Assessment of tear film parameters in females with refractive errors using a single device: An observational study.

This observational study aimed to evaluate the use of a single portable device to assess the non-invasive tear break-up time (NITBUT), tear meniscus height (TMH), and lipid layer patterns (LLP) in young females with refractive errors (REs). The study was conducted at the College of Applied Medical Science (Female campus), Riyadh, Saudi Arabia between January 5, 2021 to May 15, 2021. Forty young females, with mean age of 23.0± 4.3 years with REs (-2.53 ± 2.05 D) and 40 females, mean age 23.8± 4.5 years with healthy eyes were recruited. The tests were administered in the following order: Ocular Surface Disease Index (OSDI), followed by NITBUT, TMH, and LLP. Significant differences (via Mann-Whitney U test) were noted in the median ocular surface disease index (OSDI; p˂0.001), NITBUT (p=0.035), TMH (p=0.009), and LLP (p˂0.001) scores between the study and control groups. Females with REs have significantly lower lipid layer, TMH, and NITBUT scores than those with healthy eyes.

Standard dosing of enoxaparin versus unfractionated heparin in critically ill patient with COVID-19: a multicenter propensity-score matched study.

BACKGROUND: Thrombotic events are common in critically ill patients with COVID-19 and have been linked with COVID-19- induced hyperinflammatory state. In addition to anticoagulant effects, heparin and its derivatives have various anti-inflammatory and immunomodulatory properties that may affect patient outcomes. This study compared the effectiveness and safety of prophylactic standard-doses of enoxaparin and unfractionated heparin (UFH) in critically ill patients with COVID-19.  METHODS: A multicenter, retrospective cohort study included critically ill adult patients with COVID-19 admitted to the ICU between March 2020 and July 2021. Patients were categorized into two groups based on the type of pharmacological VTE thromboprophylaxis given in fixed doses (Enoxaparin 40 mg SQ every 24 hours versus UFH 5000 Units SQ every 8 hours) throughout their ICU stay. The primary endpoint was all cases of thrombosis. Other endpoints were considered secondary. Propensity score (PS) matching was used to match patients (1:1 ratio) between the two groups based on the predefined criteria. Multivariable logistic, Cox proportional hazards, and negative binomial regression analysis were used as appropriate.  RESULTS: A total of 306 patients were eligible based on the eligibility criteria; 130 patients were included after PS matching (1:1 ratio). Patients who received UFH compared to enoxaparin had higher all thrombosis events at crude analysis (18.3% vs. 4.6%; p-value = 0.02 as well in logistic regression analysis (OR: 4.10 (1.05, 15.93); p-value = 0.04). Although there were no significant differences in all bleeding cases and major bleeding between the two groups (OR: 0.40 (0.07, 2.29); p-value = 0.31 and OR: 1.10 (0.14, 8.56); p-value = 0.93, respectively); however, blood transfusion requirement was higher in the UFH group but did not reach statistical significance (OR: 2.98 (0.85, 10.39); p-value = 0.09). The 30-day and in-hospital mortality were similar between the two groups at Cox hazards regression analysis. In contrast, hospital LOS was longer in the UFH group; however, it did not reach the statistically significant difference (beta coefficient: 0.22; 95% CI: -0.03, 0.48; p-value = 0.09). CONCLUSION: Prophylactic enoxaparin use in critically ill patients with COVID-19 may significantly reduce all thrombosis cases with similar bleeding risk compared to UFH.

Severity and depression can impact quality of life in patients with myasthenia gravis.

