SASLT guidelines: Update in treatment of hepatitis C virus infection, 2024.

ABSTRACT: Hepatitis C virus (HCV) infection has been a major global health concern, with a significant impact on public health. In recent years, there have been remarkable advancements in our understanding of HCV and the development of novel therapeutic agents. The Saudi Society for the Study of Liver Disease and Transplantation formed a working group to develop HCV practice guidelines in Saudi Arabia. The methodology used to create these guidelines involved a comprehensive review of available evidence, local data, and major international practice guidelines regarding HCV management. This updated guideline encompasses critical aspects of HCV care, including screening and diagnosis, assessing the severity of liver disease, and treatment strategies. The aim of this updated guideline is to assist healthcare providers in the management of HCV in Saudi Arabia. It summarizes the latest local studies on HCV epidemiology, significant changes in virus prevalence, and the importance of universal screening, particularly among high-risk populations. Moreover, it discusses the promising potential for HCV elimination as a public health threat by 2030, driven by effective treatment and comprehensive prevention strategies. This guideline also highlights evolving recommendations for advancing disease management, including the treatment of HCV patients with decompensated cirrhosis, treatment of those who have previously failed treatment with the newer medications, management in the context of liver transplantation and hepatocellular carcinoma, and treatment for special populations.

Outcome of Methanol Toxicity Outbreak In Saudi Arabia: Case Series Study.

Introduction Methanol poisoning is an acute medical emergency. If not recognized in time and treated properly, it can lead to a considerable magnitude of morbidity as well as mortality. This article aims to report cases of methanol toxicity, focusing on clinical presentation, management, and outcomes. Method Nine ICU-admitted patients with confirmed positive serum methanol levels were analyzed in a case series at King Fahad General Hospital in Jeddah, Saudi Arabia, between November 2022 and January 2023. Results Among the nine patients admitted to the ICU due to methanol poisoning, the majority were middle-aged males, with two females included. Gastrointestinal symptoms were seen in two-thirds of patients, while three patients required immediate mechanical ventilation due to a low Glasgow Coma Scale. Severe metabolic acidosis was observed in most cases. All patients received sodium bicarbonate and hemodialysis, with six patients also receiving fomepizole. However, two patients in the study with low initial low Glasgow Coma Scale (GCS), severe metabolic acidosis, and diffuse brain edema, did not survive. One patient reported acute complete vision loss. Conclusion This case series highlights the importance of promptly recognizing and managing methanol toxicity in ICU settings. The clinical presentation of methanol toxicity can be challenging, and early diagnosis and treatment are crucial to prevent irreversible damage.

Hepatitis D double reflex testing of all hepatitis B carriers in low-HBV- and high-HBV/HDV-prevalence countries.

Hepatitis D virus (HDV) infection occurs as a coinfection with hepatitis B and increases the risk of hepatocellular carcinoma, decompensated cirrhosis, and mortality compared to hepatitis B virus (HBV) monoinfection. Reliable estimates of the prevalence of HDV infection and disease burden are essential to formulate strategies to find coinfected individuals more effectively and efficiently. The global prevalence of HBV infections was estimated to be 262,240,000 in 2021. Only 1,994,000 of the HBV infections were newly diagnosed in 2021, with more than half of the new diagnoses made in China. Our initial estimates indicated a much lower prevalence of HDV antibody (anti-HDV) and HDV RNA positivity than previously reported in published studies. Accurate estimates of HDV prevalence are needed. The most effective method to generate estimates of the prevalence of anti-HDV and HDV RNA positivity and to find undiagnosed individuals at the national level is to implement double reflex testing. This requires anti-HDV testing of all hepatitis B surface antigen-positive individuals and HDV RNA testing of all anti-HDV-positive individuals. This strategy is manageable for healthcare systems since the number of newly diagnosed HBV cases is low. At the global level, a comprehensive HDV screening strategy would require only 1,994,000 HDV antibody tests and less than 89,000 HDV PCR tests. Double reflex testing is the preferred strategy in countries with a low prevalence of HBV and those with a high prevalence of both HBV and HDV. For example, in the European Union and North America only 35,000 and 22,000 cases, respectively, will require anti-HDV testing annually.

