A Saudi Woman with Ceftriaxone Induced Fixed Drug Eruption.

Background: A fixed drug eruption (FDE) is an immunological cutaneous adverse reaction, classified as a cutaneous adverse drug reaction (CADR) and characterized by well-defined lichenoid lesions that occur at the same site each time. Ceftriaxone is a third-generation antibiotic of cephalosporin antibiotics of the beta-lactam antibiotic family, which has typical in vitro activity against many Gram-negative aerobic bacteria. This is the first clinical case from Saudi Arabia and the fifth in the world to document a woman's experience with recurrent FDE after repeated ceftriaxone use. Case Report. A 25-year-old Saudi woman with a known case of sickle cell anemia (SCA) with a history of avascular necrosis of the right hip after replacement was hospitalized with a pain crisis triggered by an upper respiratory tract infection. The patient denied having a history of allergy previously. Due to fever, leukocytosis, and active follicular tonsillitis, ceftriaxone was started. However, a few hours later she developed lip edema and a fixed drug eruption measuring 7 × 11 cm on the left side of her back. The lesion reformed over a hyperpigmented lesion (4 × 8 cm) that the patient did not report upon initial examination. It turned out that this was due to the intravenous administration of ceftriaxone, a year ago in another hospital. An allergy to ceftriaxone was considered, and steroids and antihistamines were started. The case was labeled as ceftriaxone induced FDE. Conclusion: Ceftriaxone induced FDE is an uncommon type of allergic reaction that has been reported infrequently. Understanding this condition and the mechanism by which FDE becomes recurrent with the same previous fixed lesion is of great importance for both academic and future research purposes.

Carpal Tunnel Syndrome Secondary to Tuberculous Tenosynovitis With Rice Bodies: A Case Report.

CASE: We report the case of a 34-year-old African man who presented with severe symptoms of recurrent left carpal tunnel syndrome (CTS) and left hand swelling after previous open decompression. Considering the recurrent unilateral affection of the left hand in a patient working in a slaughterhouse in an area with a moderate burden for tuberculosis, tuberculous infection was suspected. Open surgery and biopsy revealed tuberculous tenosynovitis of flexor tendon sheath and shiny white rice bodies. CONCLUSION: Tuberculous tenosynovitis should be considered as a differential diagnosis of the CTS when there is evidence of proliferative tenosynovitis in patients from an endemic area for tuberculosis.

The Future of Precision Medicine in the Cure of Alzheimer's Disease.

This decade has seen the beginning of ground-breaking conceptual shifts in the research of Alzheimer's disease (AD), which acknowledges risk elements and the evolving wide spectrum of complicated underlying pathophysiology among the range of diverse neurodegenerative diseases. Significant improvements in diagnosis, treatments, and mitigation of AD are likely to result from the development and application of a comprehensive approach to precision medicine (PM), as is the case with several other diseases. This strategy will probably be based on the achievements made in more sophisticated research areas, including cancer. PM will require the direct integration of neurology, neuroscience, and psychiatry into a paradigm of the healthcare field that turns away from the isolated method. PM is biomarker-guided treatment at a systems level that incorporates findings of the thorough pathophysiology of neurodegenerative disorders as well as methodological developments. Comprehensive examination and categorization of interrelated and convergent disease processes, an explanation of the genomic and epigenetic drivers, a description of the spatial and temporal paths of natural history, biological markers, and risk markers, as well as aspects about the regulation, and the ethical, governmental, and sociocultural repercussions of findings at a subclinical level all require clarification and realistic execution. Advances toward a comprehensive systems-based approach to PM may finally usher in a new era of scientific and technical achievement that will help to end the complications of AD.

Masquelet-Ilizarov technique for the management of bone loss post debridement of infected tibial nonunion.