BACKGROUND: The revised 15-item Myasthenia Gravis (MG) Quality of Life Questionnaire (MGQoL15R) is a validated scale of quality of life in patients with MG. We aimed to study the factors causing the variability within the Arabic version of the MGQoL15R (MGQoL15R-A). METHOD: A standardized questionnaire was completed by 118 patients. Correlations and hierarchical regression analyses were used to assess the contribution of sociodemographic variables, clinical factors, Patient Health Questionnaire-9 (PHQ9-A), and Generalized Anxiety Disorder-7 (GAD7-A) to the variability in the MGQoL15R-A. RESULTS: The MGQoL15R-A was highly correlated with PHQ9-A (r = 0.76), and moderately correlated with GAD7-A (r = 0.52). Clinical factors and PHQ9-A independently explained 30.4% and 34.5% of the variability, respectively. Among the clinical factors, uncontrolled MG status, relapse within the past year, and a higher number of current MG therapies were significantly associated with a higher MGQoL15R-A score. CONCLUSIONS: MG severity and depressive symptoms (measured by PHQ9-A) can affect the MGQoL15R-A score.

Langerhans cell histiocytosis presenting as a blueberry muffin rash.

Langerhans cells, often referred to as the "macrophages of the skin", are dendritic cells that normally reside in the epidermis and papillary dermis. Just like macrophages, they function as antigenpresenting cells that activate naive T cells. Certain mutations such as those involving the BRAF gene can cause unopposed production of Langerhans cells, which is known as Langerhans cell histiocytosis (LCH). LCH triggers an inflammatory immune response that causes systemic manifestations such as fever and fatigue, as well as other manifestations depending on the affected organs. The pathogenesis behind LCH remains poorly understood. It is still unknown whether it is a neoplastic process or a reactive cancer-mimicking illness. Diagnosis of LCH is confirmed by biopsy, and treatment is largely dependent on the extent and severity of the disease. Common treatments include corticosteroids, excision, radiation, and chemotherapy. We present a case of a 1-year-old Saudi male with LCH.

Frostbite secondary to antimycobacterial-induced peripheral neuropathy: a case report.

This case report describes a unique scenario in which antimycobacterial-induced peripheral neuropathy (PN) culminates in severe bilateral foot frostbite. Drug-induced peripheral neuropathy (DIPN) is explored in the context of TB treatment, highlighting the role of medications such as isoniazid (INH) and their potential to cause PN. The report highlights the importance of identifying PN in patients undergoing antimycobacterial treatment. Early recognition and proper management of PN is crucial to prevent complications. Notably, the report advocates for patient education regarding medication side effects and avoiding harmful practices, such as ice immersion, to alliviate neuropathic pain. Emphasis is directed towards the need for a multidisciplinary approach to patient care and a focus on preventative strategies to improve patient outcomes and avoid severe debilitating complications.

Exploring the Oral Manifestations and Hazards to Dental Professionals During the COVID-19 Pandemic: A Scoping Review.

The novel coronavirus (COVID-19) has inundated the whole world by causing severe acute respiratory syndrome in humans, thus posing serious public health concerns. The oral and olfactory systems are significantly impacted by the COVID-19 condition, in addition to the respiratory and digestive systems. Oral symptoms of COVID-19 can be caused by a loss in oral hygiene, immune system suppression, a decline in general health, and candidiasis due to prolonged antibiotic use. Because many aerosols and droplets are produced during various dental operations, dental professionals and dentists are at a significant risk of contracting the COVID-19 infection. Few precautionary measures include performing a pre-appointment health screening for all patients, performing aerosol-producing procedures in a designated space or operatory, using proper personal protective equipment and disinfecting the operatory between patients, and limiting the number of dental procedures at one time. Against this background, the purposes of this article are to explore the oral presentations of COVID-19 infection and to emphasize the hazards to dental professionals during COVID-19 pandemic. Additionally, few preventive measures are also highlighted.

Retraction: Pure Uterine Lipoma: A Report of a Rare Entity.

[This retracts the article DOI: 10.7759/cureus.20444.].