Compliance of Primary Healthcare Workers in Saudi Arabia With the National Surveillance System of Tropical and Non-tropical Dermatological Diseases.

BACKGROUND:  Control and prevention of infectious diseases has been a primary health mandate. The reporting system is a vital step in preventing and controlling of these diseases. Most important, healthcare workers who have a responsibility to report must be aware of this responsibility. The present study aimed to improve the compliance of primary healthcare workers against reportable tropical and non-tropical dermatological diseases. OBJECTIVE OF THE STUDY: The objective was to assess the knowledge, skills, and practice of primary healthcare workers in Saudi Arabia regarding the surveillance system of reportable tropical and non-tropical dermatological diseases using an assessment tool featuring closed-ended questions. As a secondary objective, this study assessed the satisfaction of primary healthcare workers with the surveillance system. SUBJECTS AND METHODS:  Through a cross-sectional design, the study used an electronic self-administered questionnaire targeting the primary healthcare workers who met the inclusion criteria through a non-probability sampling technique. RESULTS: By the end of the study period, data had been collected from 377 primary healthcare workers. Slightly more than half of them worked for the ministry of health facilities. In the last year, the vast majority (88%) of participants did not report any infectious diseases. Poor or low knowledge was reported by almost half of the participants concerning which dermatological diseases should be notified immediately on clinical suspicion or routinely on a weekly basis. Clinically and in response to the skills assessment, 57% of the participants had lower skills scores in detecting and identifying the skin ulcer of leishmania. Half of the participants were less satisfied with the feedback after their notification and considered the notification forms complicated and time-consuming, especially with the usual high workload in primary healthcare centers. Furthermore, the observed significant differences (p < 0.001) in knowledge and skill scores were demonstrated with female healthcare workers, older participants, employees from the Ministry of National Guard Health Affairs, and workers with more than ten years of experience. CONCLUSION: The present study has shown the limitations of public health surveillance due to underreporting and lack of timeliness. The dissatisfaction of study participants with feedback after the notification step is another finding that demonstrates the need for collaboration among public health authorities and healthcare workers. Fortunately, health departments can implement measures to improve practitioners' awareness through continuous medical education and providing frequent feedback to overcome these hurdles.

Prevalence and Risk Factors of Venous Thromboembolism in Critically Ill Patients with Severe COVID-19 and the Association between the Dose of Anticoagulants and Outcomes.

Introduction: COVID-19 is characterized by a procoagulant state that increases the risk of venous and arterial thrombosis. The dose of anticoagulants in patients with severe COVID-19 pneumonia without suspected or confirmed thrombosis has been debated. Aim of the study: We evaluated the prevalence, predictors, and outcomes of venous thromboembolism (VTE) in critically ill COVID-19 patients and assessed the association between the dose of anticoagulants and outcomes. Materials and methods: This retrospective cohort included patients with COVID-19 who were admitted to the ICU between March and July 2020. Patients with clinically suspected and confirmed VTE were compared to those not diagnosed to have VTE. Results: The study enrolled 310 consecutive patients with severe COVID-19 pneumonia: age 60.0±15.1 years, 67.1% required mechanical ventilation and 44.7% vasopressors. Most (97.1%) patients received anticoagulants during ICU stay: prophylactic unfractionated heparin (N=106), standard-dose enoxaparin (N=104) and intermediate-dose enoxaparin (N=57). Limb Doppler ultrasound was performed for 49 (15.8%) patients and chest computed tomographic angiography for 62 (20%). VTE was diagnosed in 41 (13.2%) patients; 20 patients had deep vein thrombosis and 23 had acute pulmonary embolism. Patients with VTE had significantly higher D-dimer on ICU admission. On multivariable Cox regression analysis, intermediate-dose enoxaparin versus standard-dose unfractionated heparin or enoxaparin was associated with lower VTE risk (hazard ratio, 0.06; 95% confidence interval, 0.01-0.74) and lower risk of the composite outcome of VTE or hospital mortality (hazard ratio, 0.42; 95% confidence interval, 0.23-0.78; p=0.006). Major bleeding was not different between the intermediate- and prophylactic-dose heparin groups. Conclusions: In our study, clinically suspected and confirmed VTE was diagnosed in 13.2% of critically ill patients with COVID-19. Intermediate-dose enoxaparin versus standard-dose unfractionated heparin or enoxaparin was associated with decreased risk of VTE or hospital mortality.

