Saudi National Clinical Practice Guidelines for Management of Adult Systemic Lupus Erythematosus.

OBJECTIVE: To provide evidence-based clinical practice recommendations for managing Systemic Lupus Erythematosus (SLE) in Saudi Arabia. METHODS: This EULAR-adapted national guideline in which a multidisciplinary task force utilized the modified Delphi method to develop 31 clinical key questions. A systematic literature review was conducted to update the evidence since the EULAR publication. After reaching a consensus agreement, two rounds of voting and group discussion were conducted to generate consolidated recommendations/statements. RESULTS: A significant number of patients in Saudi Arabia experience delays in accessing rheumatologists, highlighting the significance of timely referral to SLE specialists or rheumatologists to ensure accurate diagnosis and prompt treatment. The primary goal of Glucocorticoid (GC) therapy in SLE patients is to establish disease control with a minimum dose and duration. Steroid-sparing agent utilization facilitates steroid-sparing goals. Hydroxychloroquine is recommended for all SLE patients, though physicians must carefully monitor toxicity and prioritize regular medication adherence assessment. SLE management during pregnancy starts from preconception time by assessing disease activity, major organ involvement, hypercoagulability status, and concomitant diseases that may negatively impact maternal and fetal outcomes. Multidisciplinary care with close monitoring may optimize both maternal and fetal outcomes. For patients with antiphospholipid antibodies, low-dose aspirin prophylaxis is recommended. Also, Long-term anticoagulant medications are fundamental to prevent secondary antiphospholipid syndrome due to high thrombosis recurrence. CONCLUSION: This Saudi National Clinical Practice guidelines for SLE management provide evidence-based recommendations and guidance for healthcare providers in Saudi Arabia who are managing patients with SLE. These guidelines will help to standardize healthcare service, improve provider education, and perhaps lead to better treatment outcomes for SLE patients.

The Saudi consensus recommendations for the management of psoriatic arthritis (2023).

Psoriatic arthritis (PsA) is a complex inflammatory disease characterized by musculoskeletal and non-musculoskeletal manifestations. It is a distinct disease entity at the interface between rheumatology and dermatology, making it challenging to manage. The diverse clinical presentation and severity of PsA require a multidisciplinary approach for optimal care. Early diagnosis and management are necessary to improving quality of life for patients. In Saudi Arabia, there is currently no unified national consensus on the best practices for managing PsA. This lack of consensus leads to debate and uncertainty in the treatment of the disease, resulting in over or under prescribing of biological agents. To address this issue, a multidisciplinary work group was formed by the Saudi Ministry of Health. This group, consisting of dermatologists, rheumatologists, and pharmacists, aimed to develop evidence-based consensus recommendations for he use and monitoring of biological therapy in PsA management. The work group conducted five consensus workshops between December 2021 to March 2022. Using the nominal group technique, they discussed various aspects of PsA management, including eligibility criteria for biological treatment, monitoring of disease activity, treatment goals, screening, precautions, and management of PsA with biologic therapies. The group also considered special considerations for patients with comorbidities, pregnant and lactating women, as well as pediatric and adolescent populations. The resulting consensus document provides recommendations that are applicable to the Saudi setting, taking into account international guidelines and the specific needs of PsA patients in the country. The consensus document will be regularly updated to incorporate new data and therapeutic agents as they become available. Key Points • In Saudi Arabia, there is a lack of unified national consensus on the optimal management of PsA, therefore, this article aims to provide up-to-date evidence-based consensus recommendations for the optimal use and monitoring of biologic therapy in the management of PsA in Saudi Arabia. • The consensus development process was undertaken by a multidisciplinary work group of 13 experts, including two dermatologists, six rheumatologists, and five pharmacists. • There is more than one disease activity tool used in PsA disease, depending on the disease domain - peripheral arthritis Disease Activity Index in Psoriatic Arthritis (DAPSA) or Minimal Disease Activity (MDA), axial PsA Ankylosing Spondylitis Disease Activity Score (ASDAS), and dactylitis and enthesitis MDA. • The main goal of therapy in all patients with PsA is to achieve the target of remission, or alternatively, low disease activity in all disease domains and improve quality of life (QoL).

Saudi consensus guidance for the management of inflammatory bowel disease during pregnancy.