The Effects of Glutamine Supplementation on Reducing Mortality and Morbidity among Burn Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Glutamine (GLN) has been proven to improve the prognosis of severely burned patients. GLN supplementation in critical illness has gained extreme popularity among researchers over the years, and its safety and efficacy are still under question. Therefore, we aim to study the role of GLN supplements in decreasing mortality, length of hospitalization (LOH), and infection in severely burned patients. PRISMA guidelines were used to design and conduct this systematic review. MEDLINE, Cochrane, and EMBASE databases were used to search for randomized controlled trials (RCTs) in January 2022. In order to assist in the search, MeSH terms such as burn injury, GLN, and RCT were used. As a result of reviewing the literature, 1112 publications were found. We included only 7 RCTs after implanting our inclusion criteria. There were 328 patients enrolled in the study, with 166 patients (50.61%) were allocated to GLN supplementation and 162 patients in the control groups (49.39%). The risk of infection was significantly lower among patients who received GLN supplementation than those in the control groups (RR = 0.41, 95% CI, 0.18 to 0.92, p = 0.030). The risk of death was significantly lower among GLN-receiving patients compared to non-GLN-receiving patients (RR = 0.09, 95% CI, 0.01 to 0.63, p = 0.016). GLN supplementation has been linked to lower hospital mortality and infection-related morbidity in burn patients. Furthermore, larger-scale and higher-quality studies are needed to assess whether there are any statistically and clinically significant changes.

Azelaic Acid Versus Hydroquinone for Managing Patients With Melasma: Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Melasma, a commonly acquired hyperpigmentation skin condition, is usually treated with topical agents as the first line of management. This systematic review and meta-analysis aimed to assess the efficacy and safety of azelaic acid versus hydroquinone in treating melasma patients. We conducted a comprehensive search across four online databases (PubMed, Scopus, Web of Science, and Cochrane Library) from the time of their creation until May 28, 2023. We considered randomized controlled studies comparing hydroquinone with azelaic acid for the treatment of melasma patients. We used the Cochrane Risk of Bias tool 2 to evaluate the risk of bias. The mean difference (MD) for continuous variables and the risk ratio (RR) for categorical variables, with a 95% confidence interval (CI) were pooled. Six studies were included, with a total of 673 patients with melasma. The azelaic acid had a lower mean change in melasma area severity index (MASI) than the hydroquinone group [MD= -1.23, 95% CI (-2.05, -0.40), P=0.004]. No difference was observed regarding the improvement via the objective response scale, the reduction in pigmentation, or the adverse events reported. However, despite not being statistically significantly different, there was a trend towards having more good responses in the azelaic acid group. Azelaic acid may be better than hydroquinone in reducing melasma severity (measured by MASI). However, larger studies with long-term follow-up are needed to validate these findings.

Hemorrhagic Necrotizing Cholecystitis With Cholecystocolonic Fistula: A Case Report.

Cholecystocolonic fistula (CCF) and hemorrhagic cholecystitis are rare complications of gallstones that have a wide range of non-specific symptoms and clinical severity. We present a case of a 74-year-old woman on warfarin who presented to the emergency department with a 10-day history of abdominal pain, vomiting, and watery diarrhea. Her abdomen was distended with generalized tenderness and palpable mass in the right lower quadrant. Laboratory tests revealed leukocytosis and an elevated international normalized ratio (INR). After admission and imaging, exploratory laparotomy showed hemorrhagic cholecystitis with CCF in the cecum. There was no pus or stool contamination. A cholecystectomy followed by right hemicolectomy with primary ileocolic anastomosis was performed. The postoperative course was uneventful, and the patient was discharged in stable condition. The presence of hemorrhagic cholecystitis in conjunction with CCF could lead to significant consequences such as hemorrhagic and septic shock in older patients with comorbidities. It is crucial to identify and intervene early before clinical deterioration.

Plastic Surgery in the Gulf Cooperation Council Countries: Role of Telemedicine.