Effectiveness and Safety of Laser-Assisted Removal of Inferior Vena Cava (IVC) Filters in a Single Tertiary Care Center.

INTRODUCTION: Laser sheath-assisted removal of inferior vena cava (IVC) filters with long dwelling time is a technique that utilizes laser-tipped sheaths. The laser light only penetrates vascular tissue by one hundred microns, causing the target tissues to disintegrate into particles less than 5 microns in size. This approach reduces the energy used during difficult retrieval procedures, allowing permanent filters to be removed in less fluoroscopic and procedural time overall. MATERIALS AND METHODS: The radiology information system and electronic health records were used in this retrospective cohort study to retrieve the data. A total of nine consecutive patients who underwent laser-assisted filter removal utilizing GlideLightTM were included in the study between January 2016 and January 2017. The study took place at King Abdulaziz Medical City in Riyadh. In this study, five patients were male and four were female with ages ranging from 19 to 57 years with a median age of 31. RESULTS: During the period of the study, a total of nine patients had their IVC filters removed using a laser. The success rate was 100%. The indications were trauma (n=4) followed by deep vein thrombosis (DVT) (n=3) and one patient indication was prolonged immobilization. The dwelling time ranged from seven to 70 months, with a dwelling median of 19 months. CONCLUSION: A laser sheath might be necessary for closed-cell filters in order to improve the likelihood of a successful and secure retrieval. Technical efficiency, filter type, the necessity of applying a laser sheath based on an open versus closed filter design, dwell times, and unfavorable results. As a result, after typical procedures failed to successfully retrieve IVC filters with long dwell durations, laser-assisted filter removal is thought to be practical and safe.

Safety and effectiveness of newer antidiabetic medications during Ramadan fasting and safety of Ramadan fasting after bariatric surgery.

Background: Fasting during Ramadan is mandatory for all adult healthy Muslims. International studies found that most Muslims with diabetes mellitus fast during Ramadan. The main risk factors are hypoglycemia, Hyperglycemia, diabetic ketoacidosis, and dehydration during fasting. Therefore, stratification of the risks for severe acute diabetes complications needs to be considered for each individual and strategies personalized to advert these complications. The advent of new diabetes medications which are effective yet with a better safety profile and monitoring of blood glucose levels during the day are important to reduce the risk of untoward effects of hypoglycemia and hyperglycemia during Ramadan fasting. Here we review the safety and effectiveness of the newer diabetes medications for Ramadan fasting and whether it is safe to perform fasting after bariatric surgery. Methods: An extensive literature search using PubMed and Google Scholar was done using different search terms. The eligible studies were 48 randomized controlled trials, prospective observational studies, and reviews from January 2008 to June 2022 which were conducted in individuals living with diabetes. Results and Conclusions: The newer diabetes medications such as GLP-1 agonists, DPP-4 inhibitors, SGLT-2 inhibitors, and new Insulin therapy are thought to be safe and effective during fasting of Ramadan. These medications are associated with a reduction in HbA1c, body weight, systolic blood pressure and risk of hypoglycemia during Ramadan fasting. However, further studies with larger sample size are needed to confirm the efficacy and safety of these newer medications during Ramadan fasting. Individuals with Bariatric surgery should seek advice and approval to fast from the bariatric dietician, physician, and surgeon before the beginning of the month of Ramadan.

Recycling waste classification using emperor penguin optimizer with deep learning model for bioenergy production.

