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Jamal Al Saleh,1 Hani Almoallim,2 Bassel Elzorkany,3 Ali Al Belooshi,4 Omar Batouk,5 Mohamed Fathy,6 Nora Vainstein,7 Abdullah M Kaki8 1Department of Rheumatology, Dubai Hospital, Dubai Health Authority, Dubai, United Arab Emirates; 2Department of Medicine, Medical College, Umm Al-Qura University, Makkah, Saudi Arabia; 3Rheumatology Department, Cairo University, Cairo, Egypt; 4Mediclinic City Hospital, Department of Surgery, UAE University, Dubai, United Arab Emirates; 5King Saud bin Abdulaziz University for Health Sciences, National Guard Health Affairs, Jeddah, Saudi Arabia; 6Pfizer, Dubai, United Arab Emirates; 7Pfizer, Buenos Aires, Argentina; 8Department of Anesthesia and Critical Care, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi ArabiaCorrespondence: Abdullah M Kaki, MD, FRCPC, Professor of Anesthesiology and Pain Medicine, Faculty of Medicine, King Abdulaziz University, PO Box 2907, Jeddah, 21461, Saudi Arabia, Tel/Fax +966126408335, Email akaki@kau.edu.sa; amkaki@yahoo.comIntroduction/Objectives: This rapid evidence assessment (REA) was conducted to assess the burden of weight-bearing joint osteoarthritis in the developing countries of Africa and the Middle East.Methods: Our REA methodology used a standardized search strategy to identify observational studies, published between January 1, 2010, and April 23, 2020, reporting on outcomes pertaining to the epidemiology and humanistic or economic burden of weight-bearing osteoarthritis. Relevant data from the included studies were used for qualitative analysis.Results: Among the 20 publications reporting on knee osteoarthritis in 10 countries in Africa and the Middle East, 2 also reported on hip, and 1 on foot osteoarthritis. Prevalence of symptomatic/radiographic knee OA was 9– 14% among rheumatology outpatients and 31– 34% among those with mixed etiology osteoarthritis. Prevalence of knee OA diagnosed by magnetic resonance imaging was 70% among patients ≥ 40 years of age attending a hospital in Saudi Arabia. Quality-of-life outcomes were reported in 16 publications and suggested a substantial humanistic burden of osteoarthritis, including worse pain, function, and quality of life, and more depression; comparisons between studies were hampered by the variety of tools and scoring scales used, however. No studies reported on economic outcomes.Conclusion: This REA indicates a substantial burden of osteoarthritis in weight-bearing joints in Africa and the Middle East, consistent with publications from other regions of the world.Keywords: Africa, burden of disease, Middle East, osteoarthritis, quality of life

Amara Swapna Lingam,1,&ast; Pradeep Koppolu,2,&ast; Sara Ahmad Alhussein,1 Rawa Kamal Abdelrahim,2 Ghadah Salim Abusalim,3 Sally ElHaddad,1 Sadaf Asrar,4 Mohammad Zakaria Nassani,5 Sarah Salah Gaafar,5,6 Ferdous Mohammed T Bukhary,2,7 AbdulRahman Saeed AlGhamdi,8 Ali Barakat,5 Mohammed Noushad,5 Hesham Almoallim1,9 1Department of Surgical and Diagnostic Sciences, Dar Al Uloom University, Riyadh, Saudi Arabia; 2Department of Preventive Dental Sciences Dar Al Uloom University, Riyadh, Saudi Arabia; 3Department of Medical Laboratory Science, College of Applied Medical Sciences, Prince Sattam Bin Abdulaziz University, AlKharj, Kingdom of Saudi Arabia; 4Department Oral Biology, Liaquat college of Medicine and Dentistry, Karachi, Pakistan; 5Department of Restorative and Prosthetic Dental Sciences, College of Dentistry, Dar Al Uloom University, Riyadh, Saudi Arabia; 6Conservative Dentistry Department, Faculty of Dentistry, Alexandria University, Alexandria, Egypt; 7Department of Pediatric Dentistry and Orthodontics, King Saud University, Riyadh, Saudi Arabia; 8Dental Department, Security Forces Hospital Program, Riyadh, Kingdom of Saudi Arabia; 9Department of Oral and Maxillofacial Surgery, College of Dentistry, King Saud University, Riyadh, 11545, Saudi Arabia&ast;These authors contributed equally to this workCorrespondence: Amara Swapna Lingam, Department of Surgical and Diagnostic Sciences, Dar Al Uloom Univeristy, Riyadh, Saudi Arabia, Email lingam@dau.edu.saBackground: Human papilloma virus (HPV) infection forms a major etiological factor for oropharyngeal cancer (OPC), which has exhibited increased global incidence.Aim: To compare the knowledge regarding HPV, its association with OPC, and HPV vaccine among students from different countries, years of the undergraduate program, and gender.Methods: The current multinational cross-sectional study was conducted in 886 undergraduate dental students from Egypt, India, Pakistan, Saudi Arabia, UAE, and Sudan through Google survey forms from July 2021 to September 2021. The survey form comprised 27 items divided into four sections. The answers to the questionnaire were compared among students from different countries, different years of the undergraduate program, and males and females. Chi-square test was used to evaluate the correlation between the demographic characteristics of students and their knowledge regarding HPV and OPC.Results: Females exhibited a better knowledge regarding knowledge and perception on HPV vaccine, whereas males exhibited a better knowledge regarding HPV and its correlation with OPC, and these differences were statistically significant (P < 0.05). The third- and fourth-year undergraduate students displayed a higher awareness of OPC and its connection with HPV than other year students, and this variance was found to be statistically significant (P < 0.001). Third-year and internship students exhibited a more positive attitude and comfort regarding the vaccine and discussing the same with patients than the other educational-level students. Students from India exhibited better knowledge about HPV and its association with OPC than the students from other countries, and this difference was statistically significant (P < 0.001).Conclusion: Disparities in knowledge regarding HPV-related oral cancer have been detected among the female and male participants among different nations. From the entire study population, Indian students exhibited better knowledge regarding HPV. Females from all the nations exhibited a more positive attitude and comfort regarding the vaccine and discussing the same with patients than males. The results of this necessitate intervention measures including training workshops and awareness campaigns. Improving their knowledge regarding the same may increase their awareness, resulting in better patient care.Keywords: carcinoma, squamous cell, human papillomavirus 16, oropharyngeal neoplasms, papillomavirus infections, papillomavirus vaccines, sexually transmitted diseases

Altaf Abdulkhaliq,1 Mohamed Cheikh,2,3 Fahad Almuntashri,4 Haneen Alzahrani,4 Huda Nadwi,4 Eithar Kadi,4 Mutasem Abed,4 Murad Janaini,4 Alaa Monjed,4 Nahed Janoudi,2 Hani Almoallim4,5 1Department of Clinical Biochemistry, Faculty of Medicine, Umm Al Qura University, Makkah, Saudi Arabia; 2Internal Medicine Department, Doctor Soliman Fakeeh Hospital, Jeddah, Saudi Arabia; 3Department of Medicine, Fakeeh College for Medical Sciences, Jeddah, Saudi Arabia; 4Department of Medicine, Faculty of Medicine, Umm Al Qura University, Makkah, Saudi Arabia; 5Alzaidi Chair of Research in Rheumatic Diseases, Umm Al Qura University, Makkah, Saudi ArabiaCorrespondence: Fahad Almuntashri Tel +966 542626003Email fahadalmuntashri@gmail.comIntroduction: Osteoporosis (OP) is one of the most common comorbidities associated with rheumatoid arthritis (RA). Literatures reported that the risk for developing OP was strongly associated with duration and severity of RA. We aim to elaborate on the consequences of OP on disease activity and management plan in patients with RA.Patients and Methods: A retrospective cohort study recruited 408 patients, including those with RA alone and with RA plus OP. The RA disease activity in the patients was assessed using disease activity score in 28 joints (DAS28-CRP). A statistical analysis was performed to compare data between the two groups of patients and determine any significant risk factor associated with the development of OP in RA patients.Results: Of 408 patients who were included in this study, 353 patients (86.5%) had only RA, while 55 patients (13.5%) had RA with OP and showed significant difference (P = 0.04) concerning age categories. Patients diagnosed with RA and OP had RA duration longer than RA-only patients (independent t-test, P = 0.01). The two groups had almost similar disease activity at the three clinical visits, as well, had nearly similar disability at their first visit, whereas RA with OP patients had significant greater disability at their 2nd and 3rd visits (independent t-test, P = 0.001). Both groups were treated with the same biologic and non-biologic medication of similar frequency, although RA patients with OP received steroid more frequently than patients had RA only (61.7% vs. 41.7%, chi square test, P = 0.03).Conclusion: There was no significant difference in disease activity at both groups of patients. However, RA with OP group had longer duration of RA, were more frequently treated with steroids, and had greater disability. We recommend physicians focus on controlling RA disease activity, early screening for and treating of OP.Keywords: rheumatoid arthritis, osteoporosis, disease activity, biologic, disease modifying antirheumatic drugs, effects, RA OP