Internationally, telemedicine is finding its way into common day plastic surgery practice as a result of the COVID-19 pandemic. Nonetheless, no data about its practice in the Gulf region are available to date. Methodology: This is a cross-sectional survey-based study that was sent online to the plastic surgeons practicing in the Gulf region. The study aimed to look into the integration of telemedicine into the practice and the surgeons' attitude and future vision about it. Participation was voluntary, and confidentiality was preserved. Results: A total of 229 plastic surgeons enrolled in this study in mid-2020. There were 192 male participants (83.8%) and 37 female participants (16.2%). Of these, 99 (43.2%) practiced in Saudi Arabia, 85 (37.1%) in the United Arab Emirates, 24 (10.5%) in Oman, 18 (7.9%) in Kuwait, and three (1.3%) in Bahrain. In total, 85 (37.1%) used telemedicine during lockdown, and 144 (62.9%) thought that its usage will remain beneficial in the future. There was no significant difference in practicing telemedicine in different plastic surgery subspecialties, varying level of experience, and country of practice. Among those who used virtual consultations, 62 (72.9%) did not charge for consultation fees. Conclusion: The tendency toward telemedicine integration in plastic surgery practice is growing worldwide, especially after COVID-19. Its limitations are outweighed by its advantages and, with time, many of these will be bypassed. New innovations driven by advancement in technology will further embed telemedicine into the practice.

The prescribing pattern of sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists in patient with type two diabetes mellitus: A two-center retrospective cross-sectional study.

Background: The use of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RA) in patients with type 2 diabetes mellitus (T2DM) remains limited, especially in those with other compelling indications. Thus, this study aimed to describe the prescribing patterns of GLP-1-RA and SGLT2i in patients with T2DM and to determine the factors that affect the prescribing of these medications. Methods: This multicenter retrospective cross-sectional study reviewed the electronic health records of adult patients diagnosed with T2DM who received care between January and December 2020. The patients were classified according to their compelling indications into "patients who are more likely" to benefit from SGLT2i or GLP-1 RA and "patients who are less likely" to benefit from them. They were then further categorized depending on whether these medications were prescribed. Results: A total of 1,220 patients were included; most were female (56.9%). SGLT2i or GLP-1 RA were preferably prescribed in only 19% of the patients for reasons including BMI ≥ 27 kg/m2 (85.6%), uncontrolled T2DM (68.5%), high risk for ASCVD (23.9%), or established ASCVD (14%). The remaining 81.0% were underprescribed these agents. Patients at an older age or with a history of stroke or transient ischemic attack had higher odds of being underprescribed (OR 1.02; 95% CI: 1.01-1.03 and OR 2.86; 95% CI: 1.33-6.15), respectively. Conclusion: The results concur with those of previous studies highlighting the underutilization of GLP-1 RA and SGLT2i in patients with T2DM but also with compelling indications. To optimize the use of GLP-1 RA and SGLT2i for their additional benefits, prescribers need to assess the benefits of using these agents in patients who would likely benefit from them, regardless of DM control.

Diabetic foot and peripheral arterial disease. Single centre experience.

OBJECTIVES: To determine the prevalence of vasculopathic diabetic foot and the associated factors in a Saudi tertiary center. Methods: This retrospective chart review included adult patients (≥18 years) diagnosed with diabetic foot between May 2015 and July 2019 in King Saud University Medical City, Riyadh, Kingdom of Saudi Arabia. Based on clinical presentation and laboratory results, the patients were categorized into 2 groups namely, "vascular induced diabetic foot group" and "non-vascular induced diabetic foot group". RESULTS: A total of 404 diabetic patients were enrolled in the study. The mean age of the patients was 62.03±12.30 years; 61.9% were males. Most of the diabetic foot cases had a non-vascular etiology (n=327, 80.9%), while 77 cases (19.1%) were due to vasculopathy. Patient in the vascular group had a significantly higher incidence of coronary artery disease (32.5% versus 14.4%; p greater than 0.001), and a higher incidence of peripheral artery disease (PAD) in the unaffected limb (22.1% versus 2.1%; p less than 0.001). Conclusion: Most cases of diabetic foot were due to non-vascular causes. Old age, history of coronary artery disease, or PAD in the unaffected limb were factors that were significantly associated with diabetic foot due to arterial disease.