The growth and implementation of biofuels and bioenergy conversion technologies play an important part in the production of sustainable and renewable energy resources in the upcoming years. Recycling sources from waste could efficiently ease the risk of world source strain. The waste classification was a good resolution for separating the waste from the recycled objects. It is inefficient and expensive to rely solely on manual classification of garbage and recycling sources. Convolutional neural networks (CNNs) have lately been used to classify recyclable waste, and this is the primary way for recycling the waste. This study presents a recycling waste classification using emperor penguin optimizer with deep learning (RWC-EPODL) model for bioenergy production. RWC-EPODL model focuses on recycling waste materials recognition and classification. When it comes to detecting and classifying trash, the RWC-EPODL model uses two stages. At the initial stage, the RWC-EPODL model uses AX-RetinaNet model for the recognition of waste objects. In addition, Bayesian optimization (BO) algorithm is applied as hyperparameter optimizer of the AX-RetinaNet model. Following the EPO algorithm with a stacked auto-encoder (SAE) model, the EPO algorithm is used to fine-tune the parameters of the SAE technique for trash classification. The RWC-EPODL model's experimental validation is examined through a number of studies. The RWC-EPODL approach has a 98.96 percent success rate. The comparative result analysis reported the better performance of the RWC-EPODL model over recent approaches.

Rate of Cardiovascular Implantable Electronic Device-Related Infection at a Tertiary Hospital in Saudi Arabia: A Retrospective Cohort Study.

Introduction Cardiovascular implantable electronic devices (CIEDs) are long-term cardiac treatments that address a variety of cardiac diseases. In the recent years, a steady growth has been noticed in CIEDs, mainly due to expanding indications for their usage. Possible device-related infection, whether pocket or systemic, which leads to high morbidity and mortality, is one of the most worrying complications. In addition, there are limited studies conducted on the topic of CIED infection rate and their clinical presentation both regionally and locally. Methods In this retrospective cohort study, we reviewed the medical records of all patients with CIEDs who presented to our medical center (implanted, followed up, or referred to our hospital) between January 2016 and January 2019.The medical records were extracted from the BestCare electronic medical records system (ezCaretech Co, Seoul, Korea). All consecutive patients were included as we had no exclusion criteria. Results During the three years of the study period, a total of 612 patients with CIEDs were identified at our medical center. Among this cohort, 436 subjects (71.2%) were male and 176 (28.8%) were female. Thirty-four patients experienced device-related infections from among the total patient population (n = 612) who presented with CIEDs between January 2016 and January 2019, for a total rate of 5.6%. Of the infected patients, 29 (85%) presented with local infections and five (15%) presented with systemic infections. Conclusion The infection rate of 5.6% observed in this study was higher than expected. Therefore, we conclude that action should be taken to reduce infection rates at our medical center to at least that seen in prior studies or below that, if possible. Moreover, we found that CIED infections were often caused by Staphylococcus species and commonly affected the elderly and patients with chronic diseases such as diabetes and hypertension. Most of the identified cases were local infections, although systemic infections were common in those with renal disease. Further studies are needed to control the risk factors and to better understand the role of antibiotics, antiseptic prophylaxis, and other methods in avoiding CIED infection and associated complications.

Clinical Outcomes of Radiological Treatment Modalities of Hepatocellular Carcinoma: A Single-Center Experience from Saudi Arabia.

