Dental caries is one of the largest health concerns worldwide, and a key causative factor is excess sugar intake. Sugar-sweetened beverages (SSBs) are one of the largest sources of added sugars, which significantly contribute to adverse oral and general health. To reduce SSB consumption and its consequent impact on health, including dental caries, several interventional measures have been implemented; sugar taxation is one such measure. This review aimed at understanding the current knowledge available regarding the effect of sugar taxation on dental caries. Accordingly, PubMed, the Cochrane Library, Web of Science, and Scopus were searched with relevant keywords and findings from the identified studies are discussed in this review article.

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Objectives: To analyze symptomatic and asymptomatic COVID-19 patients in Saudi Arabia in terms of initial presentation, risk factors, laboratory findings, clinical outcomes and healthcare utilization. Methods: All laboratory-confirmed reverse transcription–polymerase chain reaction positive COVID-19 patients who had been tested at three governmental hospitals in Saudi Arabia (two in Riyadh and one in Makkah) between March 8 and May 18, 2020 were included. Demographics, COVID-19 variables, clinical characteristics and healthcare utilization variables were extracted and combined, and a descriptive analysis was conducted. Symptomatic and asymptomatic (on presentation) patients' data were compared. Results: Eighty percent of the patients were males (81.4% of symptomatic and 73.2% of asymptomatic patients, P = 0.02). Moreover, 47.6% and 38.4% of symptomatic and asymptomatic patients were aged 40–64 years, respectively. Fever, cough and breathing difficulties were frequent presenting symptoms. Overall, diabetes (16.4%), hypertension (11.7%), chronic respiratory disease (7.1%) were the most frequent comorbidities, with no differences between the two groups. Symptomatic patients had higher C-reactive protein levels (3.55 vs. 0.30 mg/L; P < 0.0001) and lower total lymphocytes (1.41 vs. 1.70; P = 0.02). ICU admission and mortality were 12.1% and 4.1% in symptomatic, compared to 6.0% and 2.9% in asymptomatic patients, respectively. Conclusion: In the studied COVID-19 cohort, symptomatic patients tended to be older, had higher C-reactive protein and more lymphopenia with worse outcome than asymptomatic patients. This granular analysis of COVID-19 cohorts enables identification of at-risk cohorts in future waves, optimizing development of patient pathways and public health interventions.

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Background: Long-term cigarette smoking damages the liver tissue. Alpha-lipoic acid (ALA) is used as a therapeutic agent in a number of conditions and is known to have ameliorative effects against oxidative stress in the liver. Objective: To investigate the ameliorative effects of ALA on cigarette smoke (CS)-induced oxidative liver damage by examining histopathological, immunohistopathological changes and biochemical parameters in an animal model. Materials and Methods: Twenty-eight female Sprague–Dawley rats were randomly divided into three groups. In the control group (n = 8), rats were exposed to fresh air twice a day and given 0.1 ml of saline by gavage once a day for 8 weeks. In the smoking group (n = 10), rats were exposed to CS for 1 h in the morning and afternoon and given 0.1 ml of saline by gavage once a day for 8 weeks. In the smoking + ALA group (n = 10), CS exposure was same as the smoking group in addition to 100 mg/kg of ALA per day for 8 weeks through gavage. Oxidative damage in the liver tissue was determined by evaluating malondialdehyde (MDA), catalase (CAT) and superoxide dismutase (SOD) levels. Aspartate aminotransferase (AST), alanine aminotransaminase (ALT), alkaline phosphatase (ALP), direct bilirubin and total bilirubin levels were measured in the blood. Histopathological and immunohistochemical examinations were performed. Results: MDA (P = 0.011), AST (P = 0.018) and total bilirubin levels (P < 0.001) were increased, while CAT activity (P = 0.009) and the efficiency of SOD (P = 0.010) were decreased in the smoking group compared with the control group. CAT activity was increased (P = 0.017) and AST (P = 0.018) and total bilirubin levels (P < 0.001) were decreased in ALA-treated group compared with the smoking group. We observed vascular dilatation and hemorrhagic areas in the smoking group. TNF-α expression was increased in the smoking group compared with the control group. However, TNF-α expression was high in some preparations in the ALA-treated group. Conclusions: ALA can enhance antioxidant activity, but studies with different doses of ALA are required to determine the extent of its hepatoprotective effect.