The attitude and practice of general surgeons toward cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: A cross-sectional study.

BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) mandate well-established HIPEC and oncology centers, which are not available in many medical institutions. This study assessed the knowledge, attitude, and practice toward CRS and HIPEC of general surgeons in Riyadh, Saudi Arabia. PATIENTS AND METHODS: General surgeons (n = 266) from nine hospitals who treat patients with gastrointestinal cancer were surveyed. The responses of surgeons who work in HIPEC and academic centers (Group A) and surgeons working in tertiary and secondary hospitals (Group B) were compared. The survey response rate was 48.1% (128/266). RESULTS: Surgeons in group B treated significantly more patients with peritoneal carcinomatosis per year than surgeons in group A (P = .001). Group B reported having a HIPEC specialist at their hospital, and 71.4% reported that the nearest HIPEC center was within 30 miles, compared to 4.5% of respondents in group A (P = .001). Lack of access to a HIPEC specialist was reported by 15.5% of surgeons in group B and 0% of surgeons in group A (P = .006). HIPEC as a possible therapeutic option for appendiceal cancer was cited by 60.7% of surgeons in group B compared to 84.1% of surgeons in group A (P = .007) and as a therapeutic option for ovarian cancer by 52.4% of surgeons in group B and 81.8% of surgeons in group A (P = .001). CONCLUSION: New strategies are needed to improve the knowledge and implementation of the referral system for HIPEC among general surgeons. Our study was limited by a low response rate.

Medical Faculty's and Students' Perceptions toward Pediatric Electronic OSCE during the COVID-19 Pandemic in Saudi Arabia.

BACKGROUND: The educational process in different medical schools has been negatively affected by the COVID-19 pandemic worldwide. As a part of the Saudi government's attempts to contain the spread of the virus, schools' and universities' educational activities and face-to-face lectures have been modified to virtual classrooms. The purpose of this study was to explore the perceptions of the faculty and the students of an electronic objective structured clinical examination (E-OSCE) activity that took place during the COVID-19 pandemic in the oldest medical school in Saudi Arabia. METHODS: An e-OSCE style examination was designed for the final-year medical students by the pediatrics department, College of Medicine at King Saud University in Riyadh, Saudi Arabia. The examination was administered by Zoom™ video conferencing where both students and faculty participated through their laptop or desktop computers. In order to explore the students' and the faculty's perceptions about this experience, a newly designed 13-item online questionnaire was administered at the end of the e-OSCE. RESULTS: Out of 136 participants (23 faculty and 112 students), 73 respondents (e.g., 54% response rate) filled out the questionnaire. Most of the respondents (69.8%) were very comfortable with this new virtual experience. Most participants (53.4%) preferred the e-OSCE compared to the classic face-to-face clinical OSCE during the pandemic. Regarding the e-OSCE assessment student tool, 46.6% reported that it is similar to the classic face-to-face OSCE; however, 38.4% felt it was worse. CONCLUSIONS: The e-OSCE can be a very effective alternative to the classic face-to-face OSCE due to the current circumstances that still pose a significant risk of infection transmission. Future studies should examine different virtual strategies to ensure effective OSCE delivery from the perspective of both faculty and students.

Pure Uterine Lipoma: A Report of a Rare Entity.