BACKGROUND: Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver. Most patients with HCC are unsuitable for surgical therapies. Therefore, nonsurgical therapies play a central role in the management of this disease. Several percutaneous treatment modalities are available for HCC including radiofrequency ablation (RFA), transarterial chemoembolization (TACE), and transarterial radioembolization (TARE). In this study, we aim to evaluate the clinical outcomes, morbidity and mortality rates, and survival rates of four treatment modalities for HCC (RFA, TACE, TARE, and Sorafenib) and compare the success rate of each modality. METHODS: A retrospective observational study was conducted at King Abdulaziz Medical City in Jeddah, Saudi Arabia. The inclusion criteria were composed of patients diagnosed with HCC who received RFA, TACE, TARE, or Sorafenib treatments between 2008 and 2017. The primary outcome of this study was recurrence-free patients at the last follow-up. RESULTS: A total of 108 patients were included in this study. The mean age of the patients was 68.01 ± 9.98 years. Eighty-Two patients (75.9%) underwent interventions with the intention to cure or stabilize HCC, while twentysix patients (24.1%) were started on Sorafenib as a palliative treatment. The five years recurrence-free rates were 41.2% with RFA, 40% with the combination of TACE and RFA, 23.3% with TACE, and 0% with TARE. All patients on Sorafenib died from advanced-stage HCC. CONCLUSION: This study provides further evidence for the efficacy of several treatment modalities for the management of HCC. RFA and the combination of TACE and RFA showed better outcomes with a recurrence-free rate reaching up to 40%. TACE had a moderate survival benefit up to 23.3%. TARE showed negative survival benefits. Sorafenib continues to be an important palliative treatment but does not offer curative potential.

Extremes of Anemia: The Lowest Hemoglobin Values Probably Ever Reported in the Pediatric Literature Attributed to Iron Deficiency Anemia.

BACKGROUND Iron deficiency anemia is the most widespread, preventable, and treatable cause of anemia in children. Potential causes of iron deficiency anemia are prolonged breastfeeding with poor quality of introduced solid food and the use of whole cow milk instead of iron-rich formula. We describe 2 unusual cases of nutritional iron deficiency anemia with profound low level of hemoglobin around 1 g/dl, with similar diagnosis and different hospital course. CASE REPORT First case: A 20-month-old Saudi boy presented with symptoms of acute gastroenteritis. He was noted to be very pale, with extremely low hemoglobin value of 1.1 g/dl. His nutritional status mostly consists of breastfeeding, with poor iron-rich food. He was admitted to the pediatric intensive care unit with a complicated hospital course of reversible cardiomyopathy and gut involvement. Second case: A 26-month-old Saudi girl presented with complaints of severe pallor and fatigability for 2 months, with critical result of extreme low level of hemoglobin 1.2 g/dl. A detailed nutritional history revealed being exclusively on pasteurized cow's milk with no solid food intake for 6 months. CONCLUSIONS Neglected cases of nutritional iron deficiency anemia may lead to profoundly low levels of hemoglobin. Possible manifestations include heart failure and gastrointestinal involvement in the form of leaky gut syndrome or exudative enteropathy. IV iron therapy was a very effective treatment in both patients. To our knowledge, probably no reported cases of severe iron deficiency anemia reaching this extremely low level of hemoglobin with multiple associated complications exist in the pediatric literature.

Social anxiety in E-Learning: Scale validation and socio-demographic correlation study.

During the ongoing coronavirus disease 2019 pandemic, over 1.5 billion students worldwide have been deprived of access to traditional learning. This situation has necessitated the use of social distancing-based educational methods; consequently, a tremendous shift towards e-learning has been observed. This study assesses medical students' social anxiety levels in e-learning environments. The study was conducted in two phases. In the first phase, the original Turkish Social Anxiety Scale for E-Learning Environments (SASE) was adapted in English and tested for validity and reliability. This instrument has two subscales: social anxiety in learner-learner interaction and in learner-instructor interaction. In the second stage, we explored the associations of gender, age, and perceived academic performance with medical students' social anxiety levels in e-learning environments. A total of 325 responses were analysed. Consistent with the original version, the adapted scale is a reliable and valid measure of social anxiety in e-learning. Social anxiety in e-learning was related to gender (p = 0.008) and age (p = 0.013). Social anxiety levels were higher in students with lower perceived performance during e-learning compared to students with enhanced performance, but the difference was not significant. The SASE is a useful instrument for evaluating social anxiety in e-learning environments across English educational frameworks. Considering the shift in social interaction environments, efforts are required to reduce medical students' social anxiety levels and enhance learning.

Assessment of the levels of antispike SARS-CoV-2 IgG antibodies and their association with clinical characteristics in cohort of patients in Saudi Arabia.