Rbab Taha,1 Shahd Abureesh,2 Shuruq Alghamdi,2 Rola Y Hassan,3 Mohamed M Cheikh,4,5 Rania A Bagabir,6 Hani Almoallim,2,7 Altaf Abdulkhaliq8 1Department of Transplant Infectious Disease, University Health Network, Toronto, Ontario, Canada; 2Department of Medicine, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia; 3Department of Internal Medicine, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia; 4Department of Internal Medicine, Doctor Soliman Fakeeh Hospital, Jeddah, Saudi Arabia; 5Department of Medicine, Fakeeh College for Medical Sciences, Jeddah, Saudi Arabia; 6Department of Immunology and Hematology, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia; 7Alzaidi Chair of Research in Rheumatic Diseases, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia; 8Department of Clinical Biochemistry, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi ArabiaCorrespondence: Rola Y Hassan Email r.toufiq@hotmail.comAbstract: Vitamin D is proposed to have a potential role in the pathogenicity, clinical presentation, prognosis, complications, and treatment of several diseases. In addition to its well-known role in calcium metabolism, vitamin D regulates both innate and adaptive immunity, and subsequently modulates the antiviral and antibacterial inflammatory immune responses. In view of the emerging coronavirus disease 2019 (COVID-19) pandemic, searching for potential therapeutic and protective strategies is of urgent interest, and vitamin D is one of the promising agents in this field. In this review, we present data from literature that supports the promising role of vitamin D in treatment and/or prevention of several infections including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This review summarizes vitamin D metabolism and its role in inflammation, thrombosis and immune regulation. It also reviews, in short, the role of vitamin D and the impact of its deficiency in several infections namely tuberculosis, influenza, human immunodeficiency virus (HIV), and SARS-CoV-2. Considering the roles of vitamin D on immune modulation, controlling of thrombosis, and attacking several microorganisms, the current review will elaborate on the association between these salient roles of vitamin D and the pathogenicity of various infectious agents including COVID-19. Consequently, the comprehensive finding of the current review shows a possible significant impact of vitamin D supplement as a hope in preventing, treating, and/or improving the progression of certain infections, specifically during the worldwide attempts to fight against the COVID-19 pandemic and minimize the severity of health complications encountered accordingly. In addition, avoiding a status of vitamin D deficiency to obtain its positive effects on the immune system and its protective mechanism during infections will be a general benefit overall.Keywords: 1,25(OH)2D, 1,25-dihydroxyvitamin D, 25(OH)D, 25-hydroxyvitamin D, HIV, human immunodeficiency virus, SARS, COVID-19, severe acute respiratory syndrome, TB, tuberculosis, MTB, Mycobacterium tuberculosis, influenza

Sami Alobaidi,1 Naji Dwid,2 Khaldoun Shikh Souk,3 Mohamed Cheikh,4 Ahmed Mandurah,3 Khaled Al-Khatib,3 Ans Ahmed,3 Hani Almoallim5 1Department of Medicine, University of Jeddah, Jeddah, Saudi Arabia; 2Doctor Soliman Fakeeh Hospital, Nephrology Fellow for Saudi Commission for Health Specialties, Jeddah, Saudi Arabia; 3Doctor Soliman Fakeeh Hospital, Jeddah, Saudi Arabia; 4Doctor Soliman Fakeeh Hospital, Rheumatology Fellow for Saudi Commission for Health Specialties, Jeddah, Saudi Arabia; 5Medical College, Umm Alqura University (UQU), Makkah, 21441, Saudi ArabiaCorrespondence: Sami AlobaidiDepartment of Medicine, University of Jeddah, Jeddah, Saudi ArabiaEmail salobaidi@uj.edu.saContext: Hyperuricemia is prevalent in patients with chronic kidney disease (CKD). Although it is associated with CKD incidence and progression, treating asymptomatic hyperuricemia with uric acid-lowering agents is still debatable.Aim of Work: determine the rate of non-classical prescription of allopurinol in CKD patients.Settings and Design: This was a retrospective study of adult patients prescribed allopurinol with CKD (stages 2– 5) in Doctor Soliman Fakeeh Hospital (DSFH) Jeddah, Saudi Arabia, from 1/1/2016 to 1/1/2017.Subjects and Methods: Eligible patients were identified from the hospital’s pharmacy system and cross-referenced with the electronic health records. Demographic data, laboratory results and indication as recorded by the prescribing physician were extracted. Prescriptions with no indication were categorized based on the uric acid levels. Hyperuricemia was documented as mild (6– 10 mg/dL in females and 7– 13 mg/dL in males) and severe (> 13mg/dL in men and > 10mg/dL in women).Statistical Analysis Used: Descriptive statistics (frequencies, percentages).Results: From the 594 identified patients, 464 (78.1%) were males. A third of prescriptions (209/594) had no indication, 43.5% of which (91/209) had no documented uric acid levels, and 16.3% (34/209) had normal levels. Including patients with undocumented indication, 64.2% (381/594) were prescribed allopurinol for hyperuricemia, 86.4% of which (329/381) had mild hyperuricemia, and only 13.6% (52/381) had severe hyperuricemia. Other indications included malignancy-related disorders (6.2%, 37/594), gouty arthritis (5.2%, 31/594), and stones of unknown aetiology (3.4%, 20/594).Conclusion: The percentage of allopurinol prescription to patients with CKD without a clear indication in our centre was markedly high. This might increase the risk for side effects with no evidence-based benefits.Keywords: allopurinol, gout, hyperuricemia, hyperuricosuria, over prescription, chronic kidney disease

Mohammad Balilah,1 Mohammad Babgi,2 Walaa Alnemari,3 Ahmad Binjabi,4 Rania Zaini,3 Altaf Abdulkhaliq,5 Alaa Monjed,4 Salwa Aldahlawi,6 Hani Almoallim4 1Department of Medical Education, Rabigh Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia; 2Department of Cardiac Surgery, King Abdullah Medical City, Makkah, Saudi Arabia; 3Department of Medical Education, Faculty of Medicine, Umm Alqura University, Makkah, Saudi Arabia; 4Department of Medicine, Faculty of Medicine, Umm Alqura University, Makkah, Saudi Arabia; 5Department of Biochemistry, Faculty of Medicine, Umm Alqura University, Makkah, Saudi Arabia; 6Department of basic and clinical oral sciences, Faculty of Dentistry, Umm Alqura University, Makkah, Saudi ArabiaCorrespondence: Hani AlmoallimDepartment of Medicine, Faculty of Medicine, Umm Alqura University, P.O. Box 1821, Jeddah 21441, Saudi ArabiaTel +966505703935Email hmmoallim@uqu.edu.saPhenomenon: Peer-assisted learning (PAL) is increasingly used in different fields of education, including medical education, due to its established advantages. However, there are scarce data about the best practice guidelines for PAL program evaluation. The aim of this work was to develop a framework that can describe and develop PAL programs and consequently provide a tool for evaluation and comparison of PAL programs among different institutions.Approach: A thorough literature review was made for assessment of different PAL programs development and implementation strategies, and PAL leaders at the University of Umm Al-Qura in Saudi Arabia were interviewed for development and revision of a framework for PAL program development, description and evaluation.Findings: A framework of four sections was developed ie context, theory, implementation processes and outcomes, and emergence. The context includes the learning objectives and the logistics. The theory includes the content nature, program design, number of tutees and tutors, participation, program orientation, program duration and timing, tutor recruitment and preparation and faculty involvement. Implementation process and outcome section includes the feedback collection and the pre- and post-intervention students’ assessment. The emergence includes tracking the program evolution.Insights: Development of a clear well-defined framework for description, implementation and evaluation of a PAL educational program can provide a foundation to unify the terms organizations use to communicate the parameters of PAL programs and overcome the jargon about PAL in the literature. It also can provide comparisons between the programs in an attempt to set best practice guidelines in the future for PAL program developing and implementation.Keywords: framework, development, evaluation, PAL, peer assisted learning programs

