonary function (PFT), and/or increase CF mortality. Objectives To obtain the prevalence of all bacterial pathogens in our CF patients and assess their evolution over time. Method A retrospective review of 327 patients with confirmed CF of all age groups, who had respiratory culture samples at the first visit and on a regular follow-up between January 1, 1990 and December 2018, was conducted. Results A total of 327 patients had a respiratory culture obtained at presentation. Two hundred and sixteen (66%) of 327 patients are alive, while 111 (34%) have died. Respiratory cultures were taken from nasopharyngeal aspiration (NPA) in 199 patients (61%), tracheal aspirate in 9 (3%), bronchoalveolar lavage (BAL)in one (0.29%), and in 124 patients (38%), sputum was induced. The eastern province contributed to the highest number of patients (122, 37.7%). There is a persistent increase in the prevalence of the common bacteria over the follow-up period of 7 years, namely Hemophilus influenzae (H. influenzae), Staphylococcus aureus (S. aureus), and all Pseudomonas (P. aeruginosa) culture types. Comparing cultures from the first and last follow-up visits, there was an increase in the prevalence of all (P. aeruginosa) cultures from 120 (34%) to 137 (53%), and a decrease in the prevalence of (S. aureus) and (H. influenzae) during the same follow-up period. Conclusion There is a progressive increase in the number of patients with the most pathogenic types of bacteria because of the advanced age at presentation. As more adult patients are enrolled, there is a need for improved awareness regarding the early eradication of pathogenic bacteria to prevent progressive pulmonary damage.

Diabetic neuropathy is a long-term consequence of diabetes that can cause significant morbidity and a decline in quality of life in many individuals. Low vitamin D levels, in addition to causing rickets in infants and chondrosteoma in adults, may have a role in the development of DM and its underlying disorders, according to a growing body of evidence. Vitamin D deficiency has been linked to type 1 or type 2 diabetes, as well as the microvascular and macrovascular problems that come with it. Vitamin D insufficiency has been linked to diabetic peripheral neuropathy (DPN) as an independent risk factor. Vitamin D, both topical and oral, has been shown to considerably improve DPN symptoms and pain.

Round pneumonia is a disease that occurs mainly in young children who have a clinical presentation of lower respiratory tract infection together with a chest radiograph showing round opacity. The mean age of patients with round pneumonia is five 5 years; it is uncommonly seen after the age of 8, as the collateral airways tend to be well developed by this age. In our case, we evaluated a 10-year-old girl who presented with fever, cough, and rounded densities on her chest x-ray. The rapid urinary antigen test for Streptococcus pneumoniae was positive, and serum anti-Mycoplasma pneumoniae antibodies were non-reactive. The diagnosis of round pneumonia was confirmed when the patient showed a complete recovery both clinically and radiographically after a course of penicillin and gentamicin.

Background COVID-19 is a worldwide pandemic and has placed significant demand for acute and critical care services on hospitals in many countries. Objectives To determine the predictors of severe COVID-19 disease requiring admission to an ICU by comparing patients who were ICU admitted to non-ICU groups. Methods A cohort study was conducted for the laboratory-confirmed COVID-19 patients who were admitted to six Saudi Ministry of Health’s hospitals in Alahsa, between March 1, 2020, and July 30, 2020, by reviewing patient’s medical records retrospectively. Results This cohort included 1014 patients with an overall mean age of 47.2 ± 19.3 years and 582 (57%) were males. A total of 205 (20%) of the hospitalized patients were admitted to the ICU. Hypertension, diabetes and obesity were the most common comorbidities in all study patients (27.2, 19.9, and 9%, respectively). The most prevalent symptoms were cough (47.7%), shortness of breath (35.7%) and fever (34.3%). Compared with non-ICU group, ICU patients had older age (p ≤ 0.0005) and comprised a higher proportion of the current smokers and had higher respiratory rates (p ≤ 0.0005), and more percentage of body temperatures in the range of 37.3–38.0 °C (p ≥ 0.0005); and had more comorbidities including diabetes (p ≤ 0.0005), hypertension (p ≥ 0.0005), obesity (p = 0.048), and sickle cell disease (p = 0.039). There were significant differences between the non-ICU and ICU groups for fever, shortness of breath, cough, fatigue, vomiting, dizziness; elevated white blood cells, neutrophils, alanine aminotransferase and alkaline aminotransferase, lactate dehydrogenase, and ferritin, and decreased hemoglobin; and proportion of abnormal bilateral chest CT images (p p p ≤ 0.0005). Conclusion Identifying key clinical characteristics of COVID-19 that predict ICU admission and high mortality can be useful for frontline healthcare providers in making the right clinical decision under time-sensitive and resource-constricted environment.

