Transforming Dental Care in Saudi Arabia: Challenges and Opportunities.

This comprehensive review examines the dental healthcare system in Saudi Arabia, tracing its evolution, current status, and persisting challenges. The system has evolved significantly due to government initiatives and technological integration, yet it grapples with issues like professional shortages, financial constraints, and disparities in access. Despite improvements in accessibility, geographic and socio-economic disparities persist, and oral health promotion remains limited. The integration of technology faces resistance, and specialized care for people with disabilities requires targeted strategies. Cultural and social factors influence oral health, and the system's response to the COVID-19 pandemic showcases adaptability and patient-centered approaches. Addressing these challenges is crucial for ensuring equitable and effective oral health service delivery in Saudi Arabia.

Retraction: Lymphangioma: A Rare Benign Cystic Pancreatic Lesion.

[This retracts the article DOI: 10.7759/cureus.21056.].

A Case of Isolated Bilateral Femoral Bifurcation in Saudi Arabia.

Bifurcation of the femur is a rare congenital orthopedic anomaly that is usually accompanied by tibial agenesis. Femoral bifurcation has been a part of the Gollop-Wolfgang complex criteria, which also include the tibia and fibula deformities with or without other variant abnormalities. Approximately 200 cases have been reported worldwide. This article presents a case of isolated bilateral distal femur bifurcation in a three-and-a-half-year-old girl who presented with abnormal gait and bilateral knee contractures. Extensive studies were performed to aid an appropriate diagnosis and treatment plan, including clinical history, physical examination, laboratory, and other investigations. After multiple consultations from different specialties, a gradual deformity correction was suggested as a treatment of choice. To our knowledge, there is a paucity of reported cases in the medical literature. Further research and case reporting are essential to better define the pathogenesis, prognosis, and treatment of such conditions.

Lymphangioma: A Rare Benign Cystic Pancreatic Lesion.

Pancreatic lesions are more commonly identified nowadays with the widespread use of imaging investigations. Pancreatic lesions are heterogeneous groups of pathologies with different behavior and prognosis. It is quite difficult to differentiate these lesions because of the shared clinical manifestation and the overlapping imaging features of these lesions. We report the case of a 38-year-old woman who presented with a complaint of a 3-month history of epigastric abdominal pain radiating to her back. She reported a gradual increase in the severity of the pain. She described it as sharp in quality and was exacerbated with food intake and was alleviated by oral paracetamol. There was no history of abdominal distension, weight loss, or change in appetite. Apart from asthma, she had no other comorbid conditions or previous surgeries. She was referred to have an abdominal computed tomography scan which showed a large lesion that appears to arise from the head of the pancreas and was cystic with no soft tissue component. The radiological impression was a lymphoepithelial cyst, duplication cyst, pseudocyst from previous acute pancreatitis, lymphangioma, or intraductal papillary mucinous neoplasm. The decision for open surgical removal was decided. The patient underwent laparotomy and the cystic lesion was identified as arising from the pancreatic head. Complete resection of the mass was carried out with no complications. Histopathological examination revealed cystic lesions with the presence of lymphoid cells aggregates peripherally. The lining of the channels was positive for CD31 and was negative for CD34. Such findings conferred the diagnosis of lymphangioma. Lymphangioma is a very rare tumor of the pancreas with non-specific clinical and imaging features. Complete surgical resection of the lesion is the treatment of choice and the prognosis of the tumor is favorable if the tumor was resected completely.

Primary stability of a short bone-conserving femoral stem: a two-year randomized controlled trial using radiostereometric analysis.