Rania Zaini,1 Ali Alrehaily,2,3 Ahmed Alhazmi,4,5 Hussein Halabi,6 Heba Mohamed,7 Hani Almoallim8,9 1Department of Medical Education, Faculty of Medicine, Umm Alqura University, Makkah, Saudi Arabia; 2Department of Medicine, Security Forces Hospital Program, Riyadh, Saudi Arabia; 3Chairman of the Scientific Committee of Adult Rheumatology Fellowship Program, Saudi Commission for Health Specialties (SCFHS), Riyadh, Saudi Arabia; 4Department of Medicine, King Fahad Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia; 5Chairman, Supervisory Committee for Saudi Board Adult Rheumatology Fellowship Program in Western Region, Saudi Commission For Health Specialties (SCFHS), Riyadh, Saudi Arabia; 6Department of Medicine, King Faisal Specialist Hospital And Research Center, Jeddah, Saudi Arabia; 7Pfizer Biopharmaceutical Group, Emerging Markets, Riyadh, Saudi Arabia; 8Department of Medicine, Faculty of Medicine, Umm Alqura University, Makkah, Saudi Arabia; 9Alzaidi Chair of Research in Rheumatic Diseases, Umm Alqura University, Makkah, Saudi ArabiaCorrespondence: Hani Almoallim 6604 Gais Bin Doraih, Alnaeem, Jeddah 23621-3514, Saudi ArabiaEmail hmmoallim@uqu.edu.saBackground: Worldwide research anticipates that a current shortage of rheumatologists will exacerbate over the next decade, whereas the need for arthritis specialists will continue to escalate. Saudi Arabia (SA) also encounters a limited geographical distribution of rheumatologists and rheumatology fellowship training centres.Objective: Reporting the Saudi rheumatologists’ advisory meeting conducted in Makkah, SA in January 2020 with the aim to discuss the “Saudi Vision 2030” for rheumatology training programs.Materials and Methods: A meeting of Saudi rheumatology experts and consultants was conducted to address the future directions, challenges, and recommendations of rheumatology training. The 10th Rheumatology Practice Symposium was organised by Alzaidi Chair of Research in Rheumatic Diseases (ZCRD), and conducted in Makkah Commerce Chamber, Makkah, SA on January 28, 2020. More than 30 consultants and rheumatology fellows with five Saudi experts in the field of rheumatology assembled to form 10 recommendations that tackle rheumatology training challenges in SA.Results: The meeting recommendations shed light on the clinical practice of rheumatology training in SA; challenges and opportunities in rheumatology fellowship programs; efforts of the Saudi Commission for Health Specialties (SCFHS) to design and implement a competent postgraduate rheumatology training; and challenges with trainers, trainee, and within training centres.Conclusion: To address rheumatology challenges in SA, rheumatology consultants and fellows assembled to form 10 recommendations. The recommendations tackled the challenges of rheumatology fellowship programs and the efforts to implement a competent postgraduate rheumatology training. These recommendations are expected to lead us successfully to fulfil our ambition in the “Saudi Vision of 2030”.Keywords: rheumatology, residents, Saudi, fellowship, training, training program

Hani Almoallim,1– 3 Rola Hassan,2,3 Mohamed Cheikh,2,3 Hanan Faruqui,2 Reem Alquraa,2 Ayman Eissa,2 Aous Alhazmi,3 Roaa Alsolaimani,2,4 Nahed Janoudi2 1Department of Medicine, Faculty of Medicine, Umm Alqura University, Makkah, Saudi Arabia; 2Internal Medicine Department, Doctor Soliman Fakeeh Hospital, Jeddah, Saudi Arabia; 3Alzaidi Chair of Research in Rheumatic Diseases, Umm Alqura University, Makkah, Saudi Arabia; 4Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi ArabiaCorrespondence: Rola Hassan; Hani Almoallim Email r.toufiq@hotmail.com; hanialmoallim@gmail.comBackground: National Registries are essential to direct current practice. Rheumatoid arthritis (RA) registries in the middle east and North Africa remain scarcely represented.Objective: To describe a population of Saudi RA patients and to compare the findings to internationally reported data.Methods: This is an observational study that was conducted at Doctor Soliman Fakeeh Hospital (DSFH) in Saudi Arabia. The study ran from 2014 to 2018 using a pool of 433 patients. Inclusion criteria included adults older than 18 years of age who fulfilled the 2010 American College of Rheumatology criteria for the diagnosis of RA and who were also regular visitors in our rheumatology clinics. Data were collected directly from patients and entered in a specially designed program.Results: At initial presentation, 45.5% had demonstrated active disease (moderate or high disease activity) based on DAS-28-CRP scores, while 54.5% were in low disease activity or remission. The remission rates after 1 year had increased to 79.6% (345 patients), while 9.7% (42 patients) and 10.6% (46 patients) had low disease activity and moderate disease activity, respectively. It was also found that the female gender, higher Health Assessment Questionnaire-Disability Index (HAQ-DI) and longer lag1/lag2 periods were associated with higher disease activity in our population.Conclusion: We detected higher remission rates at 1 year of follow-up. This could be attributed to many factors, including good referral systems with easier access to biologics. We aim to expand this registry to the national level.Keywords: rheumatoid arthritis, disease-modifying antirheumatic drugs, biologics, TNF blockers, registry, remission rates

Huda Nadwi,1 Murad Janaini,1 Mohammed Zammo,2 Mohamed Cheikh,2 Hani Almoallim1– 3 1Department of Medicine, College of Medicine, Umm Alqura University, Makkah, Saudi Arabia; 2Department of Medicine, Dr. Soliman Fakeeh Hospital, Jeddah, Saudi Arabia; 3Alzaidi Chair of Research in Rheumatic Diseases, Umm Alqura University, Makkah, Saudi ArabiaCorrespondence: Hani AlmoallimDepartment of Medicine, College of Medicine, Umm Alqura University, P.O. Box 1821, Jeddah 21441, Saudi ArabiaTel +966 505703935Email hmmoallim@uqu.edu.saAbstract: Secukinumab, “an IL-17 antagonist”, is one of the biological agents used to treat active ankylosing spondylitis (AS). Although it has been proven that certain agents are linked with a paradoxical increase in uveitis, there are limited data on whether secukinumab has this effect or not. We report a case of a new-onset anterior uveitis after 6 months of starting secukinumab in a 47-year-old male, HLA-B27 positive AS patient. He had a long-standing history with the disease over 25 years. He was treated in the past with methotrexate then adalimumab and later on with etanercept. He had no history of uveitis during all of this time. The uveitis was mild and treated conventionally with local measures while secukinumab was maintained. After a close follow-up, the uveitis had completely resolved. Is this part of the original disease or a possible side effect from secukinumab?Keywords: spondyloarthritis, iritis, IL-17A inhibitors, biologics, ankylosing spondylitis, uveitis, secukinumab

Abdullah Elhosiny,1 Renad Alshoubaki,1 Lama Sindi,2 Sadeem Bukhari,2 Hani Almoallim1,2 1Department of Medicine, Dr. Soliman Fakeeh Hospital, Jeddah, Saudi Arabia; 2Department of Medicine, Faculty of Medicine, Umm Alqura University, Makkah, Saudi ArabiaCorrespondence: Hani AlmoallimFaculty of Medicine, Umm Alqura University (UQU) Email hanialmoallim@gmail.comAbstract: Juvenile spondyloarthritis (SpA) affects patients below the age of 16 and mainly presents with peripheral involvement. Many atypical clinical presentations were reported in the adult SpA, but not in the juvenile group. We report a case of non-radiographic axial SpA in a 14-year-old girl presented atypically with muscle weakness and hyperthyroidism. She had sacroiliitis evident by magnetic resonance imaging (MRI) with negative HLA-B27. Muscle biopsy showed fasciitis. She responded well to adalimumab and thyroid functions returned to normal values.Keywords: juvenile spondyloarthritis, non-radiographic spondyloarthritis, hyperthyroidism, muscle weakness, ankylosing spondylitis, spondyloarthritis

