Varicocelectomy for scrotal pain: Is it effective?

Introduction: Varicocelectomy is the prevailing management of scrotal pain secondary to varicocele. However, the literature is controversial on this topic. Some data showed that pain may persist after the surgery even if the varicocele is not detected postoperatively. Objectives: The objectives of the study were to identify the effect of varicocelectomy in patients with chronic scrotal pain, to report the association between the clinical grade and postoperative pain resolution, and to identify the need for a secondary procedure after varicocelectomy to control the pain. Materials and Methods: This was a retrospective study of 47 patients who underwent varicocelectomy between March 2016 and December 2018. Results: Postoperatively, the pain totally resolved after surgery in 64.3% of patients with scrotal pain; it improved in 21.4%, 11.9% have persistent pain, and the pain got worse in only 2.4%. Our study showed 100% complete resolution or improvement with Grade I, 85.7% in Grade II, and 81.3% in Grade III. In addition, all patients who underwent bilateral varicocelectomy had pain that either completely resolved or improved postoperatively. On the other hand, all patients who had persistent pain or pain worsening postoperatively had unilateral varicocelectomy. An additional intervention for postoperative pain control was needed in only 14% of patients, 7% of them underwent embolization, 4.7% had a cord block, and 2.3% were sent to a pain clinic. Conclusion: Varicocelectomy offers good outcomes in most patients with varicocele-related scrotal pain. The most significant predictor for success was low grade and bilaterality. However, there is a subset of patients whose symptoms will not improve postoperatively. Careful preoperative counseling and expectation management are crucial when discussing surgical options for those patients.

Prescription Pattern of Tofacitinib for Alopecia Areata Among the Dermatologists in Saudi Arabia: A Cross-Sectional Study.

Introduction Alopecia areata (AA) is a complex autoimmune condition that causes nonscarring hair loss. In Saudi Arabia, AA accounts for 1-2% of new dermatological outpatient visits. It typically presents with sharply demarcated round patches of hair loss and may present at any age. Traditional medical therapies include corticosteroids and immunotherapy. Choosing the ideal treatment depends on multiple factors such as patient age, disease severity, efficacy, side effects, and remission rate. Recent medications that have been used for treating AA are Janus kinase inhibitors. Aim The aim of the study is to assess the awareness and attitude of dermatologists and their use of Tofacitinib in treating AA. Method A cross-sectional study was conducted in 2019 across 14 major cities in Saudi Arabia. A self-administered online questionnaire was specifically developed and used. Dermatologists from government hospitals and private clinics were included through non-probability convenience sampling. The collected data was entered into Microsoft Excel and analyzed using SPSS program version 24. Results In total, out of 546 Dermatologists across Saudi Arabia who responded to the questionnaire, 127 (23.2%) physicians prescribed Tofacitinib in their practice. Out of those who prescribed the drug for AA cases, 58 dermatologists (45.6%) prescribed Tofacitinib after the failure of steroid injections. Among the 127 dermatologists who have utilized Tofacitinib in their practice, 92 (72.4%) believe that Tofacitinib is effective in treating AA. Almost 200 (47.7%) Dermatologists who never prescribed Tofacitinib reported that the main reason was due to the unavailability of the drug in the clinic they were practicing. Conclusions To conclude, out of 546 dermatologists working in Saudi Arabia, 127 (23.2%) prescribe Tofacitinib to treat AA. Ninety-two (72.4%) of the participants reported the effectiveness of Tofacitinib. Two hundred (47.7%) dermatologists who never prescribe Tofacitinib reported that the main reason was due to the unavailability. However, this would raise the need for more research regarding JAK inhibitors generally and Tofacitinib specifically, focusing on the effectiveness versus the side effects of Tofacitinib.

Ocular manifestations of COVID-19 in the pediatric age group.

The coronavirus disease 2019 (COVID-19) is now known to be associated with several ocular manifestations. The literature thoroughly discussed those that affect adults, with a lesser focus in the pediatric age group. We aim to outline the various pediatric ocular manifestations described in the literature. The manifestations may be divided into isolated events attributed to COVID-19 or occurring in the new multisystem inflammatory syndrome in children (MIS-C), a novel entity associated by COVID-19 infection. Ocular manifestations have virtually affected all ages. They manifested in neonates, infants, children, and adolescents. Episcleritis, conjunctivitis, optic neuritis, cranial nerve palsies, retinal vein occlusion, retinal vasculitis, retinal changes, orbital myositis, orbital cellulitis were reported in the literature with this emerging viral illness. Conjunctivitis was the most common ocular manifestation in MIS-C in nearly half of the patients. Other ocular manifestations in MIS-C were anterior uveitis, corneal epitheliopathy, optic neuritis, idiopathic intracranial hypertension, and retinitis. The clinical outcome was favorable, and children regain their visual ability with minimal or no deficits in most of the cases. Further follow-up may be warranted to better understand the long-term effects and visual prognosis.