PURPOSE: Masquelet and Ilizarov techniques have their advantages and shortcomings in the reconstruction of bone defects. The aim of this study was to evaluate the effectiveness of the combination of both techniques for the management of infected tibial nonunion to combine the advantages of both techniques with avoidance of shortcomings of both of them. PATIENTS AND METHODS: A prospective single-centre study was performed during the period from 2012 to 2019. Patients with the infected nonunion of the tibia with bone defect were included. Patients with pathological fractures or non-infected bone loss were excluded. Management protocol for all patients consisted of two stages. The first stage was Masquelet induced membrane technique and the second stage was Ilizarov bone transport. The results were assessed based on both objective (clinical and radiographic evaluation) and subjective criteria (limb function and patient satisfaction). RESULTS: Thirty-two patients were included in this study. The mean size of the defect was 6 cm. Ilizarov bone transport was done through the induced membrane chamber in all cases with an average follow-up of 28 months. Successful reconstruction without recurrence of infection was achieved in 30 cases (94%). No other bone or soft tissue procedure was needed with satisfactory functional outcome in 27 out of 30 cases (90%). Three cases had unsatisfactory results due to leg length discrepancy, joint stiffness, and persistent pain. CONCLUSIONS: Masquelet-Ilizarov technique can be used for the management of infected nonunion tibia with high satisfactory results without the need for complex soft tissue procedures.

Field Epidemiology Training Program Response to COVID-19 During a Conflict: Experience From Yemen.

COVID-19 pandemic has underscored the need for a well-trained public health workforce to save lives through timely outbreaks detection and response. In Yemen, a country that is entering its seventh year of a protracted war, the ongoing conflict severely limited the country's capacity to implement effective preparedness and response measures to outbreaks including COVID-19. There are growing concerns that the virus may be circulating within communities undetected and unmitigated especially as underreporting continues in some areas of the country due to a lack of testing facilities, delays in seeking treatment, stigma, difficulty accessing treatment centers, the perceived risks of seeking care or for political issues. The Yemen Field Epidemiology Training Program (FETP) was launched in 2011 to address the shortage of a skilled public health workforce, with the objective of strengthening capacity in field epidemiology. Thus, events of public health importance can be detected and investigated in a timely and effective manner. During the COVID-19 pandemic, the Yemen FETP's response has been instrumental through participating in country-level coordination, planning, monitoring, and developing guidelines/standard operating procedures and strengthening surveillance capacities, outbreak investigations, contact tracing, case management, infection prevention, and control, risk communication, and research. As the third wave is circulating with a steeper upward curve than the previous ones with possible new variants, the country will not be able to deal with a surge of cases as secondary care is extremely crippled. Since COVID-19 prevention and control are the only option available to reduce its grave impact on morbidity and mortality, health partners should support the Yemen FETP to strengthen the health system's response to future epidemics. One important lesson learned from the COVID-19 pandemic, especially in the Yemen context and applicable to developing and war-torn countries, is that access to outside experts becomes limited, therefore, it is crucial to invest in building national expertise to provide timely, cost-effective, and sustainable services that are culturally appropriate. It is also essential to build such expertise at the governorate and district levels, as they are normally the first respondents, and to provide them with the necessary tools for immediate response in order to overcome the disastrous delays.

Incidence, Trend, and Mortality of Human Exposure to Rabies in Yemen, 2011-2017: Observational Study.

BACKGROUND: Rabies remains a neglected and poorly controlled disease throughout the developing world, particularly in Africa and Asia, where most human rabies deaths occur. OBJECTIVE: This study aimed to describe the epidemiology of rabies exposures, its trend, and its geographical distribution in Yemen. METHODS: Cumulative data from a rabies surveillance system for the period 2011-2017 were obtained from the National Rabies Control Program as paper-based annual reports. Data included the number of persons bitten by a suspected rabid animal, their gender and age, and the result of the animal's laboratory test. Human cases were defined as those exposed to rabies virus bitten by a suspected rabid animal, exposed to a confirmed rabid animal and then received postexposure prophylaxis (PEP), and deaths occurred after exposure to a confirmed rabid animal after having rabies symptoms during 2011-2017. RESULTS: From 2011 to 2017, a total of 76,049 persons were bitten by a suspected rabid animal. Of these, 21,927 (28.83%) were exposed to positively confirmed rabid animals and then received PEP, and 295 (0.38%) rabies-related deaths occurred. Of all cases with rabies exposure, 50,882 (66.91%) were males. The most affected age group by animal bites (31,816/76,041, 41.84%), positive exposure (8945/21,927, 40.79%), and rabies deaths (143/295, 48.47%) was 5-14 years. Rabies vaccines and immunoglobulins quantities were least available in 2016 and 2017. The annual incidence rate of exposure to animal bites and rabies exposure was 50 and 14 per 100,000, respectively. The annual mortality rate was 2 per 1,000,000. The highest incidence rate of animal bites was in Dhamar (112 per 100,000) and Ibb (94 per 100,000), whereas the highest incidence of exposed cases was in Amanat Al Asimah (40 per 100,000) and Ibb (37 per 100,000). Mortality rate was the highest in Amanat Al Asimah (6 deaths per 1,000,000) followed by Ibb and Dhamar (4 deaths per 1,000,000 in both). CONCLUSIONS: Rabies remains a worrying health problem in Yemen with higher percentage reported among children and males. Targeting school-age populations by education, communication, and information campaigns about preventive measures is strongly recommended. An electronic system should be introduced to improve reporting. It is important to have a sufficient supply of vaccines and immunoglobulins in control units, especially in the at-risk or impacted governorates. Future studies are suggested to determine incidences and risk factors of disease progression.