Rami Magliah,1 Waleed Hafiz,2,3 Ziad Abdulaziz Alahmadi,2 Muhammad Irfanullah Siddiqui,4 Haytham Mohamed Ahmed,5 Suzan Mansour Attar,6 Nahed Janoudi,7 Hani Almoallim2,3,7 1Department of Medicine, King Abdullah Medical City, Makkah, Saudi Arabia; 2Department of Medicine, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia; 3Alzaidi Chair of Research in Rheumatic Diseases, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia; 4Department of Community Medicine, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia; 5Pfizer Biopharmaceutical Group, Emerging Markets, Jeddah, Saudi Arabia; 6Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia; 7Department of Medicine, Dr. Soliman Fakeeh Hospital, Jeddah, Saudi ArabiaCorrespondence: Waleed HafizDepartment of Medicine, Faculty of Medicine, Umm Al-Qura University, 2254 Al-Taif Road, Al-Mashaer District, Makkah 7250-24255, Saudi ArabiaTel +966 12 527 0000 4041Email waleed_hafiz@hotmail.comBackground: Early diagnosis and therapeutic management of inflammatory arthritis (IA) is crucial for minimizing disease progression and improving outcomes. We recently developed the New Early Arthritis Referral Criteria to help improve the detection of suspected early IA via musculoskeletal (MSK) examination. The present study aimed to evaluate the agreement between rheumatologists and primary care physicians (PCPs) trained by rheumatologists in detecting IA when applying the standardized MSK examination techniques used to develop this criteria in a real-world setting in Jeddah, Saudi Arabia.Methods: This quasi-experimental study was conducted in 4 primary health centers and involved 30 PCPs and 3 rheumatologists. All PCPs were trained by rheumatologists to apply the standardized MSK examination techniques used to develop the New Early Arthritis Referral Criteria. Patients were eligible if they were >18 years of age and presented with small-joint pain that persisted for >6 weeks. Patients were excluded if they had prior diagnosis of osteoarthritis, hand fractures, or rheumatic disease associated with IA. All patients were examined separately by a PCP and a rheumatologist, with the findings compared via kappa statistics and the rheumatologist’s findings considered the “gold standard”.Results: Data from 202 of the 203 enrolled patients were analyzed. There was fair-to-moderate agreement between PCPs and rheumatologists when assessing swelling of the small joints and wrist of the right side (range of kappa: 0.14–0.41) and low-to-moderate agreement in similar examinations of the left side (range of kappa: 0.04–0.42). Assessments of joint tenderness showed fair-to-moderate agreement for both the right side (range of kappa: 0.22–0.47) and left side (range of kappa: 0.24–0.45). P-values were significant for virtually all comparisons.Conclusion: MSK examinations by PCPs showed a promising extent of agreement in detecting IA with those by rheumatologists following training. Refinement of the standardized training process could further improve accuracy and help PCPs to confidently identify cases of early IA, thus allowing earlier intervention than is typical in this setting.Keywords: arthritis, physician training, primary care, referral criteria, rheumatic disease

Hani Almoallim,1–3 Nahid Janoudi,2 Fahdah Alokaily,4 Zeyad Alzahrani,5 Shereen Algohary,3 Hanan Alosaimi,3,6 Suzan Attar3,7 1Department of Medicine, Faculty of Medicine, Umm Alqura University, Makkah, Saudi Arabia; 2Department of Medicine, Dr. Soliman Fakeeh Hospital, Jeddah, Saudi Arabia; 3Alzaidi Chair of Research in Rheumatic Diseases, Umm Alqura University, Makkah, Saudi Arabia; 4Division of Rheumatology, Department of Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia; 5Department of Medicine, Faculty of King Saud bin Abdulaziz for Health Sciences, Jeddah, Saudi Arabia; 6Department of Medicine, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia; 7Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia Purpose: Ability to work is an important endpoint in rheumatoid arthritis (RA). It is not clear what outcome measures should be used to guide treatment in order to maximize workability. This study addressed the impact of RA on workability in a Saudi population and examined the correlation between objective measures of disease activity and reduced workability. This will allow better understanding of treatment targets that will translate into improved workability. Patients and methods: Data were collected through a digital patient record keeper: The Rheumatoid Arthritis Saudi Database. Male and female patients, ≥18 years of age, that met the American College for Rheumatology criteria for diagnosis of RA, were recruited, regardless of treatment. Demographic and disease-specific data were collected. Disease Activity Score-28 (DAS-28) was used to define patients as low (DAS-28 ≤3.2) vs high (DAS-28 >3.2) disease activity. Health assessment questionnaire (HAQ) score, visual analog scale (VAS) score, and musculoskeletal ultrasound 7 joint score were documented also. The work productivity and activity impairment (WPAI) score was used to measure absenteeism, presenteeism, overall work impairment, and activity impairment. DAS-28 score was correlated with WPAI score and linear regression used to identify the demographic and measures of treatment response that predict improvement in WPAI score. Results: Higher absenteeism and more activity impairment were seen for patients with persistent DAS-28 >3.2 (non-achievers). HAQ and VAS scores correlated with presenteeism, overall work impairment, and activity impairment. Conclusion: Disease activity, as defined by DAS-28 score, correlates with absenteeism and work impairment in a Saudi population. However, on linear regression analysis, HAQ and VAS scores were the only measures predictive of work impairment. These scores should be used to monitor response to treatment regimens that aim to maximize work potential for Saudi individuals. Keywords: rheumatoid arthritis, work impairment, WPAI score, disease activity, HAQ score, VAS score

Rbab Taha,1 Hadeel El-Haddad,1 Abdulqader Almuallim,2 Fatma Alshaiki,3 Elaf Obaid,2 Hani Almoallim1,2,4 1Department of Medicine, Dr Soliman Fakeeh Hospital, Jeddah, 2Department of Medicine, Faculty of Medicine, Umm Al-Qura University, Mecca, 3Department of Medicine, East Jeddah Hospital, Jeddah, 4Rheumatic Diseases, Umm Al-Qura University, Mecca, Saudi Arabia Abstract: Rituximab (RTX) is established for the treatment of rheumatoid arthritis. This systematic review of the literature since 2006 summarizes evidence for the use of RTX in the treatment of additional rheumatological diseases: antineutrophil cytoplasmic autoantibody-associated vasculitis (AAV), hepatitis C virus-related cryoglobulinemic vasculitis, Henoch–Schönlein purpura, ankylosing spondylitis, and Raynaud’s phenomenon. Data from randomized controlled trials are available only for AAV, confirming efficacy for remission induction, including in disease resistant to conventional treatment, and maintenance of remission. Further studies are required to confirm optimal maintenance regimens in AAV, important questions needing to be addressed including protocol administration versus treatment in response to clinical relapse and the importance of maintaining B-cell depletion. Sufficient data are available in other diseases to suggest RTX to be useful and that randomized controlled trials should be conducted. Keywords: anti-CD20 monoclonal antibody, anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, refractory ankylosing spondylitis, resistant cryoglobulinemic vasculitis, refractory rheumatological diseases

Nahed Janoudi,1 Narges Omran,2 Waleed Hussain,3 Hanan Al-osaimi,4 Matouqa Baamer,5 Muhammad Irfanullah Siddiqui,6 Omar Fathaldin,7 Hani Almoallim1,4,8 1Department of Medicine, Dr. Soliman Fakeeh Hospital, Jeddah, 2Department of Medicine, Alnoor General Hospital, 3Department of Medicine, Heraa General Hospital, 4Alzaidi Chair of Research in Rheumatic Diseases, Umm Al-Qura University, Makkah, 5Department of Medicine, King Abdulaziz Hospital & Oncology Center, Jeddah, 6Department of Community Medicine and Public Health, Faculty of Medicine, Umm Al-Qura University, Makkah, 7Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, 8Department of Medicine, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia Objective: The objective of the study was to assess the effectiveness of adalimumab as a treatment for fatigue in patients with rheumatoid arthritis (RA). Methods: Fatigue was monitored in patients with RA who were already on an adalimumab treatment regimen. Fatigue, general well-being, comorbidities, and disease activity were measured at baseline and ~8, 16, and 24 weeks, thereafter. Results: Significant reductions in fatigue scores and disease activity were observed from baseline to 6 months after. A predictive regression model of fatigue severity was proposed and was found to be significant, with RA disease activity as the most significant predictor of fatigue severity. Conclusion: This quasi-experimental study is a good starting point for research on the efficacy of adalimumab in treating fatigue in RA patients. The results here suggest that a randomized controlled trial assessing adalimumab as a treatment option for RA patients suffering from fatigue is warranted. Keywords: rheumatoid arthritis, fatigue, adalimumab, disease activity, Saudi Arabia, FACIT-F