ABSTRACT: The management of inflammatory bowel disease (IBD) in pregnant women is challenging and must be addressed on a patient-by-patient basis. Optimal patient management requires a multidisciplinary team and clear evidence-based recommendations that cater to this subset of patients. In this article, we provide concise guidelines and clinical care pathway for the management of IBD in pregnant women. Our recommendations were developed by a multidisciplinary working group that includes experts from the Saudi Ministry of Health in collaboration with the Saudi Gastroenterology Association and the Saudi Society of Clinical Pharmacology. All recommendations are based on up-to-date information following an extensive literature review. A total of 23 evidence-based expert opinion recommendations for the management of IBD in pregnant women are herein provided.

Saudi Arabia consensus guidance for the diagnosis and management of adults with inflammatory bowel disease.

Optimal management of inflammatory bowel disease (IBD) relies on a clear understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This article provides concise guidelines for the management of IBD in adults, based on the most up-to-date information at the time of writing and will be regularly updated. These guidelines were developed by the Saudi Ministry of Health in collaboration with the Saudi Gastroenterology Association and the Saudi Society of Clinical Pharmacy. After an extensive literature review, 78 evidence-and expert opinion-based recommendations for diagnosing and treating ulcerative colitis and Crohn's disease in adults were proposed and further refined by a voting process. The consensus guidelines include the finally agreed on statements with their level of evidence covering different aspects of IBD diagnosis and treatment.

A New Era of National Guideline Development in Saudi Arabia.

Saudi Arabia's ambitious Vision 2030 project was launched in 2016 as a strategy for economic development and national growth, with 11 Vision Realization Programs put in charge of its implementation. The backbone of its Transformation Program for the Health Sector has been the definition of a new Model of Care aiming to deliver 42 coordinated interventions across 6 Systems of Care, with the development of clinical guidelines identified as a key cross-cutting intervention to foster the use of national, evidence-based practices across KSA, reduce care variation, and promote accountable care. This article provides an overview of the history, progress to date, and future outlook of the recently initiated National Guidelines Center in Saudi Arabia, established in collaboration between the Health Holding Company and the Saudi Health Council represented by its National Center for Evidence-based Medicine. The lessons learnt from previous guideline initiatives are grouped under the Center's design principles of high quality, relevance, practical implementation, and sustainability. Aspects setting the project apart from previous endeavors have been its focus on extensive engagement with key stakeholders in the Saudi guideline ecosystem, the co-development of evidence-based recommendations with aligned key performance measures, and the implementation of guideline recommendations in the clinical workflow via integrated electronic order sets. Nine activity streams aim to enable the Center to take its place among the leading regional and global guideline developing organizations and to optimally support clinicians and patients, Saudi Arabia's health sector transformation, and the work of guideline communities worldwide.

National Saudi Consensus Statement on the Management of Atopic Dermatitis (2021).

Atopic dermatitis (AD) is a chronic inflammatory skin disease with an increasing prevalence regionally and globally. It is characterized by intense itching and recurrent eczematous lesions. With the increase in the availability of treatment options for healthcare practitioner and patients, new challenges arise for treatment selection and approach. The current consensus statement has been developed to provide up-to-date evidence and evidence-based recommendations to guide dermatologists and healthcare professionals managing patients with AD in Saudi Arabia. By an initiative from the Ministry of Health (MOH), a multidisciplinary work group of 11 experts was convened to review and discuss aspects of AD management. Four consensus meetings were held on January 14, February 4, February 25, and March 18 of 2021. All consensus content was voted on by the work group, including diagnostic criteria, AD severity assessment, comorbidities, and therapeutic options for AD. Special consideration for the pediatric population, as well as women during pregnancy and lactation, was also discussed. The present consensus document will be updated as needed to incorporate new data or therapeutic agents.

Saudi consensus recommendations on the management of multiple sclerosis: MS management in children and adolescents.

Multiple sclerosis (MS) most commonly presents in young adults, although 3-5% of patients develop MS prior to the age of 18 years. The new and comprehensive consensus for the management of MS in Saudi Arabia includes recommendations for the management of MS and other CNS inflammatory demyelinating disorders in pediatric and adolescent patients. This article summarizes the key recommendations for the diagnosis and management of these disorders in young patients. Pediatric and adult populations with MS differ in their presentation and clinical course. Careful differential diagnosis is important to exclude alternative diagnoses such as acute disseminated encephalomyelitis (ADEM) or neuromyelitis optica spectrum disorders (NMOSD). The diagnosis of MS in a pediatric/adolescent patient is based on the 2017 McDonald diagnostic criteria, as in adults, once the possibility of ADEM or NMOSD has been ruled out. Few data are available from randomized trials to support the use of a specific disease-modifying therapy (DMT) in this population. Interferons and glatiramer acetate are preferred initial choices for DMTs based on observational evidence, with the requirement of a switch to a more effective DMT if breakthrough MS activity occurs.