Background Snakebite is a neglected tropical disease that causes high global rates of mortality and morbidity. Although snakebite can cause a variety of pathologies in victims, haemotoxic effects are particularly common and are typically characterised by haemorrhage and/or venom-induced consumption coagulopathy. Antivenoms are the mainstay therapeutic for treating the toxic effects of snakebite, but despite saving thousands of lives annually, these therapies are associated with limited cross-snake species efficacy due to venom variation, which ultimately restricts their therapeutic utility to particular geographical regions. Methodology/Principal findings In this study we explored the feasibility of generating globally effective pathology-specific antivenoms to counteract the haemotoxic signs of snakebite envenoming. Two different immunogen mixtures, consisting of seven and twelve haemotoxic venoms sourced from geographically diverse and/or medically important snakes, were used to raise ovine polyclonal antibodies, prior to characterisation of their immunological binding characteristics and in vitro neutralisation profiles against each of the venoms. Despite variability of the immunogen mixtures, both experimental antivenoms exhibited broadly comparable in vitro venom binding and neutralisation profiles against the individual venom immunogens in immunological and functional assays. However, in vivo assessments using a murine preclinical model of antivenom efficacy revealed substantial differences in venom neutralisation. The experimental antivenom generated from the seven venom immunogen mixture outperformed the comparator, by providing protective effects against venom lethality caused by seven of the eight geographically diverse venoms tested, including three distinct venoms that were not used as immunogens to generate this antivenom. These findings suggest that a core set of venom immunogens may be sufficient to stimulate antibodies capable of broadly neutralising a geographically diverse array of haemotoxic snake venoms, and that adding additional venom immunogens may impact negatively on the dose efficacy of the resulting antivenom. Conclusions/Significance Although selection of appropriate immunogens that encapsulate venom toxin diversity without diluting antivenom potency remains challenging and further optimisation is required, the findings from this pilot study suggest that the generation of pathology-specific antivenoms with global utility is likely to feasible, thereby highlighting their promise as future modular treatments for the world’s tropical snakebite victims., Author summary Snakebite is a major public health concern that causes extensive death and disability in the tropical world. Variation in venom composition causes major challenges for snakebite therapy by typically restricting antivenom efficacy to only the few snake species that each product was designed against, meaning that many geographically restricted therapeutics are manufactured for different parts of the world. In this study, we explored the feasibility of generating a global pathology-specific antivenom by using two different sets of haemotoxic venoms as immunogens, one including seven venoms and the other twelve venoms, to generate ovine polyclonal antibodies. Our in vitro immunological cross-reactivity and venom functional-neutralisation findings demonstrated broadly comparable venom recognition and inhibition against the various venom immunogens, irrespective of whether they were included in the immunising mixture. However, assessments of murine in vivo protection against venom-induced lethality revealed that the antivenom generated with fewer immunogens outperformed the comparator, and provided broader preclinical efficacy, even against some venoms not used to raise the antibodies. These findings suggest that careful selection of venoms used as immunogens is crucial for maintaining antivenom potency, and that a small subset of venoms may be capable of generating an antivenom with potential global efficacy against a specific pathology commonly observed after snakebite.

Highlights • Collision tumour is the concrescence of two neighbouring independent neoplasm occurring in the same site. • Collision tumours are rare and are reported in various organs. • Collision tumours in breast are reported in various combinations. • The treatment of these tumours is not tailored and prognosis depends on the histologic type and pathologic stage of the most aggressive component., Introduction Breast cancer is the most common diagnosed cancer among women worldwide. Invasive ductal carcinoma (IDC) is the most common type, on the other hand, squamous cell carcinoma of the skin (SCC) overlying the breast is a rare tumor. The co-presence of two tumor types in one organ is even a rarer entity, termed as collision tumor. Only 3 known cases of collision tumor with breast invasive ductal and skin squamous carcinoma were reported in the literature. Case presentation An otherwise medically free 91-year-old, postmenopausal, female presented with left breast fungating mass for four months. Pre-operative core tissue biopsy and incisional skin biopsy revealed two distinct tumor subtypes of invasive ductal carcinoma, positive for progesterone, estrogen receptors and negative for human epidermal growth factor receptor 2, as well as skin squamous cell carcinoma, and axillary lymph node metastasis. Patient underwent left breast modified radical mastectomy and split skin grafting for wound closure. The final histopathology was consistent with grade 2 IDC. The nipple and areola complex were involved by moderately differentiated squamous cell carcinoma. Currently patient on adjuvant hormonal treatment. Follow up showed no local recurrence or distal metastasis. Conclusion Collision tumors of the breast with IDC and SCC of the overlying skin is very rare. The surgeon has to be aware of of such entity as the proper peri-operative management should be tailored to target the most aggressive histologic subtype.

Objectives KRAS, NRAS, and BRAF mutations are commonly present in colorectal cancer (CRC). We estimated the frequency of KRAS, NRAS, and BRAF mutations and assessed their impact on survival and other clinical variables among Saudi patients. Design Retrospective cohort study design. Settings Oncology department of a tertiary hospital in Riyadh, Saudi Arabia. We gathered information from 2016 to 2018. Participants Cohort of 248 CRC patients to assess the demographic data, pathological tumour features, response to treatment modalities, disease progression, and metastasis. Statistical analysis used Correlation analysis using the chi-square test. Survival analysis using a Kaplan Meier method. Cox regression analysis to calculate the hazard ratios. Results Demographic data revealed that 84% of patients were diagnosed with CRC above the age of 50 years. Only 27% of patients presented with distant metastasis. KRAS mutations were the most prevalent (49.6%), followed by NRAS mutations (2%) and BRAF mutations (0.4%). Wild type tumours were found among 44.4% of patients. KRAS mutation showed no significant correlation with the site, type, pathological grade, and stage of the tumour. The mean survival time was shorter among patients with KRAS mutations than among patients with wild type KRAS tumours (54.46 vs. 58.02 months). Adjusted analysis showed that the survival time was significantly affected by patients’ age at diagnosis (P = 0.04). Male patients had an increased risk of mortality by 77% (hazard ratio: 1.77). Conclusions Saudi CRC patients had a high frequency of KRAS mutations and a low frequency of BRAF mutations. The KRAS mutation status did not affect the patients’ survival.

Hypoplastic left heart syndrome (HLHS) is a fatal congenital complex heart defect where the heart's left side is critically undeveloped. However, its pathogenesis remains unknown. We report a unique case of HLHS because of the rare combination of two abnormalities in the cell lines: partial monosomy X (Turner syndrome) and partial trisomy 14 (14q11.2 microduplication syndrome).

Cutaneous adenosquamous carcinoma is a mixed, squamous and glandular, rare malignant tumor of the skin characterized by a mixed, squamous, and glandular differentiation. Few cases of this tumor have been so far reported, and even fewer have been thoroughly studied by immunohistochemistry. We report here an exceptional case of cutaneous adenosquamous carcinoma which showed immunohistochemically features of intestinal differentiation, namely because of the expression of keratin 20 and CDX2, a marker of gastrointestinal tumors.