Hani Almoallim,1–3 Sultana Abdulaziz,4 Eilaf Fallatah,1 Haya Alhazmi,1 Nuha Meraiani,2 Tuqa Bazuhair,5 Mohammed Mansour,1 Anan Tayeb,1 Omar Fathaldin6 1Department of Medicine, Faculty of Medicine, Umm Al-Qura University, Makkah, 2Department of Medicine, King Faisal Specialist Hospital, Jeddah, 3Alzaidi Chair of Research in Rheumatic Diseases, Umm Al-Qura University, Makkah, 4Rheumatology Unit, Department of Medicine, King Fahad Hospital, Jeddah, 5Department of Medicine, King Abdullah Medical City, Makkah, 6Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia Objective: The objective of this report was to describe the demographics, clinical characteristics and outcomes of patients with cancer presenting with arthritis following chemotherapy in Jeddah, Saudi Arabia.Patients and methods: This is a retrospective case series report. We included any patient ≥18 years of age with an established diagnosis of cancer who had received standard therapeutic intervention and was subsequently diagnosed with arthritis after developing rheumatic symptoms either during or after treatment. Patients with clinical evidence of arthritis at the time of their cancer diagnosis were excluded.Results: Seven cases from different centers were identified. Breast cancer was the most common type of cancer reported. The diagnosis of arthritis was established by a rheumatologist. Bilateral involvement of the metacarpophalangeal and proximal interphalangeal joints was the most common presentation. The knee, back, shoulder and wrist joints were less affected. Following treatment, one patient experienced complete resolution of symptoms, four patients symptomatically improved and one patient had no improvement.Conclusion: Arthritis can develop both during and after treatment of a malignancy. Solid tumors seem to be more commonly associated with this phenomenon. In this case series, the prognosis was poor as the majority of patients developed persistent arthritis. Keywords: arthralgia, rheumatic diseases, rheumatoid arthritis, rheumatism, malignancies, breast cancer, autoimmunity

Hani Almoallim,1–3 Nahid Janoudi,2 Suzan M Attar,4 Mohammed Garout,5 Shereen Algohary,3 Muhammad Irfanullah Siddiqui,5 Hanan Alosaimi,3 Ashraf Ibrahim,3 Amira Badokhon,6 Zaki Algasemi7 1Department of Medicine, Medical College, Umm Alqura University, Makkah, 2Department of Medicine, Dr. Soliman Fakeeh Hospital, Jeddah, 3Alzaidi Chair of Research in Rheumatic Diseases, Medical College, Umm Alqura University, Makkah, 4Department of Medicine, King Abdulaziz University, Jeddah, 5Department of Community Medicine and Public Health, Umm Alqura University, Makkah, 6Administration of Public Health, Ministry of Health, Jeddah, 7Joint Program of Family and Community Medicine, Ministry of Health, Jeddah, Kingdom of Saudi Arabia Objective: Early diagnosis and initiation of treatment for inflammatory arthritis can greatly improve patient outcome. We aimed to provide standardized and validated criteria for use by primary care physicians (PCPs) in the identification of individuals requiring referral to a rheumatologist. Patients and methods: We analyzed the predictive value of a wide variety of demographic variables, patient-reported complaints, physical examination results, and biomarkers in order to identify the most useful factors for indicating a requirement for referral. Patients for this cross-sectional study were enrolled from various centers of the city of Jeddah, Saudi Arabia, if they were ≥18 years of age and presented to a PCP with small joint pain that had been present for more than 6 weeks. A total of 203 patients were enrolled, as indicated by the sample size calculation. Each patient underwent a standardized physical examination, which was subsequently compared to ultrasound findings. Biomarker analysis and a patient interview were also carried out. Results were then correlated with the final diagnosis made by a rheumatologist. Results: A total of 9 variables were identified as having high specificity and good predictive value: loss of appetite, swelling of metacarpophalangeal joint 2 or 5, swelling of proximal inter-phalangeal joint 2 or 3, wrist swelling, wrist tenderness, a positive test for rheumatoid factor, and a positive test for anti-citrullinated protein antibodies. Conclusion: Nine variables should be the basis of early referral criteria. It should aid PCPs in making appropriate early referrals of patients with suspected inflammatory arthritis, accelerating diagnosis and initiation of treatment. Keywords: inflammatory arthritis, rheumatoid, diagnosis, primary care, early referral criteria

Laila A Alharbi,1 Mohamed Cheikh,2 Manal E Alotaibi,1 Amal A Alkhotani,1 Hussam M Alim,1 Fahd Almalki,1 Mohammed S Samannodi,1 Hadeel A Khadawardi,1 Ahmad A Imam,1 Yosra A Turkistani,1 Fozya B Bashal,1 Abdullah Tawakul,1 Adeeb A Bulkhi,1 Mohammad S Dairi,1 Rania Zaini,3 Hani M Almoallim1 1Department of Medicine, Umm Al-Qura University (UQU), Makkah, Saudi Arabia; 2Department of Medicine, Al Salama Hospital, Jeddah, Saudi Arabia; 3Department of Community Medicine, Umm Al-Qura University (UQU), Makkah, Saudi ArabiaCorrespondence: Hani M Almoallim, Department of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia, Email hmmoalim@uqu.edu.saBackground: Entrustable professional activities (EPAs) define the core tasks that a graduating rheumatologist needs to perform independently in practice. The objective of this study was to develop and validate EPAs for rheumatology fellowship training programs in Saudi Arabia.Methods: Experts met to develop an initial set of potential end-of-training EPAs by conducting a comprehensive literature review of EPAs and studying the Saudi rheumatology fellowship curriculum. Then, to validate the EPAs, we conducted two rounds of the modified Delphi technique among rheumatology experts in Saudi Arabia. A response rate of 80% was considered and the minimum number of experts needed to be 25 to 30. Descriptive statistics were utilized to describe participants’ demographic characteristics and group responses to each statement in all rounds. The experts were asked to rate the relevancy of each EPA using a 5-point Likert scale in both Delphi rounds.Results: In the preliminary phase, four rheumatologists developed an initial set of 36 core EPAs for rheumatology training program in Saudi Arabia. For the two-rounds Delphi techniques, 32 experts were invited to complete the study. The response rate of the first and second round were, 78.12% (25) and 93.75% (30), respectively. The first-round Delphi resulted in a robust consensus on 31 EPAs for rheumatology training. Five EPAs were excluded, and one new EPA was proposed. In the subsequent round, all 32 EPAs achieved strong consensus. The eliminated EPAs likely fell short in one or more of the following areas: relevance to rheumatology practice in Saudi Arabia, overlapping with other EPAs, or practical challenges in the implementation.Conclusion: We have developed and validated a core set of EPAs for rheumatology fellowship training programs in Saudi Arabia. Mapping and identifying milestones for these EPAs are essential steps to follow to enhance workplace curriculum development.Keywords: entrustable professional activities, EPAs, rheumatology, training programs, fellowship, Saudi Arabia, curriculum, workplace

Chili (Capsicum annuum L.) is one of the most important vegetable cum spice crops grown throughout the world. Evaluation of genotypes based on morphological and yield contributing traits provides the opportunity to assess variability and select superior genotypes. The present investigation was carried out from April 2018 to November 2018 in the summer season and from December 2018 to June 2019 in the winter season in a net house and field, respectively, in the Department of Genetics and Plant Breeding, Patuakhali Science and Technology University, Patuakhali, Bangladesh. A set of 30 qualitative and 13 quantitative characteristics developed by Biodiversity International were recorded to evaluate the genotypes for morphological and yield-contributing traits. The estimated Shannon–Weaver diversity for qualitative traits ranged from 0 to 1.334, where the maximum diversity was recorded for fruit color at an intermediate stage, stem color after transplanting, fruit surface, stigma position, calyx margin shape, and fruit set, while the minimum diversity (H′ = 0) was observed for the traits corolla shape and anthocyanin spots, indicating no diversity of these traits. Thirteen quantitative traits were also analyzed for the selection of the genotypes with the greatest yield. The quantitative traits also exhibited a wide range of variability according to descriptive statistics and analysis of variance. Moreover, the present study revealed a high heritability for almost all of the quantitative traits, which was confirmed by the values of genotypic coefficient of variation, phenotypic coefficient of variation, h 2 b, and GA for both the summer and winter seasons. This suggests that these traits are predominantly governed by additive genes, making them highly amenable to effective selection. The heatmap analysis based on the morphological quantitative traits revealed five clusters for both the summer and winter seasons for the studied chili genotypes, four distinct clusters in the summer season, and three distinct clusters in the winter season for the parameters studied. Using the multi-trait genotype–ideotype distance index based on multiple trait information, the genotypes R-06, R-07, C0525-2, BARI (Bangladesh Agricultural Research Institute) Morich-2, Tengakhali, and Rcy 002 were selected as promising for both the summer and winter seasons. Hence, they are recommended for commercial cultivation or use as parent materials in future breeding for the development of new cultivars adaptable to climate change.