Abnormal genital tract bleeding is a commonly encountered complaint in general practice. It has a wide range of etiologies and the spectrum depends on the reproductive status of the patient. While it represents a small proportion of genital tract bleeding, endometrial carcinoma is the main concern in postmenopausal women with abnormal genital bleeding. However, the majority of cases are due to benign etiologies. We present the case of a 65-year-old woman who presented to the outpatient department complaining of vaginal bleeding and lower abdominal pain for the last two months. The patient did not report any use of hormonal replacement therapy. Her last Pap smear was five years ago and it yielded no abnormal cells. On examination, the patient appeared obese with a body mass index of 35 kg/m2. Abdominal examination revealed a palpable pelvic mass that was firm and non-tender. The patient underwent an abdominal computed tomography scan which demonstrated a well-defined oval-shaped homogeneous fat attenuation mass lesion within the uterine wall with no evidence of invasion. Such findings were suggestive of uterine lipoma. The patient underwent a total hysterectomy and bilateral salpingo-oophorectomy. Histopathological examination of the specimen confirmed the diagnosis of pure lipoma. After six months of close follow-up, the patient had no active complaints. Pure uterine lipoma is an exceedingly rare benign neoplasm of the uterus. It may present with an abdominal mass and abnormal genital bleeding. Awareness of the clinical and radiological features of this tumor is crucial to avoid unnecessary surgeries in asymptomatic patients.

Plastic Surgery and COVID-19 in the GCC: Fears, Lessons Learned, and the Plan for the Future.

BACKGROUND: With the labeling of Coronavirus Disease 2019 (COVID-19) as a pandemic by the World Health Organization, national directives were issued instructing to close all cosmetic clinics, suspend all cosmetic procedures, and only operate on an emergency basis. As a result, many plastic surgeons faced challenges sustaining their practice. We aimed to investigate the effect of these national directive instructions on the surgeons and to review their strategies for adapting their practices during this new pandemic. METHODS: A cross-sectional descriptive study was conducted using an online questionnaire. It was constructed to assess the attitudes and practices of plastic surgeons in the Gulf Cooperation Council countries during the COVID-19 lockdown. It also explored their strategies on reopening their practice, as well as their plans on modifications of practice during and after the lockdown. RESULTS: In total, 197 surgeons responded to the survey. The majority were from Saudi Arabia (42.1%), followed by the United Arab Emirates (37.6%), with relatively smaller participation from the remaining countries. Over two-thirds (69.5%) indicated that the pandemic had affected their practice. Surgeons in private practices were significantly affected (P < 0.001) compared with those in the public sector. Only 39% of respondents mentioned COVID-19 testing as part of their post-pandemic surgical protocol. CONCLUSIONS: Surgeons' responses to the pandemic varied. Fear and future uncertainty significantly led to a surge in the utilization of different technical means to maintain the patient pool. Surgeons' education about post-pandemic precautions is essential to maintain high standards of care in the region.

Profile of facial palsy in Arar, northern Saudi Arabia.

BACKGROUND: The term facial palsy generally refers to weakness of the facial muscles, mainly resulting from temporary or permanent damage to the facial nerve. Common causes of facial paralysis include infection or inflammation of the facial nerve, head trauma, head or neck tumor, stroke. OBJECTIVE: To outline the incidence of several etiologies and the profile of patients with peripheral facial paralysis attending the outpatient clinic of the neurology department in Hospitals of Arar City, Saudi Arabia. METHODS: This cross-sectional study was carried out in Arar city from October 2016 to May 2017. The study was conducted in the outpatient clinic of the neurology department in hospitals of Arar City. Any ages of both sexes of all newly diagnosed unilateral facial palsy were included in the study. Data were analyzed by SPSS version 15, using descriptive statistics and Chi-square test. P-value was considered significant if <0.05. RESULTS: The mean age of the facial palsy cases was 33.65 (±11.71) years. Among the studied participants, the total prevalence of facial palsy was 26.3% (61% females and 39% males). The right side of the face was affected in 51.2% and the etiology was exposure to cold air current in 92.7% of cases. The treatment was physiotherapy in 80.5% of the cases, medical in 17.1% and surgical in 2.4%. There was significant relationship between smoking and the occurrence of facial palsy (p<0.05). CONCLUSION: The study revealed that facial palsy was common in Arar city. The rate is higher among males than females. We also concluded that exposure to cold air current was the main etiology. We recommend health education sittings to bring awareness to the public about the nature, causes, risk factors, prevention and treatment of the disease.