Objective: To investigate the ocular tear film in patients with thyroid disorders using various tests. Methods: The study involved the assessment of the ocular tear film in 20 patients with thyroid disorders (6 men and 14 women) aged 18-43 years (mean±standard deviation=34.3±3.2 years). An age-matched control group consisting of 20 subjects (8 males and 12 females) ranging in age from 18 to 43 years (31.3±2.9 years) was also examined under similar conditions. All patients completed the Ocular Surface Disease Index questionnaire, followed by the tear ferning test within the right eye. A phenol red thread test was carried out 10 mins later followed by the fluorescein tear break-up test with a 10-min gap between the tests being implemented. Results: The median score for the Ocular Surface Disease Index (P

Background: Coinfection with bacteria, fungi, and respiratory viruses in SARS-CoV-2 is of particular importance due to the possibility of increased morbidity and mortality. In this meta-analysis, we calculated the prevalence of such coinfections. Methods: Electronic databases were searched from 1 December 2019 to 31 March 2021. Effect sizes of prevalence were pooled with 95% confidence intervals (CIs). To minimize heterogeneity, we performed sub-group analyses. Results: Of the 6189 papers that were identified, 72 articles were included in the systematic review (40 case series and 32 cohort studies) and 68 articles (38 case series and 30 cohort studies) were included in the meta-analysis. Of the 31,953 SARS-CoV-2 patients included in the meta-analysis, the overall pooled proportion who had a laboratory-confirmed bacterial infection was 15.9% (95% CI 13.6–18.2, n = 1940, 49 studies, I2 = 99%, p < 0.00001), while 3.7% (95% CI 2.6–4.8, n = 177, 16 studies, I2 = 93%, p < 0.00001) had fungal infections and 6.6% (95% CI 5.5–7.6, n = 737, 44 studies, I2 = 96%, p < 0.00001) had other respiratory viruses. SARS-CoV-2 patients in the ICU had higher co-infections compared to ICU and non-ICU patients as follows: bacterial (22.2%, 95% CI 16.1–28.4, I2 = 88% versus 14.8%, 95% CI 12.4–17.3, I2 = 99%), and fungal (9.6%, 95% CI 6.8–12.4, I2 = 74% versus 2.7%, 95% CI 0.0–3.8, I2 = 95%); however, there was an identical other respiratory viral co-infection proportion between all SARS-CoV-2 patients [(ICU and non-ICU) and the ICU only] (6.6%, 95% CI 0.0–11.3, I2 = 58% versus 6.6%, 95% CI 5.5–7.7, I2 = 96%). Funnel plots for possible publication bias for the pooled effect sizes of the prevalence of coinfections was asymmetrical on visual inspection, and Egger’s tests confirmed asymmetry (p values < 0.05). Conclusion: Bacterial co-infection is relatively high in hospitalized patients with SARS-CoV-2, with little evidence of S. aureus playing a major role. Knowledge of the prevalence and type of co-infections in SARS-CoV-2 patients may have diagnostic and management implications.

Coincidental findings of hypertrichosis in patients on minoxidil led to the development of a topical minoxidil formulation which has been approved by the Food and Drug Administration for the treatment of female pattern hair loss, the most common cause for hair loss in women. The most common side effect of topical minoxidil is irritant contact dermatitis with the typical symptoms of itching and scaling. Most commonly, these symptoms are a result of an allergic reaction to propylene glycol, or less commonly, to minoxidil itself. We present a case of a 27-year-old woman who developed facial swelling following allergic contact dermatitis to minoxidil 5% foam.

Background The first case of COVID-19 infection in Saudi Arabia was reported in Qatif on March 2nd, 2020. Here, we describe the clinical characteristics of the initial COVID-19 patients in that area. Methods This is an observational study describing the clinical presentation, radiographic and laboratory data of COVID-19 cases. Results From March 1st, 2020 to April 5th, 2020 we identified a total of 82 adult COVID-19 patients. The median age of the patients was 50 years, with a range of 30 to 60 years and most of patients were female 54 (65.9%). Of all the patients, 29 (35.4%) were contacts and 43 (52.4%) were returning travelers, mainly from Iraq (65% of the total returning travelers). Comorbidities were present in 50% of patients, G6PD deficiency in 33%, hypertension in 27%, and diabetes mellitus in 26%. Chest radiographs were abnormal in 46% of symptomatic and 15.5% of asymptomatic patients (P value = 0.0035). Of all patients, 4 (4.87%) required intensive care admission. There was no significant difference in time to negative RT-PCR with mean days to negativity of 13.6 and 16.9 for asymptomatic and symptomatic group, respectively (P value = 0.42). Conclusions In the initial Epicenter of the COVID-19 in Saudi Arabia, the majority of the patients were asymptomatic and were returning travelers. Comorbidities were present in nearly half of the patients.

Background The enhanced knowledge of cancer biology has led to considerable advancement in systemic therapy for advanced breast cancer. Recently, studies showed that cyclin-dependent kinase (CDK) 4/6 inhibitor, when added to endocrine therapy, had improved the outcomes of patients with advanced ER-positive HER2-negative breast cancer. However, the disease often progresses following a period of treatment response. In a subset of patients, disease progression may occur at limited sites, i.e., oligoprogressive disease (OPD). In the past few years, stereotactic radiotherapy (SRT) has emerged as a safe and effective treatment for advanced cancer when delivered to limited metastatic sites. Hence, it is worth investigating the role of SRT in the setting of oligoprogressive breast cancer. Method AVATAR is a multicentre phase II registry trial of SRT with endocrine therapy and CDK 4/6 inhibitor for the management of advanced ER-positive HER2-negative breast cancer. The study aims to enrol 32 patients with OPD limited to 5 lesions. The primary endpoint of the study is time to change systemic therapy measured from the commencement of SRT to change in systemic therapy. Secondary objectives include overall survival, progression free survival and treatment related toxicity. The exploratory objective is to describe the time to change in systemic therapy by the site (bone only vs. non-bone lesions) and number (1 vs. > 1) of OPD. Discussion This study aims to explore the effect of SRT in maximising the benefit of systemic therapy in patients with oligoprogressive ER-positive HER2-negative breast cancer. This approach might help reduce the burden of disease and improve the life quality in these patients. Trial registration ACTRN, ACTRN12620001212943. Date of registration 16 November 2020- Retrospectively registered.