The synthesis of silver nanoparticles (AgNPs) using bacteria is more interesting because of their non-toxic, biocompatible, environmentally friendly, and cost-effectiveness. In the present research work, AgNPs were synthesized by Klebsiella pneumoniae in two steps: first, K. pneumoniae was grown in nutrient broth, followed by mixing of bacterial supernatant and silver nitrate aqueous solution in an optimized ratio. The synthesized AgNPs were thoroughly analyzed using analytical instruments for a detailed investigation. The absorption peak observed using UV-visible spectrophotometry at 464 nm indicated the development of AgNPs, while the characteristic bands for the AgNPs by infrared spectroscopy were observed in the region of 500–4,000 cm−1. Morphological examination via field emission SEM unveiled spherical-shaped AgNPs whose sizes varied from 22.25 to 47.99 nm, along with high aggregation. The crystallinity nature of the synthesized AgNPs was demonstrated by X-ray diffraction, which revealed major intensity peaks at 2θ values of 27.6°, 31.9°, and 46°. AgNPs showed 26.6% of methyl orange dye removal within 50 min. The antibacterial activities against Bacillus cereus, Bacillus megaterium, Serratia marcescens, and Staphylococcus aureus showed maximum zones of inhibition, i.e., 14 mm (10 mg·mL−1), 16 mm (5 and 10 mg·mL−1), 13 mm (5 and 10 mg·mL−1), and 12 mm (10 mg·mL−1). Therefore, the bacterial-synthesized AgNPs exhibited potential application in the field of biomedicine, which may be further used against various other pathogens.

Mishal F Karremah,1 Rola Y Hassan,2,3 Ammar Z Faloudah,1 Lujain K Alharbi,4 Albraa F Shodari,1 Ahmad A Rahbeeni,1 Nouf K Alharazi,1 Ahmad Z Binjabi,1 Mohamed M Cheikh,3,5 Hanadi Manasfi,6 Sultana Abdulaziz,7 Albadr Hamza Hussein,4 Ahmed Alhazmi,2 Hani Almoallim1,3,8 1Department of Medicine, College of Medicine, Umm Alqura University, Makkah, Saudi Arabia; 2Department of Medicine, Division of Rheumatology, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia; 3Alzaidi Chair of Research in Rheumatic Diseases, Umm Alqura University, Makkah, Saudi Arabia; 4Department of Medicine, Division of Rheumatology, King Fahad Hospital, Madinah, Saudi Arabia; 5Department of Medicine, College of Medicine, Fakeeh College for Medical Sciences, Jeddah, Saudi Arabia; 6Department of Medicine, Specialized Medical Center, Riyadh, Saudi Arabia; 7Department of Medicine, King Fahad General Hospital, Jeddah, Saudi Arabia; 8Department of Medicine, Dr. Sameer Abbas Hospital, Jeddah, Saudi ArabiaCorrespondence: Hani Almoallim, Tel +966505703935, Email Hmmoallim@uqu.edu.saBackground and Objectives: Early diagnosis and treatment is associated with improved outcomes in patients with systemic lupus erythematosus (SLE). Studying the journey of SLE patients in Saudi Arabia is essential to direct future health-care plans.Patients and Methods: This is a cross-sectional, multicenter study. Eligibility criteria included a diagnosis of SLE that was confirmed by a rheumatologist. Patients younger than 18 at the time of interview were excluded. Primary objectives were to determine time from first symptoms to initial physician visit (Lag 1), time from initial physician visit to encounter with rheumatologist (Lag 2), time from first visit to a rheumatologist to diagnosis of SLE (Lag 3), and time from diagnosis to start of treatment (Lag 4). Secondary objectives were to determine the number and specialty of physicians seen by patients, the speciality type that confirmed the diagnosis, first symptoms experienced, and age at first diagnosis of SLE.Results: Three hundred patients (92.3% women) with SLE were evaluated. Mean age at diagnosis was 29.92 years. Mean disease duration was 8.1 years. The majority were college educated (43.0%). The most common initial symptom was joint pain (68%), followed by skin rash (23%), and fever (3.7%). Lag 1 was less than one month in 68.2% of patients. Lag 2 was less than one month in 33.4% of patients and exceeded one year in 25.8%. Lag 3 was less than 1 month in 68.7% of patients. Lag 4 was less than one month in 94.4% of patients. The diagnosis of SLE was made most frequently by rheumatologists (80%). Evaluation by primary care, orthopedic and dermatology physicians were associated with delays in diagnosis.Conclusion: Delay was marked in Lag 2. Causes of delay included evaluation by non-specialists and visiting higher numbers of physicians before diagnosis confirmation.Keywords: systemic lupus erythematosus, rheumatology, delay, Saudi Arabia, physician

Alaa S Barhamain,1 Rami F Magliah,1 Mohammad H Shaheen,1 Shurooq F Munassar,1 Ayman M Falemban,1 Mohammed M Alshareef,1 Hani M Almoallim1–3 1Department of Medicine, Faculty of Medicine, 2Alzaidi Chair of Research in Rheumatic Diseases, Umm Alqura University, Makkah, 3Department of Medicine, Dr Soleiman Fakeeh Hospital, Jeddah, Saudi Arabia Background: Even after achieving tremendous advances in diagnosis and treatment of rheumatoid arthritis (RA), many of the patients undergo delays in diagnosis and initiation of treatment, which leads to worsening of the condition and poor prognosis. Objective: The objective of this study was to perform a literature review to quantify the lag times in diagnosis and treatment of RA and study the reported factors associated with it.Methods: The authors searched literature published until September 2016 in electronic full-text and abstract databases and hand-searched the suitable articles. Results: The weighted average of median lag time from symptom onset to therapy was 11.79 months (12 studies, 5,512 patients, range 3.6–24.0 months). Lag1 was 3.14 months (onset of symptoms to first physician consultant; 12 studies, 6,055 patients, range 0–5.7 months); lag2 was 2.13 months (physician visit to RA specialist referral; 13 studies, 34,767 patients, range 0.5–6.6 months); lag3 was 2.91 months (consultation with rheumatologist to diagnosis; 3 studies, 563 patients, range 0–5 months), lag4 was 2.14 months (diagnosis to initiation of disease-modifying antirheumatic drug therapy; 5 studies, 30,685 patients, range 0–2.2 months). Numerous patient- and physician-related factors like gender, ethnicity, primary care physician knowledge of the condition, availability of diagnostics, and so on were responsible for the delays.Conclusion: This review estimated the delay times and identified the main factors for delay in RA patients in diagnosis and initiation of treatment. A most plausible solution to this is coordinated effort by the rheumatology and primary care physicians. Keywords: arthritis, rheumatoid, rheumatologists, lag time, delay, diagnosis, disease management