Background: Coronavirus disease 2019 (COVID-19) has caused a global public health crisis. The disease is known to be caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, but the detailed characteristics of the immune response to this novel virus have not been fully elucidated yet. In this study, we aimed to determine the level of immunoglobulin G (IgG) antibodies and their correlation with clinical features at three time points postinfection in a group of patients in Saudi Arabia. Method: In this prospective observational study, we collected the demographic and clinical data from 43 polymerase chain reaction (PCR)-confirmed patients and measured the COVID-19 antispike IgG levels at three different visits. Result: The seroconversion rate after COVID-19 infection was 88.4% in the study participants, with no significant changes in the IgG levels through the three visits. The duration of shortness of breath had a significant positive correlation with the IgG level of the patients. Using the logistic regression model, participants having coughs were found to be 12.48 times more likely to develop positive IgG. The IgG levels were less in smokers than nonsmokers [Odds ratio = 6.42 (95% CI 2.11-19.48); P = 0.001]. Conclusion: Positive IgG levels have been developed in most COVID-19 patients and did not significantly change over 3 months following the diagnosis. The level of IgG antibodies was found to be significantly associated with the presence of cough, duration of shortness of breath, and the smoking habit of the patients. These findings have clinical and public health significance and need to be validated in larger studies in different populations.

Higher ambient temperature is associated with worsening of HbA1c levels in a Saudi population.

BACKGROUND: Ambient temperature is predicted to rise in Saudi Arabia, and how this will impact the health of its population has not been investigated. Saudi Arabia is one of the top ten countries with the highest prevalence of diabetes. The current study investigates the correlation between ambient temperature and HbA1c levels in a group of Saudis in Riyadh. METHODS: Age, gender, and HbA1c data for six years were obtained from patients' records. The maximum daily temperature of Riyadh city for the same period was obtained. RESULTS: A total of 168,614 patient records were obtained. There was a statistically significant positive correlation between ambient temperature and HbA1c levels, where for each 1°C increase in average weekly temperature HbA1c increased by 0.007%. Patients were at higher risk of having HbA1c ≥ 7% in high and moderate temperature than in low temperature (P < 0.001, odds ratio (OR): 1.134, and P < 0.001, odds ratio (OR): 1.034; respectively). The mean of HbA1c in females (7.27±1.96) was significantly lower than in males (7.40±1.86), and the probability of males having HbA1c ≥ 7% was about 17.4% higher than females. However, the HbA1c levels in females were significantly more affected by rising temperature compared to males (B = 0.003, P = 0.008). CONCLUSION: Overall, rise in ambient temperature is associated with worsening HbA1c, which could be harmful to the health of Saudis suffering from diabetes. Possible reasons for the increase in HbA1c could include reduced physical activity, reduced sunlight exposure, and dehydration during hot weather. More research on the relationship between climate change and public health in Saudi Arabia is needed.

Revealing Hepatitis B Virus as a Silent Killer: A Call-to-Action for Saudi Arabia.

BACKGROUND: The Kingdom of Saudi Arabia (KSA) was the first country in the Middle East to adopt the hepatitis B virus (HBV) vaccine. Despite an expanded HBV immunization program and significant progress in HBV prevention in the country, HBV infection is a significant public health burden. This review lists coordinated solutions for healthcare stakeholders, patients, and health authorities to curb HBV and its impact in KSA. It further aims to draw policymakers' attention to key priorities to bridge HBV care gaps in the country. METHODS: As part of the pre-engagement activity, medical experts across KSA were interviewed to gain a preliminary understanding of the current unmet needs in HBV management in the country. Top-recommended action points derived from the pre-engagement activity were discussed. Key priority action points to curb the impact of HBV in KSA were identified. RESULTS: The priority action points together with the challenges and unmet needs in the management and care of HBV in KSA were: (a) establish a national-level registry, (b) implement screening campaigns, (c) improve linkage of care between primary care physicians (PCPs) and specialists, and (d) increase PCP education and awareness. CONCLUSION: This work is an endeavor to set the stage for a strategic policy framework aimed at eliminating HBV in KSA. The action points/steps for the identified priorities must run parallelly across various regions in KSA, to successfully manage and further eliminate the threat of HBV.