BACKGROUND: Patients' adherence to insulin therapy is crucial to achieve good glycemic control. The present study was conducted to determine psychological insulin resistance (PIR) and the effect of doctor–patient relationship on PIR among type 2 diabetes patients attending primary health-care centers of Al-Ahsa region in Saudi Arabia. MATERIALS AND METHODS: This was a cross-sectional survey of all type 2 diabetic patients attending the primary healthcare centers of Al-Ahsa. A multistage sampling technique was used. The calculated sample size was 396. Two validated structured questionnaires were used to collect information. The degree of agreement to insulin therapy was done on the Likert 5° scale. SPSS was used for data entry and analysis. Chi-square test was used to test for stistical significane at P=0.05. RESULTS: Out of 396 patients who were given the questionnaires, 366 filled the questionnaires yielding 92% response rate. Fifty-one percent were male and about 85% were older than 35 years. Willingness to use insulin was significantly associated with age (P = 0.013) and duration of diabetes (P=0.0001). The strongest negative attitudes toward insulin therapy arose from participants having heard about a bad experience with insulin (59.34%, P < 0.05) and the fear of possible dependence (54.20%, P < 0.05). Participants who responded of “mostly appropriate” and “very appropriate” to questions on patient–doctor relationship were significantly more willing to take insulin (64.9% vs 24.5%, and 70.3% vs 22.9%, P = 0.0001). CONCLUSION: The study showed that one-third of the patients with type 2 diabetes had PIR. Since the behavior of doctor plays an important role in reducing PIR, there is a need for greater emphasis on the importance of good doctor–patient relationship and the establishment of a therapeutic education program.

Patient: Female, 1-day-old Final Diagnosis: Right heterotaxy syndrome with complex heart disease • annular pancreas • radius aplasia • partial syndactyly of the thumb and index finger Symptoms: Feeding problems • tachypnea Medication:— Clinical Procedure: — Specialty: Cardiac Surgery • Cardiology • Orthopedics and Traumatology • Pediatrics and Neonatology • Radiology • Surgery Objective: Unusual clinical course Background: Heterotaxy is a syndrome of abnormal arrangement of the internal thoracic-abdominal structures across the left-right axis of the body. It is a primary disorder with 2 main settings – bilateral left sidedness (polysplenia syndrome) or right sidedness (asplenia syndrome) – although some overlapping or uncertainties may occur. Patients with right heterotaxy typically present with asplenia, complex heart disease, and other thoracoabdominal organ situs abnormalities. Case Report: We present a unique case of congenital asplenia syndrome with complex heart disease, annular pancreas, and other extra-heterotaxic anomalies (e.g., musculoskeletal) in the form of a radius aplasia and partial syndactyly of the thumb and index finger of the left hand. These associated anomalies have not been reported before. Conclusions: This case shows the need for paying increased attention to the implications of other extracardiac anomalies that can be associated with heterotaxy syndrome.

In general, the pharmacy is the last department to be visited for outpatient in the hospitals, and therefore its efficiency is directly linked to patients’ satisfactions and more important the reputation of the entire hospital. The study here is based on Medical City that is located in Riyadh, Saudi Arabia. It serves patients from all over Saudi Arabia. The aim of the study is to improve the efficiency of waiting time of outpatient pharmacy based on the problems that have been observed using management quality tools and techniques. After analyzing the data for the current situation, then trying to propose changes for improvement in system efficiency. Results showed that by proposing automated waiting system with automated prescriptions, patient categorization, reduce the unclaimed prescriptions, and modify the pharmacy's layout. All of that will help in reducing the waiting time as well as increasing the patients' satisfaction which will lead to improve the pharmacy's efficiency. From reviewing the literature, it concludes that applying management quality tools and techniques will tremendously improve the quality of services in healthcare systems. The statistical analysis presented shows some outliers points when serving patients which were studied and recommendations were proposed. This is new approach to enhance the quality of healthcare management and leads to increase in the efficiency of the outpatient pharmacies., Graphical abstract Customers satisfaction in the outpatient pharmacy using management quality tools (before and after).Image, graphical abstract

Porokeratotic eccrine ostial and dermal duct nevus (PEODDN) is a rare dermatosis initially described as 'comedo nevus' and renamed 'PEODDN'; it has also been referred to as linear eccrine nevus with comedones, porokeratotic eccrine ostial and hair follicle nevus, and porokeratotic adnexal ostial nevus. PEODDN is usually present at birth or develops early in life. Rarely, PEODDN can develop in adults. The treatment of this puzzling condition is not standardized. We report herein a new case of adultonset PEODDN with dermatoscopic images. Our patient responded favorably to topical tazarotene.

Background: Palmoplantar psoriasis (PPP) is a chronic, immune-mediated, inflammatory disorder affecting the palms and soles. Despite marked improvement in patient outcomes with use of biologic therapies, PPP remains hard to treat as the efficacy of systemic agents does not fully carry over to PPP trials. Methods: The study was approved by the institutional review board of Tufts Medical Center. It is a retrospective chart review of patients seen in Tufts Medical Center’s dermatology outpatient clinic who met the criteria of being diagnosed with PPP and received an anti-interleukin 17 A (IL-17A) concurrently with apremilast for a period of no less than 12 weeks. Four patients who met the criteria were included in the study, and descriptive analysis was performed due to the small sample size. Results: All 4 patients analyzed showed improvement in Palmoplantar Physician Global Assessment (PPPGA) while on combination apremilast and anti-IL17A therapy. Prior to anti-IL17A therapy, the first 3 patients had baseline PPPGAs of mild to severe. They then had PPPGAs of moderate while on anti-IL17A therapy and PPPGAs of clear/almost clear while on the combination of anti-IL17A therapy and apremilast. Patient 4 had a PPPGA of almost clear while on adalimumab, methotrexate, and acitretin and a PPPGA of clear after treatment with ixekizumab, apremilast, and methotrexate. Minimal side effects were reported on combination treatment. Conclusion: All 4 patients who were treated with combination anti-IL17A and apremilast achieved a PPPGA of clear or almost clear. Although the sample size is small, these encouraging results merit further investigation into combination therapy in the treatment of recalcitrant PPP.

Evidence in the literature indicates the significant association between temporomandibular joint disorders and orthodontic treatment. As a result of the epidemiological investigations that indicated the high prevalence of temporomandibular disorders among patients with malocclusions, it has been suggested that there might be a cause-and-effect correlation between both of these conditions. Evidence in the literature is inconsistent regarding the association between temporomandibular joint disorders and malocclusion, and orthodontic treatment. In the present literature review, we have discussed the different aspects of temporomandibular disorders and malocclusion and their relation to orthodontic treatment approaches. Among the different studies in the literature, solid evidence indicates a significant association between temporomandibular joint disorders and malocclusion, and accordingly, research aimed to study the impact of orthodontic treatment on curing and preventing the development of these disorders. The current evidence seems to be neutral regarding the impact of orthodontic treatment approaches on curing and preventing temporomandibular disorders. Therefore, it has been suggested that further investigations are still needed for adequate further evaluation. Finally, as we previously discussed, the attending orthodontist should adequately take care of certain parameters in these patients, including centric relation, maximal intercuspal position, simultaneous contact points, and evaluating the direction of forces applied on the relevant teeth.