The nutraceutical value, and physicochemical profile as well as anti-inflammatory activity potential of Odonthalia floccose and Odonthalia dentata (red macroalgae) dry biomass were investigated in this study. Proximate composition study results revealed that the dry biomass of O. floccose and O. dentae were found to be as ash: 9.11 & 8.7 g 100 g -1 , moisture: 8.24 & 8.1 g 100 g -1 , total fat: 6.9 & 7.2 g 100 g -1 , protein: 24.52 & 25.6 g 100 g -1 , and total carbohydrate/polysaccharides: 53.84 & 48.85 g 100 g -1 of dry weight biomass respectively. Both algae biomass contain considerable quantity of minerals (Fe, Cu, Mg, and Zn). Furthermore, the major saturated fatty acids (6.24 & 5.82 g FAME 100 g -1 of total fat of O. floccose and O. dentate) (ΣFAs) present in the test algae were stearic acid, palmitic acid, and margaric acids. O. floccose and O. dentata also contain remarkable protein composition profile that compiled with considerable quantity of essential and non-essential amino acids. The vitamins such as vitamin A, B1, B2, B3, B6, B9, C, and E of O. floccose and O. dentate biomass were also identified at sufficient quantity level. The swelling capacity (SWC), water holding capacity (WHC), and oil holding capacity (OHC) properties of O. floccose and O. dentate at various temperature conditions (25 and 37 ᵒC) were found to be 8.11 & 7.02 mL g -1 and 8.95 & 7.55 mL g -1 , 5.1 & 4.87 and 4.8 & 4.1 mL g -1 , as well as 2.11 & 1.81 and 1.96 & 1.89 mL g -1 respectively. Among these two marine red macroalgae samples, the O. dentate showed better anti-inflammatory activity than O. floccose at 150 μg mL -1 dosage. Thus, this O. floccose and O. dentate biomass can be considerable as nutritional supplement and pharmaceutical product development related research., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Nannochloropsis microalgae biochar has become increasingly attractive due to its potential as a component of microalgae-based biodiesel blends. This biochar is a by-product of the pyrolysis process, but its use in the energy sector has been limited. In this study, pellets were formed using microalgae residues and their physiochemical properties were analyzed to assess the feasibility of using microalgae biochar as a fuel source. Three types of biomasses, namely date seed dust, coconut shell waste, and microalgae biochar, were utilized to produce fuel pellets. These pellets were categorized into three types, B1, B2, and B3, based on the composition of the biomass. The inclusion of microalgae biochar in the pellets resulted in enhanced calorific value, as well as improved heating value and bulk density. Moreover, the mechanical strength of microalgae-based pellets was higher due to their high lignin content compared to another biomass. The moisture absorption test results showed that the use of mixed biomass reduced the moisture content over an extended period. Microalgae pellets exhibited higher young's modulus and greater impact resistance, indicating greater mechanical strength. Furthermore, due to their higher calorific value, the combustion time of microalgae pellets was greater than that of other biomass. In conclusion, the results of this study suggest that microalgae biochar can be a promising alternative fuel source for the energy sector., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interestsor personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Coronavirus is an emerging respiratory pathogen that causes coronavirus disease-2019 (COVID-19), as per the Chinese Center for Disease Control and Prevention., Objective: This study aimed to assess the state of awareness and extent of knowledge about COVID-19 among dental students from India, Pakistan, and Saudi Arabia., Materials and Methods: The present descriptive cross-sectional study was conducted on 872 participants from December 2020 to January 2021. Random sampling was performed using an electronic questionnaire. One-way analysis of variance and independent sample t-test were performed to assess and compare the mean knowledge score between different demographic data., Results: Approximately 60% (n = 520) of the responders were women and 40% responders were men (n = 352). The responders were from Saudi Arabia (36.9%; n = 322), India (34.2%; n = 298), and Pakistan (28.8%; n = 252). The difference within the subgroups was statistically nonsignificant (P > 0.05), indicating that dental students of all subparameters possessed equal knowledge on COVID-19., Conclusions: Dental students possess sufficient knowledge about COVID-19, qualifying them at least to work in a medical ward. However, more emphasis must be placed on infection prevention and control policies such as hand hygiene, personal protective equipment, and pre- and postexposure prophylaxis., Competing Interests: None

Globally, increasing demand for rheumatology services has led to a greater reliance on non-physician healthcare professionals (HCPs), such as rheumatology nurse specialists, to deliver care as part of a multidisciplinary team. Across Africa and the Middle East (AfME), there remains a shortage of rheumatology HCPs, including rheumatology nurses, which presents a major challenge to the delivery of rheumatology services, and subsequently the treatment and management of conditions such as rheumatoid arthritis (RA). To further explore the importance of nurse-led care (NLC) for patients with RA and create a set of proposed strategies for the implementation of NLC in the AfME region, we used a modified Delphi technique. A review of the global literature was conducted using the PubMed search engine, with the most relevant publications selected. The findings were summarized and presented to the author group, which was composed of representatives from different countries and HCP disciplines. The authors also drew on their knowledge of the wider literature to provide context. Overall, results suggest that NLC is associated with improved patient perceptions of RA care, and equivalent or superior clinical and cost outcomes versus physician-led care in RA disease management. Expert commentary provided by the authors gives insights into the challenges of implementing nurse-led RA care. We further report practical proposed strategies for the development and implementation of NLC for patients with RA, specifically in the AfME region. These proposed strategies aim to act as a foundation for the introduction and development of NLC programs across the AfME region.

Estimates of the global prevalence of rheumatoid arthritis (RA) range from 0.24 to 1%, but vary considerably around the globe. A variation in RA prevalence is also expected across Africa and the Middle East, due to ethnic, climate, and socioeconomic differences. To assess the prevalence of RA in Africa and the Middle East, we searched Medline (via PubMed) and databases of major rheumatology conferences. Seventeen journal articles and 0 abstracts met the inclusion criteria. Estimated prevalence ranged from 0.06 to 3.4%. Most studies reported values near or below 0.25%. Consistent with data from other regions, RA was more prevalent among urban than rural populations, and among women than men. The women:men prevalence ratio ranged from 1.3:1 to 12.5:1, which suggests notable differences from the global average of 2:1. Relative increases in prevalence were observed in North Africa and the Middle East (13% since 1990) and Western Sub-Saharan Africa (14%), whereas rates in Eastern, Central, and Southern Sub-Saharan Africa show decreases (4-12%). Low disease awareness, delays to visit rheumatologists, and socioeconomic factors appear to hinder early diagnosis and aggressive treatment. Few countries have developed RA-specific treatment guidelines, and many physicians and patients face limited access to even basic treatments. An improved understanding of the epidemiology and management of RA, and the related socioeconomic consequences is necessary, so that targeted attempts can be made to encourage early diagnosis and treatment.

Background: Inhibitors of tumor necrosis factor alpha (TNF-α) are current mainstay of therapies for rheumatoid arthritis (RA). The decision when to withdraw TNF-α inhibitors after achieving remission and the incidence of relapse rates with elective discontinuation are both important questions that demand intense survey in these patients. In this meta-analysis we aimed to estimate the magnitude of relapse rate after elective TNF-α inhibitor discontinuation in RA patients with remission., Methods: Systematic searches of PubMed/MEDLINE, Cochrane Library databases, grey literature (unpublished and ongoing trials) from the WHO International Clinical Trials Registry Platform and the US National Institutes of Health were performed for studies reporting the outcomes of elective discontinuation of TNF-α inhibitor in RA patients after remission. Random-effects models for meta-analyses were conducted on extracted data., Results: Out of 390 references screened, 16 RCTs were included. Meta-analysis of 1264 patient data revealed a relapse rate of 0.47 (95% CI 0.41-0.54). Sensitivity analysis showed that none of the studies had higher influence on the results., Conclusions: Almost half of all the RA patients in remission relapse after elective TNF-α inhibitor discontinuation. This information might be useful when considering this management option with individual patients., Competing Interests: Not applicable (systematic review).Not applicable (systematic review).The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Objective: Conventional treatment of systemic lupus erythematosus (SLE) and lupus nephritis (LN) is associated with damage accrual, hence increased morbidity rate. Off-label use of rituximab (RTX) has shown significant promise in this patient group; however, data are still controversial. We aimed to analyze the outcomes of RTX therapy in refractory lupus using a meta-analysis approach., Methods: Electronic search of the medical literature was conducted using a combination of relevant keywords to retrieve studies on the safety and efficacy of RTX in SLE and LN patients. Results were screened against our inclusion and exclusion criteria and two reviewers independently extracted the data for analysis. Comprehensive meta-analysis software was used to pool the data from individual studies and provide summary effect estimates., Results: Thirty-one studies that enrolled 1112 patients were finally eligible for the meta-analysis. The overall global, complete, and partial response rates to RTX therapy were 72%, 46%, and 32%, respectively. RTX significantly decreased Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and British Isles Lupus Activity Group (BILAG) scores (p<0.001). Prednisone dose was significantly reduced after RTX treatment in both SLE and LN groups (p<0.001), and proteinuria was lowered in SLE (p<0.001) than in LN patients (p=0.07). Infection and infusion-related reactions were the most common side effects., Conclusion: RTX therapy in refractory SLE and LN patients proved clinical efficacy and favorable safety outcomes. Larger well-designed randomized clinical trials are warranted.