Aims: The aim of this study was to determine the stability of a new short femoral stem compared with a conventional femoral stem in patients undergoing cementless total hip arthroplasty (THA), in a prospective randomized controlled trial using radiostereometric analysis (RSA). Patients and Methods: A total of 53 patients were randomized to receive cementless THA with either a short femoral stem (MiniHip, 26 patients, mean age: 52 years, nine male) or a conventional length femoral stem (MetaFix, 23 patients, mean age: 53 years, 11 male). All patients received the same cementless acetabular component. Two-year follow-up was available on 38 patients. Stability was assessed through migration and dynamically inducible micromotion. Radiographs for RSA were taken postoperatively and at three, six, 12, 18, and 24 months. Results: At two years, there was significantly less subsidence (inferior migration) of the short femoral stem (head, 0.26 mm, 95% confidence interval (CI) 0.08 to 0.43, sd 0.38; tip, 0.11 mm, 95% CI -0.08 to 0.31, sd 0.42) compared with the conventional stem (head, 0.62 mm, 95% CI 0.34 to 0.90, sd 0.56, p = 0.02; tip, 0.43 mm, 95% CI 0.21 to 0.65, sd 0.44, p = 0.03). There was no significant difference in dynamically inducible micromotion, rate of complications or functional outcome. Conclusion: This study demonstrates that the short femoral stem has a stable and predictable migration. However, longer-term survival analysis still needs to be determined. Cite this article: Bone Joint J 2018;100-B:1148-56.

Past and projected temporal trends in arthroscopic hip surgery in England between 2002 and 2013.

INTRODUCTION: Hip arthroscopy is increasingly adopted for the treatment of intra-articular and extra-articular pathologies. Studies from USA demonstrate a 365% increase in the number of procedures performed between 2004 and 2009 and 250% increase between 2007 and 2011. There is limited evidence of long-term efficacy for this procedure and hip arthroscopy is not universally funded across England. The aim of this study is to describe temporal trends in the adoption of hip arthroscopy in England between 2002 and 2013 and to forecast trends for the next 10 years. METHODS: A search of the Hospital Episodes Database was performed for all codes describing arthroscopic hip procedures with patient age, sex and area of residence. RESULTS: 11 329 hip arthroscopies were performed in National Health Service hospitals in England between 2002 and 2013. The number of hip arthroscopies performed increased by 727% (p<0.0001) during this period and is forecast to increase by 1388% in 2023. Females represent 60% of all patients undergoing hip arthroscopy (p<0.001). Median age category is 40-44 for females and 35-39 for males and average age decreased during the study period (p<0.0001). There is significant regional variation in procedure incidence. In the final year of this study the highest incidence was in the Southwest (8.63/100 000 population) and lowest in East Midlands (1.29/100 000 population). CONCLUSIONS: The increase in number of hip arthroscopies performed in England reflects trends in USA and continued increases are forecast. Evidence from robust clinical trials is required to justify the increasing number of procedures performed and regional variation suggests potential inequality in the provision of this intervention.

Surrogate markers of long-term outcome in primary total hip arthroplasty: A systematic review.

OBJECTIVES: High failure rates of metal-on-metal hip arthroplasty implants have highlighted the need for more careful introduction and monitoring of new implants and for the evaluation of the safety of medical devices. The National Joint Registry and other regulatory services are unable to detect failing implants at an early enough stage. We aimed to identify validated surrogate markers of long-term outcome in patients undergoing primary total hip arthroplasty (THA). METHODS: We conducted a systematic review of studies evaluating surrogate markers for predicting long-term outcome in primary THA. Long-term outcome was defined as revision rate of an implant at ten years according to National Institute of Health and Care Excellence guidelines. We conducted a search of Medline and Embase (OVID) databases. Separate search strategies were devised for the Cochrane database and Google Scholar. Each search was performed to include articles from the date of their inception to June 8, 2015. RESULTS: Our search strategy identified 1082 studies of which 115 studies were included for full article review. Following review, 17 articles were found that investigated surrogate markers of long-term outcome. These included one systematic review, one randomised control trial (RCT), one case control study and 13 case series. Validated surrogate markers included Radiostereometric Analysis (RSA) and Einzel-Bild-Röntgen-Analyse (EBRA), each measuring implant migration and wear. We identified five RSA studies (one systematic review and four case series) and four EBRA studies (one RCT and three case series). Patient Reported Outcome Measures (PROMs) at six months have been investigated but have not been validated against long-term outcomes. CONCLUSIONS: This systematic review identified two validated surrogate markers of long-term primary THA outcome: RSA and EBRA, each measuring implant migration and wear. We recommend the consideration of RSA in the pre-market testing of new implants. EBRA can be used to investigate acetabular wear but not femoral migration. Further studies are needed to validate the use of PROMs for post-market surveillance.Cite this article: T. T. Malak, J. A. J. Broomfield, A. J. R. Palmer, S. Hopewell, A. Carr, C. Brown, D. Prieto-Alhambra, S. Glyn-Jones. Surrogate markers of long-term outcome in primary total hip arthroplasty: A systematic review. Bone Joint Res 2016;5:206-214. DOI: 10.1302/2046-3758.56.2000568.