Surgeons preferences in descemet membrane endothelial keratoplasty (DMEK).

AIM: To explore the attitudes, preferences, and barriers of DMEK among corneal specialists in Saudi Arabia. METHOD: An anonymous survey was sent through an online platform to members of the Saudi Ophthalmological Society. The survey was designed to capture data covering: demographic data, practice patterns of keratoplasty techniques, DMEK technique preferences, barriers, and facilitators to performing DMEK. RESULTS: Thirty-five (33% response rate) surgeons participated in the questionnaire. Sixty-eight percent were in practice for less than or equal to 10 years. Thirteen surgeons were performing DMEK. Participating in any training capacity was observed among surgeons who performed DMEK (92%). The main selection criteria for this procedure were patients with normal anterior chamber anatomy (77%). The main barrier against DMEK adoption among surgeons who do not perform the procedure was the lack of experience (91%). Strategies to help begin performing DMEK were eye banks support (prepared grafts, backup tissue for inadvertent loss), access to wet-lab training courses, and higher surgical volume. CONCLUSION: DMEK is not highly performed among corneal specialists in Saudi Arabia; however, there is evident interest in adopting this technique. Strategies toward filling the gap of lacking experience would facilitate the adoption of the procedure. Eye banks play a crucial role by providing prepared tissues, which would lessen part of the technical difficulty.

Tubercular Episcleritis: A Review of Literature.

Episcleritis is rarely reported to be associated with tuberculosis (TB). In this review, we highlight this underreported entity and elaborate on the natural history of the reported cases in the literature. Eighteen articles were found to describe numerous cases throughout the past century. Forty patients diagnosed with tuberculous episcleritis were found in the literature. The majority of the patients presented with a latent form of TB and fewer cases were linked with active/pulmonary disease. The natural history of episcleritis was found to have chronic and recurrent attacks refractory to traditional treatment, and the most commonly reported type was the nodular form. The described cases were eventually treated by quadruple antituberculous therapy, and fortunately, recurrence after treatment completion was not documented. It is imperative to highlight such entities that may be underreported in endemic countries, as successful therapy would decrease ocular morbidity and prevent potential unforeseen tuberculous complications.

Recurrent Tubercular Episcleritis.

Ocular tuberculosis (TB) is one of the extrapulmonary manifestations of mycobacterium TB. Episcleritis is a rare entity that may affect patients in endemic areas of TB. In this paper, we report a case of presumed recurrent episcleritis attributed to TB. TB should be kept as a possible cause of recurrent simple episcleritis upon encountering patients with endemic backgrounds to prevent the complication sequalae and halt recurrence.

The impact of the English medical curriculum on medical history taking from Arabic speaking patients by medical students.

INTRODUCTION: Medical education in Saudi medical colleges is delivered to students through a completely English language curriculum, whereas the practice that students face in the hospital is generally conducted in Arabic language settings. We suggest that the linguistic gap between the adopted medical curriculum and actual practice could influence students' confidence and level of difficulty in history taking in Arabic. The study aimed to identify the effects of learning history taking in the English language on applying it in the medical student's native language. METHODS: This cross-sectional design study was held in the College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS). The targeted sample size was 377 medical students from the fourth to the sixth year, and stratified random sampling was used. The questionnaire used was self-developed, validated, and pilot tested in other medical colleges. The questionnaire asked about students' confidence, the difficulty of Arabic history taking, and suggested strategies to improve the current curriculum. RESULTS: The response rate was 290 participants (76.9%), males were 205 (71%), and 136 (47%) were in the fourth year. Agreement on feeling confident while taking history taking in Arabic was 98 (33.8%), 102 (35.2%) were neutral, and 90 (31%) disagreed. Moreover, 138 (47.6%) of students preferred training for Objective Structured Clinical Examination (OSCE) in Arabic more than English, 86 (29.7%) were neutral, while 66 (22.8%) disagreed. The mean level of difficulty was 2.1 ± 0.7 (range 1- 5). Additionally, 198 (68%) of students suggested adding short Arabic history courses. CONCLUSION: Students considered history taking in Arabic as easy, even though they were not completely confident. Further efforts are needed to uplift students' of confidence to optimal levels. ADVANCES IN KNOWLEDGE: Communication is the cornerstone of medical education as well as clinical practice. The study explores the impact of instruction language on the physician-patient communication dynamic, providing better infrastructure for evidence-based educational practice. APPLICATION TO PATIENT CARE: This study gives insight into the students' level of preparation to practice in their local community and language. Furthermore, the study addresses strategies to enhance students communication skills and alleviate linguistic barriers in the physician-patient encounter.