Performance of the Neonatal Tetanus Surveillance System (NTSS) in Sana'a, Yemen: Evaluation Study.

BACKGROUND: The Neonatal Tetanus Surveillance System (NTSS) in Yemen was established in 2009 to identify high-risk areas, determine trends, and evaluate elimination activities. Since its launch, the NTSS had never been evaluated. OBJECTIVE: This study aimed to assess the performance of NTSS and determine its strengths and weaknesses to recommend improvements. METHODS: The US Centers for Disease Control and Prevention (CDC) guidelines were used for evaluating the NTSS. Stakeholders at the central, district, and facility levels were interviewed to rate the attributes of the NTSS. The percentage scores for attributes were ranked as poor (<60%), average (≥60% to <80%) and good (≥80%). RESULTS: The overall usefulness score percentage was 38%, which indicates a poor performance. The performance of the NTSS was rated as average on flexibility (score percent: 68%) and acceptability (score percent: 64%) attributes and poor on stability (score percentage: 33%), simplicity (score percentage: 57%), and representativeness (score percentage: 39%) attributes. About 65% of investigation forms were completed within 48 hours of notification date. Data quality was poor, as 41% of the core variables were missing. CONCLUSIONS: The overall performance of the NTSS was poor. Most of the system attributes require improvement, including stability, simplicity, quality of data, and completeness of investigation. To improve the performance of NTSS, the following are recommended: capacity building of staff (focal points), strengthening NTSS through technical support and government funding to ensure its sustainability, establishing electronic investigation forms for improving the system data quality, and expansion of NTSS coverage to include all private health care facilities.

Malignant haemangiopericytomas of omentum presenting as left inguinal hernia: A case report.

BACKGROUND: Hemangiopericytomas (HPC) are vascular tumors and can be found at any place where vessels are present. These were previously known as 'extrapleural Solitary Fibrous Tumour'. These tumors may reoccur and metastasize after surgical excision. We present herein a HPC of the greater omentum, diagnosed as left inguinal hernia preoperatively. CASE PRESENTATION: A 61-year-old male, presented with a huge painless mass in his left inguinoscrotal region secondary to weigh-lifting associated with malaise and vague abdominal pain. A well-defined, non-tender, and firm mass was found at the left lower abdomen extending to the left inguinoscrotal region. Based on the examination, a diagnosis of indirect inguinal hernia was made. Abdominal ultrasound showed a heterogeneous, hyporeflective, and vascularized mass. Contrast-enhanced computed tomography scan identified a localized, extraperitoneal, heterogeneously hypodense, well-defined, and lobulated mass, with marked contrast enhancement. On exploration, an encapsulated large mass originating from the omentum with enormously dilated blood vessels was excised. On histopathology, a neoplastic lesion, composed of spindle-shaped cells and moderate cytoplasm was identified. The blood vessels appeared thin-walled with a staghorn appearance in hemangiopericytic pattern. Omental sections showed fibro adipose tissue with dilated lymphatics and thick-walled blood vessels. Features were consistent with a malignant HPC of 20 × 14 × 10 cm. CONCLUSION: We present an unusual presentation of primary omental malignant HPC as an inguinal hernia, treated by complete surgical resection. These tumors are rare therefore, timely diagnosis is important for proper evaluation, diagnosis, and treatment. It also requires long-term follow up for better survival.

A rare case of idiopathic ileocolic intussusception in an adult.