Causes, Prevention, and Correction of Complications of Primary and Revision Septorhinoplasty.

BACKGROUND: Rhinoplasty is one of the most challenging esthetic operations as it demands an optimal esthetic and practical outcome. Complications of rhinoplasty may occur intraoperatively or postoperatively during wound healing and contracture. OBJECTIVES: The aim of this study was to assess the complications of septorhinoplasty at King Abdullah Medical City Hospital (KAMCH) and to evaluate the satisfaction scores of the patients and the doctors after primary and revision septorhinoplasty. MATERIALS AND METHODS: In the last five years, 32 out of 425 patients (7.5%) underwent revision septorhinoplasty to correct complications of the previous operations performed at KAMCH. This is a retrospective single descriptive study that included Saudi patients aged 18 years and above who underwent primary and revision septorhinoplasty at KAMCH from January 2015 to March 2020. We reviewed the medical records of the patients to identify postoperative complications. Data were analyzed using SPSS statistical program (versions 7 and 8; SPSS Inc, Chicago). RESULTS: The mean age of the 32 patients who underwent revision septorhinoplasty was 26 ± 8.5 years. Most of the complications involved the nasofrontal angle and the columellolabial angle. Statistically significant improvements in the satisfaction scores of the patients and the doctors were observed before the first surgery, after the first surgery, and after the second surgery (P = 0.000 for each time point). CONCLUSION: The satisfaction levels of the patients and the doctors improve after the second surgery.

Osteochondral fracture of the patella without soft tissue injury and with no dislocation: A case report.

INTRODUCTION: Osteochondral fracture of the patella is a fairly common pathology, but almost always associated with a spectrum of soft tissue injuries including anterior cruciate ligament (ACL) rupture. We present a rare case of an osteochondral fracture of the patella in the absence of ligament or soft tissue injuries and with no dislocation of the patella in a pediatric patient. PRESENTATION OF CASE: An 11-year-old male presented to the orthopedic clinic on crutches following a football injury. The patient had pain in his left knee with flexion deformity. Plain film radiography of the left knee was taken, and an osteochondral fracture of the patella was suspected. Further imaging studies were conducted including computed tomography (CT) and magnetic resonance imaging (MRI) which revealed an isolated osteochondral fracture of the patella with no other associated injuries. Open reduction and internal fixation of the displaced fragment was successfully preformed with favorable outcomes. During follow-up, almost full range of motion was regained, and plain film radiography revealed healed fracture with a normal appearance of the patella. DISCUSSION: Traumatic osteochondral fracture of the patella is a common injury and most of these injuries are commonly accompanied by an acute dislocation of the patella or soft tissue injuries such as rupture of the anterior cruciate ligament (ACL) and almost half of all patellar dislocations incidence are associated with osteochondral fractures of the patella. This case had an isolated osteochondral fracture of patella. CONCLUSION: As demonstrated in this case, osteochondral fractures are common among younger population and patients need to be thoroughly evaluated. Advanced Imaging such as MRI and CT are essential to exclude soft tissue injuries. Although management is highly variable, the importance of open reduction and early fixation should be emphasized for optimal outcomes.

The Influence of Gender and Menopausal Status on Hba1c Variation in a Big Data Study of a Saudi Population.