Nasopharyngeal carcinoma (NPC) in the ophthalmic practice: A serious neoplasm presenting initially to ophthalmologists.

PURPOSE: Nasopharyngeal carcinoma (NPC) is an aggressive malignant tumor that arises from the nasopharyngeal epithelial lining. Most patients with NPC present with a neck mass or cranial nerve palsy. It is infrequent for patients with NPC to present to an ophthalmologist initially with ophthalmic complaints and absence of prior diagnosis of NPC. We are reporting a series of six NPC cases that presented solely with ophthalmic complaints, to attract the attention of ophthalmologist to such a serious neoplasm. METHODS: A retrospective observational study of all consecutive patients diagnosed with NPC based on their initial ophthalmic presentation with no prior diagnosis of this neoplasm. Patients presented for the first time to two tertiary eye hospitals. Data were collected by the chart review for demographics, clinical presentation, radiological imaging, treatment regimen, and follow-up. Histopathological review of their tissue specimens was conducted by two pathologists. RESULTS: We had six patients who presented for the first time to our ophthalmic service complaining mostly of limitation of extraocular muscle motility with or without diplopia (4/6), orbital or facial pain (2/6), and disturbance in vision (2/6). The age ranged from 35 to 92 years with a mean of 58 years. A male predominance was observed with male-to-female ratio of 5:1. The cases are described along with their imaging and histopathological findings. Relevant literature review was also presented. Most of our patients (5/6) received combination of radiotherapy and chemotherapy. One patient refused treatment and 2 eventually passed away after 7 months. CONCLUSION: Ophthalmologists may play a major role in diagnosing such patients accurately and referring them for early management and better prognosis.

Genetic Profile of Epidermolysis Bullosa Cases in King Abdulaziz Medical City, Riyadh, Saudi Arabia.

Epidermolysis bullosa (EB) is a rare heterogeneous genetic mechanobullous skin disorder that is characterized by increased skin fragility leading to blistering following minor trauma. EB may be inherited as an autosomal dominant or an autosomal recessive disorder and can be classified into dystrophic EB (DEB), junctional EB (JEB), and EB simplex (EBS). A total of 28 Saudi patients with EB were included in this observational, retrospective chart-review study. A consecutive non-probability sampling technique was used to approach all affected patients. Molecular analysis was done to test the patients' genomic DNA using a custom-designed AmpliSeq panel of suspected genes. All disease-causing variants were checked against available public databases. Twelve patients (42.9%) were found to have DEB, 6 patients (21.4%) with JEB, and 10 patients (35.7%) with EBS. The molecular genetic results revealed detections of 24 various homozygous genetic variations in the genes associated with EB, of which 14 were novel mutations. The most frequent variations were detected in COL7A1 in 12 cases (42.9%), followed by LAMB3 in 5 cases (17.9%), TGM5 in 4 cases (14.3%), and other genes. Furthermore, the majority (87.5%) of EB cases were confirmed to have homozygous mutations, and few were documented with positive consanguinity history. Only 3 cases (12.5%) were found to be autosomal dominant displaying heterozygous mutations. This is the first study to establish the EB genetic profile in Saudi Arabia where DEB is the most frequent type. A total of 14 novel mutations were identified that had not been previously reported. Consanguineous marriage is clearly recognized in the Saudi population; therefore, we propose a nationwide EB program that would help extend the spectrum of the genetic profile and help in the diagnosis and better understanding of this disease.

Patterns and Outcomes of Complementary and Alternative Medicine Use Among Adult Patients With Multiple Sclerosis.