Introduction and Background: Acne is a very common dermatological condition found among the adolescent population in Saudi Arabia. Many patients with acne try various forms of self-medication, over the counter medicines (OTC), and prescription medicines for the same. Materials and Methods: This was a cross-sectional study among university students in the Kingdom of Saudi Arabia (KSA). A validated questionnaire was distributed to a convenience sample of university students to evaluate their knowledge and attitudes towards OTC (mainly) as well as prescription medicine for acne. Chi-square and multiple logistic regression tests were used for comparisons between groups. Results: Four hundred and twenty valid, completed questionnaires were obtained. A total of 220 (52.4%) used some type of OTC medications at least once, where as 108 (25.7%) used prescription medicines and 92 (21.9%) used both. The most common OTC medications used were cleansers by 250 participants (41.9%). Among prescription medicines, the most common were topical and oral antibiotics (11.4%). Bivariate and multivariate analysis showed that females are statistically more likely to use OTC medicines compared to males (Odds ratio: 1.7). Conclusion: The use of self-medications and OTC medications is common among university students in KSA. The most common OTC medicine used for acne was cleanser.

Ovarian hyper stimulation syndrome (OHSS) and venous thromboembolic are known complications of ovarian stimulation therapy. Pulmonary embolism accounts for 7.9% of the episodes of thromboembolic diseases reported in OHSS. We describe a case of 33-year-old Bahraini woman who presented to the Bahrain Defense Force Hospital (Banoon Center) with a history of 13 years primary infertility, and previous unsuccessful intrauterine insemination. Through the In-vitro fertilization (IVF) treatment cycle she had Ovarian hyperstimulation which was further complicated with ovarian bleeding and pulmonary embolism.Our case addresses this rare complication and its management challenges related to the event of thromboembolic disease with anticoagulants in the presence of bleeding. Keywords: OHSS, Pulmonary embolism

Background Air pollution is one of the top 10 global health risk factors and has been associated with premature mortality, cardiovascular, cerebrovascular, respiratory, and metabolic disease. Currently, there is a lack of health assessments on the public health impacts of air pollution in the Kingdom of Saudi Arabia. Aim This study aims to assess the ambient particulate matter burden of disease in the Kingdom of Saudi Arabia. Methods A comparative risk assessment (CRA) using the 2017 Global Burden of Disease was performed to estimate ambient particulate matter exposure, mortality, and lost years of a healthy life. Saudi Arabia population-weighted mean concentrations of particle mass with an aerodynamic diameter less than 2·5 μm (PM2.5), at an approximate 11 km × 11 km resolution was estimated using satellite-based estimates, chemical transport models, and ground-level measurements. The CRA for PM2.5 was based on relative risks originated from epidemiological studies using integrated exposure-response functions for ischemic heart disease, cerebrovascular disease, chronic obstructive pulmonary disease, lung cancer, lower respiratory infections, and type 2 diabetes. Mortality, years of life lost (YLL), years lived with disability (YLD) and disability-adjusted life years (DALYs) attributable to PM2.5 were estimated at the national level for all ages and both sexes from 1990 to 2017. Results In 2017, the annual exposure to ambient particulate matter in the population-weighted mean PM2.5 in Saudi Arabia was 87.9 μg/m3 (95% UI 29.6–197.9). The PM2.5 population-weighted mean has increased by 24% since 1990. Annual deaths attributable to PM2.5 were estimated at 8536 (95% UI 6046–11,080), representing 9% of the total annual deaths in Saudi Arabia. In 2017, 315,200 (95% UI 231,608–401,926) DALYs were attributable to PM2.5. Males contributed to 67% (209,822 (95% UI 151,322–277,503)) of DALYs, and females contributed to 33% (105,378 (95% UI 76,014–135,269) of DALYs. Ischemic heart disease represented 44% of the PM2.5 attributable DALYs, followed by type 2 diabetes (20%), lower respiratory infections (13%), stroke (11%), COPD (10%), and tracheal, bronchus, and lung cancer (3%). In 2017, 240,966 (95% UI 168,833–319,178) years of life lost (YLL) and 74,234 (95% UI 50,229–100,410) years lived with disability (YLD) were attributed to PM2.5. Conclusion Ambient particulate matter is the fifth health risk factor in Saudi Arabia, contributing 9% of total mortality. Over the past 27 years, estimated exposure levels of PM2.5 in Saudi Arabia have been above WHO's air quality guidelines. Although since 2011 mortality and DALY rates attributable to PM2.5 have decreased, air pollution concentrations continue to increase. National and local authorities in Saudi Arabia should consider policies to reduce industrial and traffic-related air pollution in combination with the strengthening of current investments and improvements in health care and prevention services.

Patient: Male, 24-year-old Final Diagnosis: Colon cancer Symptoms: — Medication: — Clinical Procedure: Laparoscopic right hemi-colectomy Specialty: Surgery Objective: Rare co-existance of disease or pathology Background: Colonic varices are rare entity that often results from portal vein hypertension and hepatic cirrhosis. In the absence of underlying pathology, they are termed “idiopathic colonic varices”. They are usually an incidental finding; however, they can present with varying degrees of lower gastrointestinal bleeding. There is only one reported case in the literature of colonic varices with a concomitant colonic tumor; our patient is the second one with such a presentation. We report a case of this rare combination with the outcomes of the elected surgical management and review the literature. Case Report: A 24-year-old male was referred to our hospital with a 1-month history of colicky abdominal pain. His family history is remarkable of 2 relatives with colonic varices. A computed tomography scan of the abdomen and pelvis showed a hepatic flexure colonic mass. Colonoscopy revealed pancolonic varices. Biopsy from the lesion revealed adenocarcinoma. Options were discussed with the patient to undergo only a right hemicolectomy for his cancer or a total colectomy to include the colonic segment involved with varices, and he elected the first option, with no complications upon 1 year follow up. Conclusions: Idiopathic pan-colonic varices are rare pathology. Their presence with colonic tumor presents a dilemma as to whether a subtotal/total colectomy is needed on the premise that a limited resection may carry the risk of subsequent bleeding. In the literature, the only similar case to ours had brisk postoperative bleeding, while ours did not experience such a complication.