Development and validation of bioanalytical UHPLC-UV method for simultaneous analysis of unchanged fenofibrate and its metabolite fenofibric acid in rat plasma: Application to pharmacokinetics.

A simple, precise, selective and fast ultra-high performance liquid chromatography (UHPLC-UV) method has been developed and validated for the simultaneous determination of a lipid regulating agent fenofibrate and its metabolite fenofibric acid in rat plasma. The chromatographic separation was carried out on a reversed-phase Acquity® BEH C18 column using methanol-water (65:35, v/v) as the mobile phase. The isocratic flow was 0.3 ml/min with rapid run time of 2.5 min and UV detection was at 284 nm. The method was validated over a concentration range of 100-10000 ng/ml (r2 â©¾ 0.9993). The selectivity, specificity, recovery, accuracy and precision were validated for determination of fenofibrate/fenofibric acid in rat plasma. The lower limits of detection and quantitation of the method were 30 and 90 ng/ml for fenofibrate and 40 and 100 ng/ml for fenofibric acid, respectively. The within and between-day coefficients of variation were less than 5%. The validated method has been successfully applied to measure the plasma concentrations in pharmacokinetics study of fenofibrate in an animal model to illustrate the scope and application of the method.

Characterization of a Biomimetic Mesophase Composed of Nonionic Surfactants and an Aqueous Solvent.

We have investigated the physical and biomimetic properties of a sponge (L3) phase composed of pentaethylene glycol monododecyl ether (C12E5), a nonionic surfactant, an aqueous solvent, and a cosurfactant. The following cosurfactants, commonly used for solubilizing membrane proteins, were incorporated: n-octyl-ß-d-glucopyranoside (ß-OG), n-dodecyl-ß-d-maltopyranoside (DDM), 4-cyclohexyl-1-butyl-ß-d-maltoside (CYMAL-4), and 5-cyclohexyl-1-pentyl-ß-d-maltoside (CYMAL-5). Partial phase diagrams of these systems were created. The L3 phase was characterized using crossed polarizers, diffusion of a fluorescent probe by fluorescence recovery after pattern photobleaching (FRAPP), and freeze fracture electron microscopy (FFEM). By varying the hydration of the phase, we were able to tune the distance between adjacent bilayers. The characteristic distance (db) of the phase was obtained from small angle scattering (SAXS/SANS) as well as from FFEM, which yielded complementary db values. These db values were neither affected by the nature of the cosurfactant nor by the addition of membrane proteins. These findings illustrate that a biomimetic surfactant sponge phase can be created in the presence of several common membrane protein-solubilizing detergents, thus making it a versatile medium for membrane protein studies.

Effect of long-term selection for egg production on eggshell quality of Japanese quail (Coturnix japonica).

An experiment was conducted to evaluate egg quality and ultrastuctural measurements of eggshell using a Scanning Electron Microscope (SEM) in 2 lines (selected and control) of Japanese quail. A selection program was applied over 22 consecutive generations for higher egg production and lower broken egg percentage. The results revealed that the females of the selected line produced significantly (P < 0.01) higher egg mass compared to that of the control line. Also, the selection procedure significantly improved feed conversion ratio. The eggshells of the selected line had a higher breaking strength compared to those of the control line, although there was no difference between them in shell thickness. Significantly higher wet (P < 0.01) and dry (P < 0.05) eggshell percentages were found in the selected line. In general, the eggshells of the selected line had a lower total score (good) of ultrastructural evaluation compared to the control line. According to scanning electron microscope data, the incidence of certain structural variants was more common in eggshells of the control line suggesting poor shell strength. The incidence of alignment was more prevalent in control eggshells compared to selected ones, suggesting lower resistance to breakage. Late fusion and large interstitial spaces of the palisade layer indicating decreased resistance to fracture were observed in control eggshells. It could be concluded that the improvement eggshell quality may be caused by the long-term selection for lower cracked and broken egg rates from generation to generation.

Hand injuries during hand surgery: a survey of intraoperative sharp injuries of the hand among hand surgeons.