Background: In contrast to most regions of the world where a decline of the HIV epidemic can be seen, data from the Middle East and North Africa (MENA) region suggests increasing incidence among key populations in the region. Accurate data collection has long been limited by social, cultural, and religious taboos. Understanding knowledge levels and attitudes toward HIV/AIDS is an important component to design adequate and culturally appropriate awareness and prevention programs., Methods: A survey was conducted including 3841 participants during a series of public HIV/AIDS awareness campaigns from 2013 to 2015 in Jeddah, Saudi Arabia. Participants completed a questionnaire including socio-demographic data, and questions around knowledge and attitudes toward HIV/AIDS. A knowledge score was created. Frequencies were calculated for all variables, mean knowledge scores were compared using non-parametric tests. Categorical variables were compared using Chi-squared test. The mean knowledge score was 5.2 out of 9 possible points. Respondents in the age class 19-25, respondents with university degrees, and those who know people living with HIV/AIDS had higher scores. Overall the attitude toward people living with HIV/AIDS was negative, more than 40% suggested that HIV positive people should be isolated and less than 20% would support a marriage with an HIV positive person. Negative attitudes were more common among people in older age groups, with a lower educational background, and respondents that did not know anyone living with HIV/AIDS., Conclusion: Knowledge gaps and negative attitudes of the general public toward people living with HIV/AIDS have been identified and can be used to tailor educational campaigns in Saudi Arabia., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: To delineate the clinical features and outcomes of dengue infection and to guide clinician of early diagnosis and identification of risks factors for dengue hemorrhagic fever. Methods: This study is a retrospective cross-sectional. Clinical records of 567 patients with a confirmed diagnosis of dengue infection, admitted to a single hospital in Jeddah, Saudi Arabia, between January 2010 and  June 2014 were reviewed.  Results: Dengue infection was most common in adult males. Sixty-eight percent of infections were in Saudi nationals. In addition to the diagnostic clinical features, leucopenia and thrombocytopenia were typical of dengue infection. Approximately 4.1% of adult patients and 7.1% of pediatric patients developed dengue hemorrhagic fever (DHF). Abdominal pain and vomiting were more common in patients developing DHF. Mean platelet count was lower in adult, but not pediatric patients developing DHF. Peak alanine aminotransferase (ALT) was higher in adult and pediatric patients developing DHF. Three patients died, 2 of them developed DHF. Ninety-eight percent of adult patients and 92% of pediatric patients made a full recovery. Conclusions:   Dengue infection is common in Jeddah.  Abdominal pain and vomiting, thrombocytopenia, and elevated ALT are typical of severe infection, which is more likely to be associated with significant morbidity and mortality.

Objective: Reactivation of viral hepatitis B (HBV) and C (HCV) has been reported in various case reports of patients with arthritis on biological therapy. The objective of this study was to describe the clinical characteristics and outcomes of arthritis patients with HBV or HCV treated with biological therapy., Material and Methods: This is a retrospective case series including all patients above 13 years of age with arthritis patients from four centers in Saudi Arabia with concurrent chronic viral hepatitis infection (HBV or HCV) who received biological agents in the rheumatology clinics during their course of their disease from duration of the disease onset until last outpatient visit up to November 2015. Demographic information, full details about the hepatitis status of each patient, rheumatic disease diagnosis and different therapies used were reviewed., Results: We identified 10 cases each with HBV and HCV on biological therapy. The mean age in the HBV group was 51 (34-85) years and 80% were females. Eight patients had rheumatoid arthritis (RA), one patient had RA/systemic lupus erythematosus, and one had human immunodeficiency virus related-arthritis. Seven were chronic inactive HBsAg carriers and three had chronic active HBV. Nine HBV patients received prophylactic antiviral therapy. Two cases with chronic HBV had reactivation with no elevation of the transaminases.The mean age in the HCV group was 54 (23-79) years and all were female RA patients. Three had detectable hepatitis C virus-ribonuecleic acid (HCV-RNA) before the start of biological therapy. Nine HCV patients received antiviral treatment and seven had a sustained virologic response (SVR) before start of biological treatment. Three patients had detectable HCV-RNA during the course of biological therapy. One of the three was a non-responder and two were relapsers. One of the patients with HCV relapse was started on sofosbuvir plus ribavirin and achieved SVR on follow-up., Conclusion: We report the successful use of biological therapy in arthritis patients with hepatitis B infection with antiviral therapy with no detoriation of their viral status. Due to the lack of sufficient prospective studies demonstrating the rate of HCV flare on biological therapy, caution should be exercised and careful monitoring with liver enzymes and viral load is mandated in vulnerable HCV RNA patients. Treatment should be individualized by the rheumatologist in collaboration with the hepatologist to minimize complications., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors.

BACKGROUND Ankylosing spondylitis (AS) is a chronic inflammatory disease that predominantly affects the axial skeleton. The ability of anti-TNF-α agents to reduce disease activity in patients with axial spondyloarthritis (axSpA), including AS, has been demonstrated in multiple randomized trials and several meta-analyses. Reports on the efficacy of rituximab in treatment of AS have described good results. We report on a patient with AS who failed anti-TNF-α therapy but showed good clinical improvement with rituximab therapy. CASE REPORT A 38-year-old male patient was diagnosed with AS and showed poor response to sulfasalazine and non-steroidal anti-inflammatory drugs (NSAIDs). Infliximab was initiated with marked improvement as per the Bath ankylosing spondylitis disease activity index (BASDAI). Due to disease flare, the patient was switched to etanercept. He subsequently acquired papillary thyroid cancer and etanercept was discontinued. He underwent a total thyroidectomy followed by radioiodine therapy. For his ongoing active disease, NSAIDs and sulfasalazine were resumed with a lack of response (BASDAI=7.1). Rituximab was started and resulted in significant improvement (BASDAI=2.3). CONCLUSIONS Rituximab can be a potential target therapy for patients who start to lose response to TNF-inhibitors or for those who develop solid malignancies. Further placebo-controlled studies are required.

Objectives: Rheumatoid arthritis (RA) is often not diagnosed or treated quickly enough to alter outcomes. We aimed to evaluate the lag times from disease onset to first clinical consultation and diagnosis and to identify factors contributing to delayed diagnosis in Saudi Arabia., Methods: This retrospective, multicenter study collected data on 250 patients, from six hospitals in Saudi Arabia, who met the 2010 American College of Rheumatology criteria for RA., Results: The patients mean age was 43.3±12.0 years (mean disease duration: 6.6±5.8 years). The majority were female (84.8%) and presented with joint pain during RA onset (83.6%). On average, they consulted 4.3±2.5 physicians from the first symptoms to the final diagnosis. The mean time from onset to first physician visit (lag 1) was 6.2±5.5 months, whereas the mean time was 30.2±16.0 months between the initial visit and final RA diagnosis (lag 2). Only 3.2% of patients initially sought consultation from a rheumatologist, while 67.2%, 23.6%, and 6.0% first met with orthopedic surgeons, general practitioners, and non-rheumatologists, respectively. Non-rheumatologists offered diagnoses in 24.4% of cases while rheumatologists diagnosed 75.6%. The absence of early hand/wrist involvement and fatigue were associated with delayed RA diagnosis (long lag 2; p<0.010). Moreover, geographic distribution influenced RA diagnosis, with rural patients experiencing a greater delay than urban patients (p<0.0001)., Conclusions: Failure of patients to be seen by rheumatologists at RA onset delayed diagnosis and treatment. Thus, RA diagnosis can be accelerated by encouraging early referral to rheumatologists.

Vitamin B12 is essential for neurological function and its deficiency is associated with many neuropsychiatric disorders. We report the case of a previously healthy 53-year-old male patient presenting with delirium and multiple neurological findings. Complete blood analysis indicated megaloblastic anemia. All infectious causes were excluded owing to negative cultures (blood and urine). Tests for human immunodeficiency virus, syphilis, and toxoplasma were also negative. Metabolic workup showed severe vitamin B12 deficiency, decreased reticulocyte count, and increased direct bilirubin and lactate dehydrogenase. Intramuscular injection of cobalamin was started, and the patient showed significant improvement., Competing Interests: The authors declare no conflict of interests regarding the publication of this paper.