Background: Hidradenitis suppurativa (HS) is a chronic immune-mediated skin disorder characterized by inflamed, painful abscesses most commonly located in the intertriginous regions that ma...

Illness perception questionnaires for various medical conditions have become more useful in recent years. However, very few have addressed this issue for Type 2 diabetes in Saudi Arabia. A self-administered questionnaire was distributed to Type 2 diabetic patients attendees of primary health care centers and Al Kharj Military Industries Corporation Hospital in Al Kharj, Saudi Arabia, from November 24th 2016 to April 24th, 2017. Overall, 383 of the 500 distributed questionnaires were returned, and 187 were males (48.8). Most participants understood that what led to diabetes was hereditary, including diet or eating habits. The Cronbach’s alpha value for identity, timeline (cyclical), and emotional factors were relatively high, showing that these scales had a strong level of internal consistency; it also showed that the timeline (acute/chronic) and treatment control scales were low, thus showing internal consistency of these scales. Cronbach’s value of coherence and consequences scales were low. Saudis with type 2 diabetes mellitus had appropriate knowledge of their disease. They agreed that diabetes was likely to be permanent and would have major consequences on their lives.

Asymmetric allele content in the transcriptome can be indicative of functional and selective features of the underlying genetic variants. Yet, imbalanced alleles, especially from diploid genome regions, are poorly explored in cancer. Here we systematically quantify and integrate the variant allele fraction from corresponding RNA and DNA sequence data from patients with breast cancer acquired through The Cancer Genome Atlas (TCGA). We test for correlation between allele prevalence and functionality in known cancer-implicated genes from the Cancer Gene Census (CGC). We document significant allele-preferential expression of functional variants in CGC genes and across the entire dataset. Notably, we find frequent allele-specific overexpression of variants in tumor-suppressor genes. We also report a list of over-expressed variants from non-CGC genes. Overall, our analysis presents an integrated set of features of somatic allele expression and points to the vast information content of the asymmetric alleles in the cancer transcriptome.

Background We describe an original method to treat tandem lesions of the internal carotid artery (ICA) and the common carotid artery (CCA). In this manuscript, we describe a “double eversion carotid endarterectomy” technique (DECE) and report our results. Methods A retrospective review in the medical records of patients that underwent DECE over a 15-year period was performed. Patient characteristics, operative details, preoperative imaging and lesion characteristics, perioperative outcomes, and follow-up data were documented and analyzed. Patients with ostial and mediastinal lesions were excluded from our study. Operations were divided into 2 categories: “planned,” when the lesions were identified during preoperative imaging, and “necessary” when performed for secondary defects of the CCA detected intraoperatively. Results Between 1996 and 2011, a total of 15 patients with 17 tandem lesions underwent DECE. The mean age was 74.3 years. The mean degree of stenosis was 76.3% for the ICA and 61.5% for the CCA, with the majority of the lesions being asymptomatic (12/17). All procedures were performed under general anesthesia, and in 1 case an intraluminal shunt was used. The mean operative time was 83.4 min, with a mean primary clamping time of 29.2 min. In cases of secondary lesions, the mean reclamping time was 16.2 min. There was no mortality or major neurologic event within 30 days postoperatively. Postoperative complications included 2 major cardiac events and 1 case of cranial nerve XII injury that resolved during follow-up. There were no deaths or neurologic events during a mean follow-up of 27.5 months (range: 1–188 months). One patient required a reintervention after 5 years because of restenosis of the ICA. Conclusion DECE is an alternative surgical technique for select tandem, nonostial carotid lesions. In addition, DECE can be performed as a “bailout” procedure for secondary CCA defects during conventional eversion carotid endarterectomy.

A 60-year-old male patient presented with a false aneurysm of the common iliac artery and methicillin-resistant Staphylococcus aureus septicemia complicating previously placed kissing covered stents of the aortic bifurcation. We removed the prosthetic material and repaired the aortic bifurcation with a composite saphenous vein panel graft. To our knowledge, this technique is presented for the first time in the literature.

The prevalence of iliac artery aneurysms is extremely rare in children. The most common etiologies for developing an aneurysm in children are infections, inflammatory diseases, and trauma. An idiopathic or congenital etiology is the least common cause in the pediatric population. We report a case of a 9-year-old girl with no previous history of trauma, intervention, or family history of vascular diseases who presented with a sudden severe right lower quadrant pain suggesting appendicitis. Upon examination, a large tender pulsatile mass was felt in the right lower quadrant. Ultrasound and computed tomography scans revealed a large right common iliac aneurysm. The aneurysm was noted to have a high risk of rupture due to the sudden symptomatic presentation and its large size. Therefore, the patient underwent an urgent operation, during which an aneurysmal repair was performed with an interposition graft. Postoperative ultrasound imaging showed a patent graft and no residual aneurysm. The patient has been followed up for two years, and no complications were found.

Background The aim of this retrospective study was to examine the impact of graft oversizing on gutter area and stent compression in chimney graft (CG) for complex abdominal aortic aneurysm (CAAA) repair. The influence of stent-graft oversizing on type Ia endoleaks and bridging stent occlusion rates was also examined. Methods Preoperative and postoperative computed tomographic angiography scans of patients requiring CGs for CAAA between June 2009 and April 2013 in our institution were analyzed. Two groups were identified: proximal oversizing of the stent-graft component 25% (group 2). Relative gutter areas were calculated and compared between both groups. Incidence of target vessel stent compression, target vessel occlusions, and type Ia endoleaks was also analyzed. Results Of 39 patients treated with CG during the study period, 23 fulfilled the selection criteria for analysis. Group 1 included 10 patients and group 2 included 13 patients (mean oversizing: 18.4 ± 4.9% and 34.5 ± 6% respectively). Relative gutter areas were significantly higher in group 1 when compared with group 2 (6.1 ± 2.1% vs. 4.2 ± 3.2%, P = 0.03). No stent compression and no target vessel occlusion occurred in either groups. There was no statistical difference in type Ia endoleak in both groups (group 1 n = 0, group 2 n = 2; P = 0.48). Conclusions In our study, a >25% stent-graft oversizing reduced the gutter area without modifying the bridging stent patency. However, no benefit in terms of type Ia endoleak was observed.