An e-mail survey comprising 19 questions was directed towards members of the American Society for Surgery of the Hand (ASSH) to investigate the prevalence and nature of intraoperative injuries to hand surgeons during hand surgery. The responses were collected, statistical analysis was done and trends were extrapolated. Two hundred members of the ASSH completed the e-mail survey. A hand surgeon in practice for greater than 10 years has a 97% chance of sustaining an intraoperative "sharps" injury. The injury is self-inflicted (88%) in most cases and the index finger (94%) of the left hand (87%) is the most likely site. The suture needle was the cause in 91% of cases. Awareness of the risks and factors associated with hand injuries during hand surgery and adopting intraoperative measures are important strategies for preventing these potentially serious and life-threatening accidents.

Subungual carcinomas in multiple digits.

We report a patient with subungual squamous cell carcinoma arising in more than one digit who also had positive immunostaining for human papillomavirus (HPV). The patient worked for a wastewater utility company for 22 years and placed his hands in stagnant wastewater daily.

Non-Dupuytren's disease of the palmar fascia.

The typical Dupuytren's disease patient is of Northern European descent with bilateral progressive multiple digital contractures and is genetically predisposed, with a family history. Palmar fascial proliferations sometimes present as a different entity without the typical Dupuytren's disease characteristics. We identified 39 patients (20 women and 19 men) over a 4-year period with "Non-Dupuytren's palmar fascial disease", with unilateral involvement, without family history or ectopic manifestations. Twenty-three patients presented with unrelated complaints and were discovered, incidentally, to have the condition. In 28 patients, prior ipsilateral hand surgery or trauma precipitated the condition. Other related factors were diabetes mellitus and cardiovascular disease. Ten patients had skin tethering and subcutaneous thickening akin to Dupuytren's nodules and 29 had palmar fascial thickening into ill-defined pretendinous cords. The diseased tissue was in the line of the ring finger in 30 patients. The time from insult to onset of contracture averaged 3.6 months and from onset to follow-up averaged 5.3 years. The condition was non-progressive, or partially regressive, in 33 patients. Seven patients had operations for unrelated conditions and underwent simultaneous fasciectomy without recurrence. Environmental factors, especially trauma, surgery and diabetes, are important in the pathogenesis of Non-Dupuytren's palmar fascial disease, but these patients do not appear to be genetically predisposed for Dupuytren's disease. Typical Dupuytren's disease and Non-Dupuytren's palmar fascial disease are two clinical entities that run different courses and do not share a similar prognosis. This should be taken into account in future epidemiological and outcome studies.

V-Y slide of the common extensor origin for lateral elbow tendonopathy.

Twenty-two patients (23 limbs) with chronic lateral elbow tendonopathy were examined retrospectively after surgical management. Thirteen men and 9 women with an average age of 43 years (range, 32-54 years) had a mean follow-up time of 41.2 months (range, 9-97 months). All patients underwent at least 6 months of nonsurgical treatment without favorable response. V-Y slide of the common extensor origin was done for all patients. Sixteen patients (17 elbows) were examined after surgery and 6 were interviewed by telephone. None of the patients had major complications or permanent loss of elbow motion. A pain rating scale of 1 to 10 (10 being the worst) showed a difference from a rating of 9.0 (range, 7-10) before surgery to 1.4 (range, 0-4) after surgery. Grip strength increased from 57 lb (range, 5-125 lb) to 99 lb (range, 60-135 lb). Five patients (23%) reported some degree of cold intolerance. Twenty-one patients (95%) returned to their preoperative occupation with 1 patient not returning to work because of elbow pain caused by heavy and repetitive elbow stress especially from vibrating tools. Twenty-one patients (95%) reported no limitations in daily activities; 1 patient reported difficulty with opening jars. Seven people (32%) reported limitations in high-demand recreational activities. All patients were rated as poor before surgery and excellent or good after surgery by a grading scale. All patients were satisfied with the outcome of surgery. After surgical treatment for lateral elbow tendonopathy, pain relief and restoration of elbow function can be achieved. V-Y slide of the extensor origin has low morbidity, does not violate the joint space or lateral stabilizing ligaments of the elbow, allows adequate release, and has a high rate of satisfaction.

Treatment of trapeziometacarpal arthritis with silastic and metallic implant arthroplasty.

Implant arthroplasty was once viewed as a feasible and effective trapeziometacarpal joint disease. Silastic implants are now used rarely because of concerns of implant failure and particulate synovitis. Metallic implants, including total joint prostheses and those utilizing a spacer concept, have been used with some success. Indications, technical consideration, and potential complications of these implants are discussed.

Ulnar polydactyly.