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Background: Antiretroviral therapy (ART) has transformed the management of human immunodeficiency virus (HIV) infection and significantly improved survival rates, but there is lack of such survival data from Malaysia. Objective: The objective was to determine the survival rates and prognostic factors of survival in HIV-infected adults treated with ART in Malaysia. Materials and Methods: This retrospective cohort study considered all HIV-positive adult patients registered in Sungai Buloh Hospital, a major referral center in Malaysia, between January 1, 2007 and December 31, 2016. Then, patients were selected through a systematic sampling method. Demographic, clinical, and treatment data were extracted from electronic medical records. Person–years at risk and incidence of mortality rate per 100 person–years were calculated. The Kaplan–Meier survival curve and log-rank test were used to compare the overall survival rates. Cox proportional hazards regression was applied to determine the prognostic factors for survival. Results: A total of 339 patients were included. The estimated overall survival rates were 93.8%, 90.4%, 84.9%, and 72.8% at 1, 3, 5, and 10 years, respectively, from ART initiation. The results of multiple Cox proportional hazard regression indicated that anemic patients were at a 3.76 times higher risk of mortality (95% confidence interval [CI]: 1.97–7.18; P < 0.001). The hazard risk was 2.09 times higher for HIV patients co-infected with tuberculosis (95% CI: 1.10, 3.96; P = 0.024). Conclusion: The overall survival rates among HIV-infected adults in this study are higher than that from low-income countries but lower than that from high-income countries. Low baseline hemoglobin levels of <11 g/dL and tuberculosis co-infection were strong prognostic factors for survival.

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Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, acquired hematopoietic stem cell disorder, and eculizumab and ravulizumab are its two approved therapies. Only few case series/reports have reported the outcomes of pregnancies in patients with PNH despite the increased risk of thrombosis. Similarly, there is limited knowledge regarding the effect of the approved treatments on conception and pregnancy outcomes. Here, we report the first series of pregnancies in PNH patients from the Middle Eastern region from our tertiary care hospital. Ten pregnancies in four females after diagnosis with PNH were identified. In terms of PNH management, only eculizumab was used, as the safety of ravulizumab use in pregnancies has not yet been established. In the antepartum period, the patients had variable symptoms that ranged from mild symptoms including epistaxis, tea-colored urine and vaginal bleeding to life-threatening vessel thrombosis. Further, red blood cell and platelet transfusions were required because of bleeding and hemolysis in four pregnancies. The pregnancy outcomes varied, but based on these, the safety of eculizumab use during pregnancy remained inconclusive. The postpartum period was complicated in one case by portal vein thrombosis and was managed accordingly. In conclusion, pregnant females with PNH are at an increased risk for complications due to PNH, and thus experienced hematologists and obstetricians should be involved jointly in their care.

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Background: A well-established first-line chemotherapy standard for metastatic nasopharyngeal carcinoma is yet lacking. Objectives: To compare the efficacy and safety of gemcitabine plus platinum versus docetaxel plus platinum regimen as first-line therapies for distal metastatic nasopharyngeal carcinoma. Study Design and Participants: A single center, randomized, open-label, parallel-arm study. The study included 120 patients with metastatic nasopharyngeal carcinoma who met the study requirements. Interventions: Participants were randomized in a 1:1 ratio through a sealed envelope selection. Gemcitabine 1000 mg/m²/d intravenously (IV) for >30 min (days 1 and 8) or docetaxel 75 mg/m²/d IV for 1 h (day 1) were administered to the respective group participants. Nedaplatin 75 mg/m²/d, IV (day 1), cisplatin 75 mg/m²/d IV (day 1) or carboplatin (area under the curve set as 5) IV (day 1) were used in both groups. One cycle duration was 21 days, with 4–6 cycles for all participants. Outcomes: The primary assessed outcomes were progression-free survival (PFS) and overall survival (OS), and the secondary outcomes were short-term efficacy [i.e., response rate (RR) and disease control rate (DCR)] and safety. Results: Seven patients withdrew from the study, and efficacy and adverse reactions were obtained for 113 patients (gemcitabine: 56; docetaxel: 57). Compared with the docetaxel plus platinum group, the gemcitabine plus platinum group had significantly higher RR (71.4% vs. 52.6%, P < 0.05); mPFS (9.7 vs. 7.8 months, P < 0.05), and mOS (20.6 vs. 16.8 months, P < 0.01). The significance was not associated with increased adverse reactions, as both groups showed similar Grades 3 and 4 adverse reactions (P > 0.05). DCR was non-significantly higher in the gemcitabine group (85.7% vs. 75.4%, P > 0.05). Multivariable analysis revealed that time to disease progression, number of involved organs, liver metastasis, and grouping were associated with mPFS and mOS (all P < 0.05). Conclusion: The combination of gemcitabine with platinum is likely superior to that of docetaxel with platinum as first-line treatment for metastatic nasopharyngeal carcinoma.