Primary hip replacement prostheses and their evidence base: systematic review of literature.

OBJECTIVE: To determine the extent to which prostheses with no readily available evidence to support their use are being implanted in primary total hip arthroplasty. DESIGN: Systematic review of the literature. DATA SOURCES: The 9th annual report of the National Joint Registry of England and Wales (NJR) was analysed to identify prostheses with an Orthopaedic Data Evaluation Panel rating of "unclassified" or "pre-entry" used in primary total hip arthroplasty in 2011. A systematic review of those prostheses was carried out using PubMed, Cochrane, Embase, OVID, and Google databases. STUDY SELECTION: Prostheses used in primary total hip arthroplasty as published in the NJR's 9th annual report were analysed. Only literature that included the name of the prosthesis was included. Literature yielded in the search results was excluded if it reported animal, non-orthopaedic, non-total hip arthroplasty, or non-device related studies. RESULTS: The systematic review found that 24% (57/235) of all hip replacement implants available to surgeons in the UK have no evidence for their clinical effectiveness. It also shows that 10,617 (7.8%) of the 136,593 components used in primary hip replacements in 2011 were implanted without readily identifiable evidence of clinical effectiveness. These comprised 157 cemented stems (0.5% of 34,655 implanted), 936 (2.8% of 33,367) uncemented stems, 1732 (7.1% of 24,349) cemented cups, and 7577 (17.1% of 44,222) uncemented cups. CONCLUSIONS: This study shows that a considerable proportion of prostheses available to orthopaedic surgeons have no readily available evidence of clinical effectiveness to support their use. Concern exists about the current system of device regulation, and the need for a revised process for introducing new orthopaedic devices is highlighted.

Polymyositis and ovarian carcinoma: a case report.

We are reporting a case of ovarian carcinoma, who presented with polymyositis. Polymyositis, without any evidence of dermatomyositis, as the presentation of ovarian carcinoma has never been reported. In fact, for patients with polymyositis, there does not appear to be a great increase in the risk of malignancy. The purpose of this report is to make the gynaecologists aware that polymyositis alone can also be the presenting symptom for ovarian carcinoma.

Alternatively spliced tenascin-C mRNA isoforms in human fetal membranes.

Tenascin-C is an extracellular matrix glycoprotein whose monomers include eight consecutive fibronectin type III-like repeats, encoded by exons 10-16, and which are subject to alternative splicing. Transcripts containing these exons are expressed during tissue wounding and active tissue remodelling. Human fetal membranes have been proposed to undergo active tissue remodelling as part of the mechanisms leading to their rupture and immunoreactive tenascin-C has been detected in this tissue. Employing reverse transcription-polymerase chain reaction (RT-PCR) and exon-specific primers, products corresponding to multiple splicing events in the alternatively spliced region have now been identified. The overall splicing pattern would indicate that the major transcripts correspond to complete exclusion of the alternatively spliced region; inclusion of only exon 16; and inclusion of exons 10-14 and 16, including or excluding exon 12. The sole site in tenascin-C susceptible to cleavage by matrix metalloproteinases (MMP)-2 and MMP-3 is found within the exon 12 encoded repeat, therefore translation of isoforms which include or exclude exon 12 may produce 'large' tenascins mediating functions ascribed to this form but susceptible or resistant to these MMPs. The demonstration of expression of 'large' tenascin mRNA isoforms supports the concept that fetal membranes at term are a site of active tissue remodelling.

Structural characteristics of term human fetal membranes prior to labour: identification of an area of altered morphology overlying the cervix.