Intussusception is an invagination of one segment of the bowel into its adjoining segment. In children, the cause is usually benign, while in adults it is secondary to a mass lesion. Here we present a case in which the preoperative diagnosis of intussusception secondary to colonic mass was made, but no definitive cause was identified by histopathology. A 30-year-old male presented with abdominal pain, altered bowel habits, weight loss, loose motions, bleeding per rectum, and vomiting. The abdomen was distended, firm, mildly tender, and guarded. A vague mass of 15 × 10 cm was palpated on the left upper quadrant. X-ray and ultrasound showed dilated small bowel. A computed tomography scan suggested ileoileal intussusception. Colonoscopy showed a growth at 15 cm of the anal verge. Exploratory laparotomy was performed, showing the presence of ileocolic intussusception with two large perforations. Subtotal colectomy with ileostomy was done. The histopathological examination showed signs of perforation.

Ongoing diphtheria outbreak in Yemen: a cross-sectional and genomic epidemiology study.

BACKGROUND: An outbreak of diphtheria, declared in Yemen in October, 2017, is ongoing. We did a cross-sectional study to investigate the epidemiological, clinical, and microbiological features of the outbreak. METHODS: Probable cases of diphtheria that were defined clinically and recorded through a weekly electronic diseases early warning system (from 2017, week 22, to 2020, week 17) were used to identify trends of the outbreak (we divided the epidemic into three time periods: May 29, 2017, to June 10, 2018; June 11, 2018, to June 3, 2019; and June 4, 2019, to April 26, 2020). We used the line list of diphtheria reports for governorate-level descriptions. Vaccination coverage was estimated using the 2017 and 2018 annual reports by the national Expanded Programme on Immunization. To confirm cases biologically, Corynebacterium diphtheriae was isolated and identified from throat swabs using standard microbiological culture and identification procedures. We assessed differences in the temporal and geographical distributions of cases, including between different age groups. For in-depth microbiological analysis, tox gene and species-specific rpoB real-time PCR, Illumina genomic sequencing, antimicrobial susceptibility analysis (disk diffusion, E-test), and the Elek diphtheria toxin production test were done on confirmed cases. We used genomic data for phylogenetic analyses and to estimate the nucleotide substitution rate. FINDINGS: The Yemen diphtheria outbreak affected almost all governorates (provinces), with 5701 probable cases and 330 deaths recorded up to April 26, 2020. We collected clinical data for 888 probable cases with throat swab samples referred for biological confirmation, and genomic data for 42 positive cases, corresponding to 43 isolates (two isolates from one culture were included due to distinct colony morphologies). The median age of patients was 12 years (range 0·2-80). The proportion of cases in children aged 0-4 years was reduced during the second time period, after a vaccination campaign, compared with the first period (19% [95% CI 18-21] in the first period vs 14% [12-15] in the second period, p<0·0001). Among 43 tested isolates, 39 (91%) produced the diphtheria toxin and two had low level (0·25 mg/L) antimicrobial resistance to penicillin. We identified six C diphtheriae phylogenetic sublineages, four of which are genetically related to isolates from Saudi Arabia, Eritrea, and Somalia. Inter-sublineage genomic variations in genes associated with antimicrobial resistance, iron acquisition, and adhesion were observed. The predominant sublineage (30 [70%] of 43 isolates) was resistant to trimethoprim and was associated with unique genomic features, more frequent neck swelling (p=0·0029) and a younger age of patients (p=0·060) compared with the other sublineages. Its evolutionary rate was estimated at 1·67 × 10-6 substitutions per site per year, placing its most recent common ancestor in 2015, and indicating silent circulation of C diphtheriae in Yemen before the outbreak was declared. INTERPRETATION: In the Yemen outbreak, C diphtheriae shows high phylogenetic, genomic, and phenotypic variation. Laboratory capacity and real-time microbiological monitoring of diphtheria outbreaks need to be scaled up to inform case management and transmission control of diphtheria. Catch-up vaccination might have provided some protection to the targeted population (children aged 0-4 years). FUNDING: National Centre of the Public Health Laboratories (Yemen), Institut Pasteur, and the French Government Investissement d'Avenir Programme. TRANSLATION: For the Arabic translation of the abstract see Supplementary Materials section.

Perception of Altered Smile Esthetics by Orthodontists, Dentists, and Laypeople in Riyadh, Saudi Arabia.