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Background: Glaucomas remain asymptomatic until severe, indicating that the actual number of affected individuals may be higher than those diagnosed. Objective: To study the clinical patterns of glaucoma cases in the Eastern Province of Saudi Arabia. Patients and Methods: This retrospective study was conducted at King Fahd Hospital of the University, Al-Khobar, and Dhahran Eye Specialist Hospital, Dhahran, Saudi Arabia. The medical records of all patients with glaucoma who visited these hospitals from January 2015 to December 2018 were critically reviewed. Data regarding patients' demographic characteristic, clinical data and their medical and surgical management techniques were collected and analyzed. Results: A total of 999 patients were included, of which 52.9% were males, 94.8% were Saudi, and the mean age was 58.8 years. Bilateral involvement was observed in 82.3% of cases. Primary open-angle glaucoma (POAG) was the most prevalent type of glaucoma (27.7%), followed by secondary glaucomas (26.7%), primary angle-closure glaucoma (PACG) (18.2%), primary congenital glaucoma (2.7%), and juvenile open-angle glaucoma (2.2%), which were the most frequent glaucoma subsets. Conclusion: The study population was most affected by POAG, secondary glaucomas and PACG. Knowledge regarding prevalence of glaucoma is important to plan services, allocate resources, and prevent blindness.

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Background: Inflammatory bowel disease (IBD), which can have a considerable effect on quality of life, productivity and performance, is typically diagnosed during periods of life in which patients have academic and career-related responsibilities. Objective: The objective of the study was to determine the effect of IBD symptoms on work and school absenteeism in patients from Saudi Arabia. Patients and Methods: This cross-sectional survey included patients diagnosed with IBD, aged >8–60 years, at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. The validated 32-question IBD quality-of-life questionnaire was used to elicit information regarding quality of life and another 9-question validated questionnaire was used to assess work and school absenteeism. A logistic regression analysis was used to identify possible determinants of absenteeism. Results: A total of 123 IBD patients were included, with a 1:1 male-to-female ratio. The median age at presentation was 26 years (range: 8–59 years), 56.9% had Crohn's disease, and 43.1% had ulcerative colitis. Further, 58 (47.2%) were employed, 49 (39.8%) were students and 16 (13%) were unemployed. Forty-seven (43.9%) participants reported absenteeism: 26 were employees (55.3%) and 21 were students (44.7%). A binary logistic regression analysis identified IBD subtype (P = 0.006) and the presence of perianal disease (P = 0.028) as clinical predictors for absenteeism from school or work. A feeling of abdominal pain (P = 0.015), fatigue (P = 0.015) and difficulty taking part in social engagements (P < 0.001) were also significantly associated with absenteeism. Conclusions: A sizeable proportion of the participants reported absenteeism owing to the effects of IBD. IBD subtype, perianal disease, presence of ongoing abdominal pain, fatigue and difficulty in social engagement were strongly associated with nonattendance.