Premature rupture of fetal membranes can have serious clinical implications, especially for the initiation of preterm labour and its consequences. To account for this phenomenon many studies have attempted to identify membrane features that may be uniquely associated with the site of rupture. Our previous work has identified an area of the fetal membrane, following spontaneous term birth which exhibits alterations consistent with structural weakness. The aim of this study was to determine if these changes existed prior to labour. In formalin-fixed paraffin-embedded tissue sections an area of the fetal membrane overlying the cervix, termed the 'cervical membranes', was characterized by an increased thickness of the connective tissue layer (215% increase, P < 0.01) and decreased thickness of both the cytotrophoblast (36% reduction, P < 0.01) and decidual layers (64% reduction, P < 0.01) compared to the rest of the membrane. This resulted in the cervical membranes being significantly thinner (P < 0.05) than the rest of the membrane. Similar changes were also detected in frozen sections of fetal membranes. These regional differences have two important implications in that: (i) the cervical membrane may represent a region of structural weakness susceptible to rupture during labour, and (ii) the paracrine relationships between fetal membranes and the myometrium may be qualitatively affected within different regions of the uterus.

Fetal fibronectin in cervicovaginal secretions as a predictor of preterm birth.

OBJECTIVE: To determine whether fetal fibronectin detected in cervicovaginal secretions of patients with symptoms suggestive of preterm labour is a predictor for preterm birth. DESIGN: A blind prospective observational study. SETTING: A teaching hospital. PARTICIPANTS: One hundred and forty-one women presenting to the delivery suite between 24 and 37 weeks of gestation (112 were between 24 and 34 weeks of gestation) with symptoms suggestive of preterm labour, with intact membranes and cervical dilation of < 2 cm. INTERVENTION: Specimens of cervicovaginal secretions were collected from the ectocervix and posterior fornix. Fetal fibronectin levels were measured by an ELISA and samples were considered positive if the level of fetal fibronectin present was > or = 0.05 microgram/ml. MAIN OUTCOME MEASURES: Gestation at birth and sampling-birth interval. RESULTS: The preterm birth (before 37 weeks of gestation) rate in the population studied was 19.1%. Fetal fibronectin predicted preterm birth with sensitivity of 63%, specificity of 95.6%, positive predictive value of 77.3%, and negative predictive value of 91.6%. Analysis of the data from women at less than 34 weeks of gestation showed similar results. A negative test accurately excluded (97.9%) the chance of subsequent birth during the three weeks interval following sampling. CONCLUSIONS: The presence of fetal fibronectin in the cervicovaginal secretions of women admitted with symptoms suggestive of preterm labour indicates a significant risk for subsequent preterm birth. The absence of fetal fibronectin in this group is a very strong indication that subsequent preterm birth is unlikely to occur. Fetal fibronectin test, if combined with clinical findings, has a potentially important role in clinical management of women with symptoms suggestive of preterm labour.

Differential expression of the integrin subunits in human fetal membranes.

The distribution of the alpha 1, alpha 3-alpha 6, beta 1, beta 3 and beta 4 integrin subunits in fetal membranes at term was examined using an indirect immunofluorescence technique and confocal laser scanning microscopy. In the amniotic epithelium, beta 4 integrin (alpha 6 beta 4) exhibited distinct basal localization, whereas beta 1 integrins (alpha 3 beta 1, alpha 5 beta 1) were localized basolaterally. This finding suggests that integrins, especially alpha 6 beta 4 which is a structural component of the hemidesmosomes, may function as basement membrane receptors. Integrins localized laterally may play a role in cell-cell interactions. beta 1 (alpha 1 beta 1, alpha 5 beta 1) integrins are probably involved in cell-matrix interactions in the connective tissue layers which are rich in collagens and fibronectin. Cytotrophoblasts, located predominantly towards the chorionic basement membrane, mainly expressed alpha 6 beta 4, while those located predominantly in the vicinity of decidua expressed alpha 5 beta 1, alpha 3 beta 1 and alpha 1 beta 1. Decidual cells expressed alpha 3 beta 1 and alpha 1 beta 1, whereas alpha 1, alpha 5, alpha 6, beta 1 and beta 4 were expressed in blood vessels. This pattern of integrin expression reflects the reported difference in composition of the extracellular matrix at these locations and obviates an important role for alpha 5 beta 1 at the chorio-decidual interface. The differential integrin expression at the cell-basement membrane interfaces demonstrated in this study (at amniotic epithelium, cytotrophoblasts, decidual cells and blood vessels) indicated a differential recognition of basement membranes by these cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Distribution of fibrillin-containing microfibrils and elastin in human fetal membranes: a novel molecular basis for membrane elasticity.