BACKGROUND: Mini-esthetics is an important concept in orthodontics concerned with relatedness of dentition to the face. PURPOSE: We compared the perception of altered smile esthetics between orthodontists, dentists, and laypeople in Riyadh, Saudi Arabia. PATIENTS AND METHODS: A total of 216 participants (orthodontists, dentists, and laypeople) were conveniently surveyed. An image representing the ideal smile was altered in terms of buccal corridor, gingival display, and midline diastema. Using Likert scale, participants were asked to rate the attractiveness of the altered images. RESULTS: The three surveyed groups preferred wide rather than narrow buccal corridors. Also, as the amount of gingival display and midline diastema increased, the smile was rated less attractive. Age of participants was significantly associated with more precise recognition of gingival display and midline diastema, P<0.05 and P<0.001, respectively. CONCLUSION: The concept of an ideal smile holds true across the heterogenous groups we studied despite gender and professional background.

The prevalence and determinants of body dysmorphic disorder among young social media users: A cross-sectional study.

Social media that is heavily used in Saudi Arabia has been linked to a negative impact on body image satisfaction. The objective of the current study was to examine the burden, determinants, and impacts of Body Dysmorphic Disorder (BDD) among a community sample of social media users in Saudi Arabia. The Internet-based cross-sectional study was conducted among social media users during January and February 2020. BDD was assessed using a validated BDD Questionnaire. A total of 1010 participants were included in the current analysis. A total of 42 (4.2%) met the criteria of BDD, with higher prevalence in younger participants. The defects of high concerns were skin disfigurements (64.2%) and hair issues (42.3%). BDD was significantly associated with spending a longer time on Snapchat and Instagram and less interest in religious topics. BDD group was more likely to compare their appearance with famous people in social media. BDD group reported more harassment and more history of psychiatric problems. There is a need to educate the public about the risk of BDD and to promote safe social networking.

The Acute Flaccid Paralysis (AFP) Surveillance System in Yemen, 2010-2015: Descriptive Study Based on Secondary Data Analysis.

BACKGROUND: Acute flaccid paralysis (AFP) surveillance is an essential strategy for poliovirus eradication. OBJECTIVE: This study aimed to evaluate the performance of the AFP surveillance system in Yemen from 2010 to 2015, identify components that require strengthening, and compare the indicators by year and governorates. METHODS: This descriptive study was based on secondary analysis of AFP surveillance data reported during 2010-2015 from all Yemeni governorates. The World Health Organization (WHO) minimum performance standards were used to evaluate the performance of the AFP surveillance system. RESULTS: A total of 3019 AFP cases were reported between January 2010 and December 2015. At the national level, AFP surveillance achieved WHO targets throughout the evaluating period for the nonpolio AFP rate of cases per 100,000 members of the population younger than 15 years of age, proportion of AFP cases reported within 7 days, proportion of AFP cases investigated within 48 hours of notification, proportion of AFP cases with two adequate stool specimens, and proportion of stool specimens from which nonpolio enterovirus was isolated. However, the proportion of specimens that arrived at the central level within 3 days of the first sample collection and the proportion of stool specimens with results sent from the reference laboratory within 28 days of receipt did not reach targets in 2011 and 2015, respectively. CONCLUSIONS: The AFP surveillance system in Yemen has met most of the WHO indicator levels. Nevertheless, the evaluation showed areas of weakness regarding the arrival of specimens at the central level within 3 days of the first sample collection and delays in processing of the results and submitting feedback by the laboratory. Therefore, there is a need to strengthen the follow-up of specimens submitted to the laboratory.

Use of Abdominal Binders after a Major Abdominal Surgery: A Randomized Controlled Trial.

Objective To compare the effect of abdominal binder versus no binder after major abdominal surgery and cesarean section on various post-operative recovery parameters. Materials and methods This is a randomized controlled trial conducted at the Department of General Surgery and Obstetrics, Civil Hospital, Karachi, Pakistan. All those patients aged ≥18 years having abdominal surgery including elective and emergency abdominal surgery and cesarean sections with American Society of Anesthesiologists Class I-III were included in the study. Randomization was done using the sealed envelope method by the principal investigator. The intervention group wore an abdominal binder postoperatively while the control group did not use it. Mobilization and the pain status of both groups were evaluated on the first, fourth, and seventh days after surgery. Results Primary outcome variables were mobility, assessed via 6-minute walk test (6MWT) and postoperative pain, evaluated via visual analogue scale. There was no statistically significant difference in the 6MWT distance before (p = 0.278) and on postoperative day one of the surgery (p = 0.0762). However, the difference was significant on fourth (p < 0.001) and seventh day (p value < 0.001). With regards to the pain status, patients in the binder group reported significantly less postoperative pain on first, fourth, and seventh (p value < 0.001) day compared to the non-binder group. Conclusion The use of abdominal binder postoperatively significantly reduced pain and improved mobility in both obstetric and surgery patients.