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Background: Patients with shoulder pain may have proprioceptive and balance deficits. However, studies on balance in patients with shoulder pain are scarce. Objective: This study aims to investigate if patients with chronic shoulder pain demonstrate deficits in standing and walking balance and to study the relationship between outcome measures of balance and age and body mass index (BMI). Materials and Methods: This case–control study was conducted at Dammam Medical Complex, Dammam, Saudi Arabia, between March and November 2018. The study recruited patients (n = 15) with chronic shoulder pain (>4 months) and healthy controls (n = 15) matched for age, gender and BMI. Standing balance was tested using a Challenge Disc test, the Romberg test and timed unipedal stance test (UPST). Walking balance was assessed using the timed up and go (TUG) test, stance phase duration and center of pressure (COP) deviation. Independent t-tests were used to investigate the differences between the two groups in demographic data and all the outcome measurements. Pearson correlation coefficients were used for correlation analysis. Results: No statistically significant differences were found between the two groups in any outcome of the standing balance (P ≥ 0.095) or walking balance (P ≥ 0.160). However, medium effect sizes were found for the UPST (η²: ≥0.06), Challenge Disc (η²: 0.06), TUG (Cohen's d: 0.54) and COP deviation (Cohen's d: 0.53). There was a moderate correlation between BMI and Challenge Disc (P = 0.025) and between age and Challenge Disc (P = 0.012) in both the groups. Conclusion: Patients with chronic shoulder pain had lower balance measurements compared with healthy people, although this difference was not statistically significant.

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Background: Timely access to comprehensive stroke centers for patients suffering from acute ischemic stroke due to large vessel occlusion (LVO) remains a commonly encountered obstacle worldwide, especially in areas with no comprehensive stroke or thrombectomy-capable stroke centers. Objective: To present our novel experience with a “thrombectomy-and-back” model implemented in the Eastern Province of Saudi Arabia. Methods: King Fahd Hospital of the University (KFHU), a 600-bed hospital located in Al Khobar with an open-access emergency department, was designated as a comprehensive stroke center in the Eastern Province. “Thrombectomy-and-back” was designed such that the neurologist in the referring hospital directly communicates with the attending neurovascular team at KFHU for their anticipation of the case, and subsequently confirms LVO presence through urgent acquisition of a CT and a CT angiogram. Once LVO was confirmed, the patients were timely transferred to KFHU for mechanical thrombectomy. Upon procedure completion, the patients returned to the referring hospital with the same medical and EMS team. The safety of transfer and peri-procedural complications were analyzed. Results: From December 2017 to December 2019, 20 thrombectomy-and-back codes were activated, of which 10 were deactivated on negative LVO and 10 remained activated. Of these 10 patients, 2 required admission to our hospital's Neuro-ICU: one was because the middle cerebral artery reoccluded during the procedure and the other was due to hemodynamic instability upon arrival; this first patient passed away 2 months later due to the complications of the malignant left middle cerebral artery stroke. Conclusions: The novel Thrombectomy-and-Back model in the Eastern Province of Saudi Arabia has proved to be a safe and efficient approach for patients presenting with LVO to receive timely interventional therapy and minimizing futile transfers.

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Rosai–Dorfman–Destombes disease (RDD) is a rare histocytic disorder with a broad spectrum of clinical presentations. The disease typically presents with lymphadenopathy but may involve multiple systems. Usually, RDD lesions demonstrate intense ^[18]F-Fluorodeoxyglucose (FDG) uptake in positron emission tomography/computed tomography (PET/CT) imaging due to the inflammation and infiltration with high metabolic process of the disease. Here, we describe a rare case of 37-year-old man who presented with multiple systemic symptoms, including fever, weight loss and bilateral cervical, and inguinal lymphadenopathy who underwent FDG PET/CT for detection of disease extension. This case highlights the role of FDG PET/CT in establishing the disease extent in newly diagnosed RDD and guiding the therapeutic recommendations and for follow-up to monitor the disease response to therapy. To the best of our knowledge, this is the first case report from Saudi Arabia highlighting the role of FDG PET/CT in newly diagnosed RDD.

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Perineal trauma in children are rare, but they can be life-threatening and surgically challenging conditions in the absence of a standardized therapeutic approach. Colostomy remains important and plays an essential role in minimizing the frequency of perineal wound infections but has known complications. Here, we describe a case of a 7-year-old boy who was a victim of a road traffic accident polytrauma and sustained severe perineal injury. The patient was managed primarily without stoma creation and achieved complete wound healing and continence. This case highlights that selection of primary repair without colostomy must be meticulous and individualized.

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