OBJECTIVES: The aim of this study was to determine the distribution of the elastic fiber components, elastin and the extensible fibrillin-containing microfibrils, in human fetal membranes, to understand the possible molecular basis of the membrane elasticity. STUDY DESIGN: Multiple fetal membrane specimens were obtained immediately after 10 normal vaginal deliveries at term. The distribution of elastin and fibrillin-containing microfibrils was studied by histochemical, immunohistochemical, immunofluorescence, and electron microscopic techniques. RESULTS: We failed to detect elastin in the fetal membranes with any of the applied techniques. However, fibrillin-containing microfibrils formed abundant longitudinal bundles that were primarily found in the fibroblast and reticular layers. The orientation of these bundles was parallel to direction of membrane stretch. They also formed bundles that extended from the amniotic, chorionic, and decidual basement membranes to the adjacent tissues. The fibrillin-containing microfibrils were also identified in the compact layer and in intercellular spaces of the trophoblasts but not in the spongy layer. CONCLUSIONS: We suggest that, in the absence of elastin, the structural organization and the extensibility of the fibrillin-containing microfibrils may represent a novel molecular basis for the elastic properties of the fetal membranes and contribute to their strength.

Structural characteristics of term human fetal membranes: a novel zone of extreme morphological alteration within the rupture site.

OBJECTIVE: To determine the structural characteristics of the rupture site of term fetal membranes (amniochorion and decidua) that rupture spontaneously after the onset of labour. DESIGN: Fourteen term fetal membranes were examined immediately after delivery at the light microscope level. Multiple samples were taken along the whole rupture site and long an axis between this site and placental edge. Morphometric analysis of the thickness of the constituent layers of the fetal membranes was performed. SETTING: Leicester Royal Infirmary Maternity Hospital. RESULTS: A restricted zone of extreme altered morphology, characterised by marked swelling and disruption of the connective tissue, thinning of the trophoblast layer and thinning or absence of decidua, was identified in the rupture site of all patients. Morphometric analysis of the thickness of membrane layers showed that these changes and the ratio between the thickness of the connective tissue layers and that of the trophoblast and decidua (termed fetal membrane morphometric index) were significant between the zone of extreme altered morphology and the rest of the membranes. CONCLUSIONS: The morphological features of the zone of extreme altered morphology suggests that it represents an area of structural weakness of the membranes. Since this zone did not include the whole length of the rupture site, it is likely that it was present before membrane rupture and was generated during pregnancy. We hypothesise that the zone of extreme altered morphology represents the site of initial rupture after which the tear is transmitted through the membranes to produce the rupture site. It is possible that if these changes become more extreme, then prelabour membrane rupture may occur. Further characterisation of this zone may help to understand the mechanism of its genesis and its role in predisposing the fetal membranes to rupture.

Confocal and conventional immunofluorescence and ultrastructural localisation of intracellular strength-giving components of human amniochorion.

Key cytoskeletal polypeptides of human fetal membranes have been localised at subcellular level using confocal and conventional indirect immunofluorescence microscopy. Correlation with electron microscope data has allowed us to examine how cellular compartments of this multilaminar tissue maintain their mechanical integrity until the time of membrane rupture at parturition. Evidence is presented for myofibroblastic characteristics of cells in both the fibroblast and reticular layers which may therefore have tension-generating, position-adjustment and wound-healing roles in the amniochorion. Desmin and vimentin are coexpressed in these cells, but a small localised population of cells in the fibroblast layer contains vimentin alone. An interaction of cytokeratin filaments with nuclei and desmosomes of amniotic epithelium in vivo is demonstrated, indicating that nuclei of cells of ectodermal origin are integrated into a mechanical structure extending throughout the tissue as a whole. Cells of the basal 1 or 2 layers of trophoblast have been shown to have a more extensive and better integrated cytoskeletal organisation than those overlying and forming the boundary with decidua. Structures within the trophoblast, identified previously as degenerate villi, contain cells with intermediate filaments with similar immunofluorescence properties to those of the neighbouring reticular layer and thus may represent papillae that prevent shearing at this interface.