BACKGROUND: Glycated haemoglobin (HbA1c) is the gold standard measurement in the screening, diagnosis and monitoring of diabetes mellitus. Saudi Arabia has a high prevalence of diabetes mellitus that is expected to rise, and the HbA1c test is commonly used in the screening, diagnosis and monitoring of diabetes. OBJECTIVE: This study aims to assess the impact of age and gender on HbA1c levels, and the influence of menopausal status on HbA1c variation in a large group of Saudis. METHODS: Age, gender, and HbA1c results of 168,614 Saudi adult individuals were obtained from their medical records. Patients' records were extracted irrespective of their status regarding the presence of diabetes and the status of glycaemic control. Linear regression models were used for predicting HbA1c from age and gender, and their interaction term. HbA1c levels were compared between genders in different age groups and different HbA1c categories. RESULTS: There was a statistically significant positive correlation between age and HbA1c levels, where for each ten years increase in age, HbA1c increased by 0.35%. Although the overall mean HbA1c in women was significantly lower than in men (P < 0.001), women showed a significant increase in HbA1c with older age compared to men (B = 0.014, P < 0.001). Furthermore, the mean HbA1c levels in the age group > 50 years was significantly higher than before that age (P < 0.001). Thus, HbA1c increased by 1.118% in age > 50 years group compared to age ≤ 50 years, and this increase in HbA1c was significantly higher in women compared to men (B = 0.495, P < 0.001). CONCLUSION: HbA1c levels are lower in women before the estimated menopausal age, which should be taken into consideration when using HbA1c for screening, diagnosis, and monitoring of diabetes in Saudi adult women. The short lifespan of red blood cells, due to loss of blood through menstruation, in women before menopause age, is a possible reason for these variations.

Clinical Characteristics of Hepatitis B Virus Patients After Switching to Tenofovir Alafenamide Fumarate: A Retrospective Observational Study.

Background Hepatitis B Virus (HBV) continues to be a significant global health problem despite vaccination programs and effective antiviral drugs. Aim Assess tenofovir alafenamide fumarate (TAF) as a new treatment modality in light of the clinical characteristics of HBV patients. Settings and design A real-world observational study Methods and material We collected data of 71 HBV patients and recorded the hepatitis B virus deoxyribonucleic acid (HBV-DNA) plasma levels and biochemistry test results for the alanine aminotransferase (ALT), aspartate aminotransferase (AST), and serum creatinine levels at three time points, including baseline, time of switching to TAF, and six months after switching. Results From the time of switching to TAF till six months later, HBV-DNA plasma levels significantly decreased from 838.61 IU/mL to 16.7 IU/mL (p-value of <0.05). ALT and AST levels dropped from 29.05 U/L to 27 U/L and from 21.34 U/L to 20.7 U/L (p-values 0.328 and 0.410, respectively). Although TAF did not show a statistically significant reduction in the serum levels of AST, ALT, and creatinine, it showed a detectable maintenance level. Conclusions In the evaluated cohort, all clinical characteristics of HBV were maintained six months after switching patients to TAF.

Carotid Artery Angioplasty and Stenting for Carotid Stenosis: A Single-Center Experience from Saudi Arabia.

PURPOSE: Atherosclerotic stenosis of the extracranial carotid artery accounts for approximately 20% of all strokes. Both carotid artery endarterectomy and carotid artery angioplasty with stenting (CAAS) are recommended for symptomatic patients with 50% or more stenosis or asymptomatic patients with 70% or more stenosis. CAAS is under-reported in Saudi Arabia, as evidenced by a thorough literature search. In this article, we aim to share our experience of CAAS to call for the necessity of conducting more research on stroke and emphasize the local need of utilizing more endovascular treatments like CAAS. MATERIALS AND METHODS: A retrospective single-center observational study was conducted at King Abdulaziz Medical City in Jeddah, Saudi Arabia. The inclusion criteria consisted of all adult patients (18 years and above) with carotid stenosis who were treated with CAAS. RESULTS: A total of 16 patients were included in the study. The mean age of the participants was 66.9±13.5 years (range 30-87 years). All patients were symptomatic (had a previous stroke or transient ischemic attack). The procedure was successful in 14 patients (87.5%), while it failed in 2 patients (12.5%) due to technical reasons. All patients had no stroke or myocardial infarction within 30 days of the procedure. CONCLUSION: Despite the advancement in medicine with free healthcare services in Saudi Arabia, the interventional procedures for secondary prevention of strokes are underutilized. Collaboration between different hospitals will be extremely helpful since few centers in each city are providing such treatments by an expert neurointerventionist and/or strokologist. The good selection of candidates, optimal management of comorbid conditions, and multidisciplinary care may improve outcomes and reduce mortality.