Aim of the work: diabetic foot disease(DFD) is diabetic patient's foot affection by ulcers which are accompanied by peripheral vascular disease and/or diabetic neuropathy of the lower limb. Prevalence of diabetic ulcer is ranging from 2%-10%. High rate of lower limb amputation in DFD (More than 15%) and survival rate for undertaken amputation patient are short. Ninety diabetic amputations are performed monthly in Saudi Arabia capital of Riyadh. Identification of DFD and diabetic patient's awareness of DFD and how to take care of it will reduce the incidence of more complications like amputation. This study aimed to evaluate knowledge, education, attitude and practice with diabetic foot among diabetic patients all over Saudi Arabia. Patients and Method: cross-sectional study directed among the diabetic clinic visitors in Primary Health Care Centers (PHCs s). Selection of 55 PHCs was done by random sampling. Ten diabetic patients were randomly selected from each PHCs and collecting of data was done by interviews. Research questionnaire contains three parts; first part is asking about demographic data; second part is about data that are focusing on diabetes and its related questions and last part is the main part which asking about diabetic foot. Results: 519 diabetic patients were participated in this study. Only 180 participants were complaining of diabetic complications (34.7%). Most of participants (55.1%) get high score 7-8 out of 8 questions in Knowledge. Although, there were 166 persons (32%) who couldn’t reach full score in attitude evaluation. There was a large percentage of our participants (69%) had very low score 0-2 out of 6 in assessment of previous education of diabetic foot. More than half of participants (56.5%) had score 6-10 out of 15 in evaluation of practice with diabetic foot. Conclusion: diabetic foot in Saudi Arabia is existing, even amputations and other diabetic foot complications were also present. Diabetic patients have good knowledge and attitude toward diabetic foot. Education about diabetic foot and practice is still weak.

BACKGROUND: Illness perception questionnaires for various medical conditions have become more useful in recent years. However, very few have used this to address the issue of type 2 diabetes in Saudi Arabia. MATERIALS AND METHODS: This study was conducted among type 2 diabetic patients attending primary healthcare centers and Al Kharj Military Industries Corporation Hospital in Al Kharj, Saudi Arabia, during November 24, 2016, to April 24, 2017. SPSS used for analysis that included descriptive statistics, t-test, and a one-way analysis of variance (ANOVA). RESULTS: A total of 500 questionnaires were distributed, and 383 of them were returned; response rate about 77%. Majority of participants (80.4%) were educated, 69.5% were married, and 51% were females. About 57% were on OHA, and 57% had no other chronic disease. Most participants perceived that diabetes was hereditary (75%), and 62.4% thought it is due to diet or eating habits. About 80% participants believed that there is a lot they can do to control symptoms. About 73% participants believed they have the power to influence diabetes, whereas 78% think there is very little that can be done to improve diabetes and treatment can control diabetes. The Cronbach's alpha value for identity, timeline (cyclical), and emotional factors were relatively high, showing that these scales had a strong level of internal consistency. CONCLUSION: Saudis with type 2 diabetes mellitus had adequate knowledge of their disease. They agreed that diabetes was likely to be permanent and would have major consequences on their lives.

Non-union following high tibial osteotomy (HTO) is very uncommon. We present a case of bilateral non-union of HTOs with end-stage knee arthritis treated with staged, bilateral, posterior stabilized knee replacements. A 77-year-old female presented to our clinic with complaints of debilitating knee pain. She used a frame to get about in her home, she was unable to get up stairs, and she rarely went outside. Simple radiographs revealed bilateral non-unions of her osteotomies, subluxation of the tibial plateauxs and severe knee osteoarthritis. At the time of surgery, the non-unions were found to be fibrous stable. We took a minimal tibial plateaux resection and used long stem tibial stems with offset couplers to bypass the non-unions. At minimum 1 year follow-up, she was walking pain free with full knee range of motion. We found that primary total knee replacement (TKR) using tibial stems and without treating the tibial non-union gave satisfactory results.

We report a case of a 63-year-old man presenting with abdominal pain and hydronephrosis secondary to periaortic fibrosis (PAF) 8 months after an endovascular aortic repair (EVAR) using a woven polyester bifurcated graft. De novo delayed PAF after open repair is rare and even more infrequent after EVAR. All 3 previously reported cases occurred after woven polyester grafts and no reported cases after polytetrafluorethylene grafts. Management included steroidal anti-inflammatory treatment and bilateral double J tube placement. Satisfactory results were obtained.

ObjectivesLung cancer is one of the most lethal cancers. Currently, there are no biomarkers for early detection, monitoring treatment response, and detecting recurrent lung cancer. We undertook this study to determine if1H magnetic resonance spectroscopy (MRS) of sputum and exhaled breath condensate (EBC), as a noninvasive tool, can identify metabolic biomarkers of lung cancer.Materials and MethodsSputum and EBC samples were collected from 20 patients, comprising patients with pathologically confirmed non-small cell lung cancer ( n = 10) and patients with benign respiratory conditions ( n = 10). Both sputum and EBC samples were collected from 18 patients; 2 patients provided EBC samples only.1H MR spectra were obtained on a Bruker Avance 400 MHz nuclear magnetic resonance (NMR) spectrometer. Sputum samples were further confirmed cytologically to distinguish between true sputum and saliva.ResultsIn the EBC samples, median concentrations of propionate, ethanol, acetate, and acetone were higher in lung cancer patients compared to the patients with benign conditions. Median concentration of methanol was lower in lung cancer patients (0.028 mM) than in patients with benign conditions (0.067 mM; P = 0.028). In the combined sputum and saliva and the cytologically confirmed sputum samples, median concentrations of N-acetyl sugars, glycoprotein, propionate, lysine, acetate, and formate were lower in the lung cancer patients than in patients with benign conditions. Glucose was found to be consistently absent in the combined sputum and saliva samples (88%) as well as in the cytologically confirmed sputum samples (86%) of lung cancer patients.ConclusionAbsence of glucose in sputum and lower concentrations of methanol in EBC of lung cancer patients discerned by1H MRS may serve as metabolic biomarkers of lung cancer for early detection, monitoring treatment response, and detecting recurrence.