A retrospective review of 148 patients with ulnar polydactyly was conducted to analyze the types, patterns of involvement, associated anomalies, treatments, and outcomes of this malformation. The hands only were involved in 123 patients, both hands and feet in 20 patients, and five patients had mixed radial and ulnar polydactyly. Ulnar polydactyly was more prevalent among males. Among African Americans, the condition was often bilateral. When unilateral, ulnar polydactyly occurred more often on the left side. The racial distribution was 103 African Americans (70 percent), 37 Caucasians (25 percent), four Native Americans, three Latin Americans, and one Asian. Five types were encountered: type I cutaneous nubbin, type II pedunculated digit, type III articulating digit with fifth metacarpal, type IV fully developed digit with sixth metacarpal, and type V polysyndactyly. The distribution of types in order of frequency was type II, III, V, I, and IV. Types I and II ulnar polydactyly combined were more prevalent (82 percent) than types III, IV, and V (18 percent). Types I and II were more common among African Americans. Types III, IV, and V ulnar polydactyly occurred more frequently among Caucasians, but these were slightly less prevalent than types I and II in this racial group. Five patients were syndromic; four were Caucasians, and one Asian. Most cases of ulnar polydactyly of the hand were treated by ligation (71 percent) in the nursery, whereas polydactyly of the foot was more often referred to a specialist to be treated by surgical ablation (92 percent). Treatment complications occurred more frequently in the hands than in the feet. The complication rate after ligation of ulnar polydactyly of the hand was 23.5 percent. The two main complications were tender or unacceptable nubbins and infections.

The sagittal band: anatomic and biomechanical study.

Forty-eight digits from 12 human adult fresh-frozen and formalin-preserved cadaveric hands were used to study the anatomy and biomechanics of the sagittal band (SB) and to investigate the mechanism of its injury. The SB was observed to be part of a complex retinacular system in proximity to the metacarpophalangeal (MCP) joint collateral ligaments and the palmar plate. Dynamic changes in SB fiber orientation were observed with different positions of the MCP and wrist joints. The fibers were perpendicular (0 degrees ) to the extensor tendon in neutral position, distally angulated 25 degrees at 45 degrees of MCP flexion, and 55 degrees with full flexion. Swan-Ganz catheter measurements were obtained deep to the SB in varying positions of the MCP joint. The average pressure generation was greatest (50 mm Hg) during full MCP joint flexion and least (30 mm Hg) during 45 degrees flexion. When MCP joint radial or ulnar deviation was added the average measurement was greatest (57) in neutral MCP position and least (35 mm Hg) in 45 degrees flexion. Serial sectioning of the ulnar SB produced no extensor tendon instability. Partial proximal but not distal sectioning of the radial SB produced tendon subluxation. Complete sectioning of the radial SB produced tendon dislocation. Wrist flexion increased tendon instability after radial SB sectioning. We conclude that (1) extensor tendon instability following SB disruption is most common in the long finger and least common in the small finger; (2) ulnar instability of the extensor tendon is due to partial or complete radial SB disruption, (3) the degree of extensor tendon instability is determined by the extent of SB disruption, (4) proximal rather than distal SB compromise contributes to extensor tendon instability, (5) great forces are inflicted on the SB while the MCP joint is in full extension or less frequently in full flexion, which may be the mechanism of its injury, and (6) wrist flexion contributes to extensor tendon instability after SB disruption and may exacerbate the severity of its injury.

Thumb digital neuropathy caused by splinting.

Healthcare professionals are currently faced with a great variety of splints and splinting materials. Choices range from prefabricated products to custom splints made on-site from plaster, orthoplast, or fiberglass. In addition to providing immobilization to maintain a particular posture, a splint must protect important soft tissues. Patients with hand or wrist injuries often receive a prefabricated metal cock-up wrist splint in emergency departments. Complications from splints are not uncommon but are infrequently reported. We report a case in which a metal wrist cock-up splint caused compression of the thumb ulnar digital nerve. Preventive measures for such complication are included.

Triple central ray amputation for clear cell sarcoma of the hand.

A 16-year-old girl presented for evaluation and management of a recurrent soft-tissue mass in her left hand after excision at another facility. She was given a diagnosis of clear cell sarcoma. She chose a limb salvage procedure over amputation. A triple central ray amputation of her index, middle, and ring fingers was performed. After 3 years, she has reasonable grasp function with her remaining fingers and has chosen not to use a prosthesis. Long-term follow-up is necessary for this tumor, as local recurrence and metastatic disease have been reported frequently.