Multiple sclerosis (MS) is a chronic autoimmune disease that causes demyelination of the central nervous system. No treatment has been shown to be curative; thus, we assume that the tendency for patients with MS to use unconventional therapies, such as complementary and alternative medicine (CAM), might increase. The aim of this study was to explore the pattern of CAM use among patients with MS at a tertiary health care center in Saudi Arabia (SA). This was a questionnaire-based observational cross-sectional study that targeted adult patients diagnosed with MS at King Abdulaziz Medical City in Riyadh, SA, from 2018 to 2019. The sample size included 176 patients, and a consecutive non-probability sampling technique was used to engage them during their appointments. An Arabic questionnaire was used to evaluate patients' use of CAM. The mean age of participants was 34.6 ± 10.9 years, females represented the majority 125 (71%) of participants, and 89% of the participants reported using CAM at least once, with one or more modalities being used. Prayer, Salat, was the most frequent modality (60%) followed by supplication, Dua'a (59%), Ruqia, reciting Holy Quran (52%), and vitamins (44%). Symptomatic improvement was reported by 49 (27.8%) of dietary supplement users and 81 (46%) of non-dietary supplement medicine users. The study found a high prevalence of CAM utilization among Saudi adult patients with MS, which exceeded internationally reported rates. Although some patients described some improvement in their symptoms, further research is needed to evaluate the effectiveness of CAM.

Risk factors for transposition of the great arteries in Saudi population.

OBJECTIVES: To assess potential risk factors and their effect on the development of transposition of the great arteries (TGA). Methods: A retrospective case-control study of all patients diagnosed with TGA between 1999 to 2016 at King Abdulaziz Medical City, Riyadh, Saudi Arabia. Age and gender-matched controls were selected. Risk factors, including consanguinity, gestational diabetes, family history of congenital heart disease, parental age, and maternal parity, were collected. Regression modeling was used to analyze the effects of risk factors on the development of TGA. Results: A total of 206 patients with transposition of the great arteries were enrolled in the study. Transposition of the great arteries  cases were divided into simple and complex TGA. Selected healthy controls were 446. In the studied cases, consanguinity was found in 95 (46%) of cases, gestational diabetes was diagnosed in 36 (17.5%) mothers, and 35 (17%) had a confirmed family history of congenital heart disease. When risk factors of the cases were compared to the controls, consanguinity, gestational diabetes, maternal age, and parity were found to significantly increase the incidence of TGA. Conclusion: Our study revealed significant risk factors for the development of transposition of great arteries including first degree consanguineous marriages, gestational diabetes, family history of congenital cardiac anomalies, and increasing maternal age and parity. These factors increased the risk by at least 2 folds.

Alemtuzumab-induced simultaneous onset of autoimmune haemolytic anaemia, alveolar haemorrhage, nephropathy, and stroke: A case report.

BACKGROUND: Alemtuzumab is a humanized anti-CD 52 monoclonal antibody approved as a disease-modifying therapy for active relapsing-remitting Multiple Sclerosis (MS). Alemtuzumab has been associated with several adverse effects, including infusion-associated reactions, infections, acquired autoimmune diseases, and malignancies. CASE PRESENTATION: We report a case of Alemtuzumab-induced simultaneous onset of autoimmune haemolytic anaemia, alveolar haemorrhage, nephropathy and stroke in a 52-year-old man that occurred 8 months after initiation of alemtuzumab. The laboratory testing was consistent with autoimmune haemolytic anaemia. Computed tomography of the chest and bronchoscopy revealed an alveolar haemorrhage. Stroke workup revealed acute infarcts in bilateral occipital territories. CONCLUSION: This is the first case report of a simultaneous onset of autoimmune haemolytic anaemia, alveolar haemorrhage, nephropathy, and ischaemic stroke after the first alemtuzumab course in relapsing-remitting MS patient. This case highlights the potential for the co-occurrence of unexpected and potentially life-threatening complications of alemtuzumab therapy necessitating rigorous monitoring once prescribed.

Delayed tacrolimus-induced optic neuropathy.

Tacrolimus is an immunosuppressant agent utilized for solid organ transplantations. It has been associated with rare neurotoxic effects. This case highlights one possible delayed neurotoxic effect. A 52-year-old lady on tacrolimus (3mg daily) among her immunosuppressive regimen for her kidney transplant 16 year ago. She presented with unilateral left paracentral black dots progressing over a week, associated with periorbital and temporal pain. The patient was diagnosed with left papillitis. Tacrolimus was tapered and then changed to cyclosporine. However, patient did not show any improvement of any parameter. Reports have indicated such neurotoxic effects with Tacrolimus use. Here, the report emphasizes on the unilateral optic neuropathic effect of tacrolimus even after one decade.