Preservation of native arteriovenous fistulas (AVFs) in the long term can be technically challenging. Various anatomic or functional problems can occur and multiple open and/or endovascular interventions may be required for extended preservation of native accesses. In this report, we review vascular access maintenance in a 72-year-old woman during a 5-year period. Multiple complications of her native radiocephalic AVF included recurrent occlusions, a central venous stent fracture and symptomatic venous outflow stenosis. We present this case to illustrate the various techniques and combination of approaches used in the long-term preservation of a native AVF.

Objectives This review article provides an overview of the current state of imaging of synovitis in osteoarthritis (OA), looking at recent advances and controversies and focusing particularly on the application of ultrasound and magnetic resonance imaging (MRI) in the assessment of the hand and knee joint. Computed tomography and nuclear medicine including positron emission tomography are also briefly discussed. Methods PubMed and MEDLINE search for articles published up to 2010, using the keywords synovitis, osteoarthritis, rheumatoid arthritis, pathogenesis, imaging, radiography, computed tomography, nuclear medicine, magnetic resonance imaging, ultrasound, and pain. Results Synovitis is defined as inflammation of the synovial membrane. Modern imaging techniques have demonstrated that synovial pathology is common in the early and late stages of OA and may be associated with pain. The current standard for OA imaging in clinical practice is conventional radiography but it does not allow direct visualization of synovitis. MRI without contrast administration, although widely used in clinical studies, cannot assess synovitis directly. Contrast-enhanced MRI and ultrasound, however, both allow direct visualization of synovitis including early inflammatory changes. They are regularly used to image synovitis in rheumatoid arthritis and increasingly in OA. Conclusions Synovitis is increasingly recognized as an important feature of the pathophysiology of OA, although there is conflicting evidence with respect to its association with disease severity and clinical parameters. Contrast-enhanced MRI and ultrasound are the most important methods for assessing synovitis associated with OA.

A case of steroid-induced osteoporosis-related multiple fractures and dislocations are described after a seizure is reported. Patient had two years history of steroid use with no supplement or antiresorptive therapy. There was a delay in the diagnosis which affected an otherwise good outcome in such situations. It is recommended that patients on steroid should be given calcium, vitamin D, and an antiresorptive. Furthermore, a meticulous clinical examination is required in patients who are on steroids and suffer epileptic seizures to rule out skeletal injury.

Chest pain is usually a benign presentation in children who present to emergency departments (ED) or primary care centers. Unlike adults, where chest pain is commonly due to cardiac causes, in children the cause is more likely secondary to non-cardiac causes. Here we present a case of a child known to have hyper-eosinophilic syndrome (HES) who presented with sudden onset of chest pain and had a rapidly progressive and fatal outcome in the ED. We discuss the ED approach to the child with chest pain and review acute myocardial infarction (AMI) in children.

With current treatment of glioblastomas 85% of the tumors recur within the field of high dose radiation. This tumor recurrence requires formation of new blood vessels. We have developed a new therapeutic paradigm based on the dual origin of tumor blood vessels: Angiogenesis - the sprouting of endothelial cells from nearby blood vessels, and vasculogenesis - the formation of blood vessels from circulating cells. Because tumor irradiation abrogates local angiogenesis the tumor must rely on the vasculogenesis pathway for regrowth after irradiation. We have previously demonstrated that the post-irradiation recurrence of human glioblastomas implanted intracranially in the mouse brain can be delayed or prevented by inhibiting circulating blood vessel forming cells by blocking the interaction of the chemokine receptor CXCR4 with its ligand SDF-1 (CXCL12)1. However, SDF-1 has a second receptor, CXCR7, which has been implicated in endothelial cell migration, is present on tumor vasculature, and is potentially also able to activate vasculogenesis. To block both receptors we have therefore used NOX-A12, an L-enantiomeric RNA oligonucleotide (Spiegelmer®), which inhibits SDF-1 with subnanomolar affinity. We have tested the effect of this inhibitor on the response to irradiation of the U251 human GBM in nude mice and on ENU-induced brain tumors in the Sprague-Dawley rat. In the mouse model we found that inhibition of SDF-1 post-irradiation was highly effective in enhancing tumor response to a single dose of 20 Gy whole brain irradiation. In the rat model the pups from ENU-treated pregnant mothers begin to die of brain tumors from approximately 120 days of age. We performed two studies with this model: In the first we delivered a single dose of whole brain irradiation (20 Gy) on day 115 of age and began treatment with NOX-A12 immediately following irradiation and continued every 2 days with either 5 or 20 mg/kg injected subcutaneously for either 4 or 8 weeks. These doses and times were chosen as equivalent to human doses and times that based on existing data have been found to be safe and well tolerated in human volunteers and which are effective in inhibiting the action of SDF-1. We found a marked prolongation of life of the rats that was dependent both on drug dose and length of treatment. In the second study we measured the size of the tumors post-irradiation using MRI and again found a pronounced enhancement of the efficacy of irradiation that was superior to the addition of temozolomide at doses equivalent to those used with concomitant radiotherapy in treating GBM. We believe that these encouraging data justify a human trial in first line glioblastoma patients. 1. Kioi M, Vogel H, Schultz G, Hoffman RM, Harsh GR, Brown JM: Inhibition of vasculogenesis, but not angiogenesis, prevents the recurrence of glioblastoma after irradiation in mice. J Clin Invest 120:694-705, 2010 Citation Format: Shie-Chau Liu, Reem Alomran, Jason Stafford, Milton Merchant, Taichang Jang, Stefan Zollner, Anna Kruschinski, Laurence Recht, J. Martin Brown. Inhibition of recurrences of experimental brain tumors after irradiation by blocking the activity of SDF-1 (CXCL12) using the Spiegelmer® NOX-A12. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 385. doi:10.1158/1538-7445.AM2013-385