Dental Panoramic Radiographic Indices as a Predictor of Osteoporosis in Postmenopausal Saudi Women.

BACKGROUND: Many oral presentations of osteoporosis-a bone metabolic disease-were recorded. Thus, we aimed to assess panoramic radiomorphometric indices with bone mineral density (BMD) values among Saudi postmenopausal women and its importance in the prediction of osteoporosis. METHODS: A total of 431 Saudi women were enrolled in this study. Panoramic radiographs were obtained at the time of BMD measurement. Subjects were fatherly classified into; normal BMD, osteopenia, and osteoporosis groups. Serum follicle-stimulating hormone, luteinizing hormone (LH), estradiol (E2), 25-hydroxy-vitamin D (25[OH]D) and intact-parathyroid hormone were measured. Moreover, serum creatinine, calcium, and phosphate, together with serum osteocalcin (s-OC), procollagen type I N-terminal propeptide (s-PINP) and cross-linked C-terminal telopeptide of type 1 collagen (s-CTX) were measured. Receiver-operator curve (ROC) curve analysis for use of mandibular cortical width (MCW), panoramic mandibular index (PMI), and maxillary-mandibular ratio (M/M ratio) to differentiate women with osteoporosis or osteopenia from normal subjects was calculated. Cut off values of 4.6 at T score <-1 and 4.1 at T score ≤-2.5 were used. RESULTS: Body mass index is significantly low in the osteoporotic group. There is no significant difference in serum levels of LH, E2, calcium, phosphate, and 25(OH)D between the studied groups. Moreover, s-OC, C-terminal propeptide of procollagen type I, s-PINP, s-CTX, and urinary-CTX are significantly higher in osteoporosis than normal and osteopenia groups. ROC curve analysis revealed that MCW and PMI showed significant data while M/M ratio is non-significant. CONCLUSIONS: It could be concluded that MCW as an important panoramic radiographic parameter can be used for prediction and diagnosis of osteoporosis in postmenopausal Saudi women with low BMD.

Prevalence and awareness of Anabolic Androgenic Steroids (AAS) among gymnasts in the western province of Riyadh, Saudi Arabia.

BACKGROUND: Anabolic Androgenic Steroids (AAS) are synthetic derivatives of the male sex hormone (testosterone) that are increasingly used by athletes as performance enhancing drugs to increase muscle mass and strength. Multiple health adverse effects may be caused by its non-medical use. Several international and regional studies showed the high prevalence of AAS usage and low level of awareness of it among different populations. OBJECTIVE: To estimate the prevalence of AAS and to determine the level of awareness toward it among gymnasts in the western province of Riyadh. METHODS: This cross-sectional survey was conducted using a self-administered questionnaire distributed on 400 male gymnasts from 10 different fitness centers which have been chosen randomly from 23 centers in the western province of Riyadh city (Kingdom of Saudi Arabia) during 2016. Data analysis was performed by SPSS version 21, using descriptive statistics and Chi-square test. RESULTS: Among the 400 gymnasts who participated in the survey, a total of n=363 questionnaires were received completed. Of the responders, (n=89) were AAS users with a percentage 24.50%. The testosterone was the most commonly used type followed by Methandrostenolone then Stanozolol. The major sources for obtaining AAS were online shopping (45%) and gym-coach (22.5%). Regarding awareness, 74% of AAS users had an inadequate perception about AAS concept versus 55% of non-users with no significant difference (p=0.076). In addition, 82% of AAS users and 83% of non-users had inadequate knowledge of AAS adverse effects with no significant difference between the two categories (p=0.087). CONCLUSION: The usage of AAS is high amongst gymnasts in the western province of Riyadh city considering they are prohibited. The level of awareness toward AAS is low among most gymnasts. We recommend for educational programs to be established in order to increase public awareness, in addition to a tightening of control by the responsible authorities over the sources of AAS procurement.

Managing infection: a holistic approach.

All wound infection presents risks for the patient, but the risks are multiplied in the presence of a comorbidity such as diabetes, when they can potentially be fatal. Where diabetic foot ulcer (DFU) infection is concerned, early recognition is crucial. Prompt treatment, comprising wound cleansing, debridement of devitalised tissue and use of antimicrobial dressings, can stop locally infected ulcers from deteriorating further.