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   Table of Contents - Current issue
Coverpage
October-December 2020
Volume 3 | Issue 4
Page Nos. 231-367

Online since Friday, October 2, 2020

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EDITORIAL  

Thymic stromal lymphopoietin polymorphism and asthma: Pros and cons p. 231
Arjumand S Warsy
DOI:10.4103/jnsm.jnsm_110_20  
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ORIGINAL ARTICLES Top

Three common single-nucleotide variants in the promoter region of thymic stromal lymphopoietin cytokine are not associated with asthma prevalence in a Saudi Arabian population p. 234
Maha Fahad Alenazy, Alejandro Vazquez-Tello, Rosan Kenana, Fatemeh Saheb Sharif-Askari, Areej Rashid Alkahtani, Amer Jamhawi, Sibtain Afzal, Roua Al-Kufiedy, Mohamed-Hani Temsah, Abeer Al-Masri, Fahad Alsohaime, Ayman Al-Eyadhy, Adel M Zakri, Elaref Ratemi, Saleh Al-Muhsen, Rabih Halwani
DOI:10.4103/JNSM.JNSM_44_20  
Background: Thymic stromal lymphopoietin (TSLP) is recognized for its key role in promoting asthma, hence drawing considerable clinical interest as a potential therapeutic target. Population-based studies found association between single nucleotide polymorphisms (SNPs) located in the TSLP promoter region, and asthma; however, discrepancies have been also reported. Aims and Objectives: To determine whether rs1837253, rs2289276, and rs3806933 SNPs of TSLP gene are associated with asthma predisposition in a Saudi population. Materials and Methods: A total of, 272 asthmatic patients and 398 normal controls, all of Saudi citizenship, were recruited. The TSLP target DNA sequences were polymerase chain reaction (PCR) amplified using specific primers and allelic determination was performed by Sanger sequencing and capillary electrophoresis. Results: The relative frequencies for the minor allele, “T,” in all three SNPs, were smaller in asthmatics although not significant. When testing for genotypes, the homozygous T/T of all three SNPs was less frequent in asthmatic patients, but not to statistically significant levels. Both the recessive and dominant genetic models were tested. Homozygous T/T individuals for each SNP had lower odds of being asthmatics, thus suggesting a “protective” effect, although none of the SNPs in either model reached a statistical significance. Conclusion: Three SNPs in TSLP's promoter gene were not significantly associated with asthma in the Saudi population.
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Knowledge and awareness of ischemic heart disease among primary health-care patients in Riyadh hospitals p. 241
Hesham M Alshaikh, Mosfer S Aldosari, Nujaim H Alnujaim, Hamad F Albraidi, Sulaiman H Alajlan, Ali H Alfuraydi, Ahmad S Hersi
DOI:10.4103/JNSM.JNSM_7_20  
Objectives: This study aims to assess the level of knowledge and awareness about ischemic heart disease (IHD), specifically its warning symptoms and risk factors, among primary health-care (PHC) patients in Riyadh hospitals. Methods: We conducted an observational, descriptive, cross-sectional study in PHC clinics across four main public hospitals in Riyadh from October 2014 to April 2015. Convenience sampling was used to select 162 individuals. The level of knowledge was assessed using a new structured, self-administered questionnaire. Results: Level of knowledge regarding IHD in Riyadh hospitals (King Khalid University Hospital, Al-Iman General Hospital, King Salman Hospital, and King Abdulaziz Medical City) was 69%, 29%, 56%, and 58%, respectively. The level of education played a significant role, as participants with bachelor's and advanced degrees exhibited greater knowledge. Dyspnea was the most frequently cited symptom, while smoking and obesity were the most frequently identified risk factors. Interestingly, only 32% of participants recognized family history as a risk factor. Conclusions: This study highlighted the inadequate knowledge about IHD among PHC patients in Riyadh hospitals. The demographic characteristics had a significant effect on the level of knowledge. This study recommends health-care systems in Saudi Arabia to formulate strategies for IHD awareness.
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Prevalence of transfusion-transmissible infections among blood donors in Riyadh: A tertiary care hospital-based experience p. 247
Fahad AL Majid
DOI:10.4103/JNSM.JNSM_25_20  
Background: Transfusion-transmissible infections (TTIs) such as hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), and Treponema pallidum are a serious threat to the safety of recipients. Materials and Methods: This was a retrospective analysis of 38,621 blood donors screened for TTIs between January 2016 and December 2018 at King Khalid University Hospital, Riyadh, Saudi Arabia. Viral serology comprised of detection of hepatitis B surface antigen (HBsAg) and anti-core HBV antibody (anti-HBc), HCV antibody, and HIV antigen/antibody assays. Nucleic acid testing for viral genetic material was performed using Roche Cobas TaqScreen MPX v2 (Roche Molecular Systems, NJ, USA.) on Cobas s201 system. T. pallidum infection was confirmed by a reactive T. pallidum hemagglutination assay. Results: Of the total donors, 37,202 (96%) were males and 1419 (4%) were females, with a mean age of 30.3 ± 5 years. Majority of the donors (27,963; 72.4%) were Saudi nationals, whereas 10,658 (27.6%) individuals were of other nationalities comprising 24,356 (63%) volunteers and 14,265 (37%) repeat donors. The overall prevalence of TTIs among blood donors was 0.7%, with a prevalence of HBsAg of 0.29%, anti-HBc of 4%, HCV of 0.3%, HIV of 0.005%, human T-lymphotropic virus type I and II of 0.002%, and T. pallidum of 0.02%. No significant differences were observed in the annual prevalence rates of TTIs. Conclusion: Relatively low prevalence rates of TTIs were observed among the blood donors during the study period.
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Predictors and prevalence of social jet lag among King Saud employees and their families p. 252
Jumana Fatani, Reema Alnasser, Nouf Aljomah, Sarah Alhusaini, Ahmad Hersi
DOI:10.4103/JNSM.JNSM_6_20  
Background: Sleep is a crucial element in human beings' development and sustainment of a healthy lifestyle; any chronic misalignment between the sleep–wake cycles could be associated with numerous physical and mental disturbances. Social jet lag (SJL) is the discrepancy between the midpoints of sleep in workdays and free days. Up to date, there is a scarcity of studies conducted regarding this disorder in the Middle East. Hence, we aimed toward studying the prevalence and predictors of SJL. Methods: This was an observational cross-sectional study. The sample size was 328 participants who are King Saud University employees and their families. Saudi individuals aged 18 years and above were included in the study. Pregnant women were excluded from the study. Data were collected using an interview-administered questionnaire (Munich ChronoType Questionnaire). SJL was calculated as the absolute difference between the midpoints of sleep on free days and workdays. The association between SJL and predictors was assessed using the Chi-square test. Results: A sample of 226 females and 62 males were analyzed. SJL was categorized into three groups, which are <1 h, 1–2 h, and >2 h. Our results showed that SJL of >2 h represents approximately half of the participants (49.7%) and appeared to be more among the 18–33 years' age group (56.5%). Participants with >2 h were found to have a significant difference between sleep durations on work and free days (5.9 ± 1.8 vs. 8.67 ± 1.91 h, P < 0.001, respectively). Conclusion: Lower SJL hours are associated with factors such as increased age and similar sleep duration on work and free days, in addition to alarm use on free days. Whereas, younger age, inflexible work schedule, smoking, and soft drinks' consumption are linked with higher SJL hours. Our future aim is to increase the awareness of controlling the factors which lead to higher SJL hours and the importance of having a balanced sleep.
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Risk factor for urinary tract infections caused by Gram-negative Escherichia coli extended spectrum ß lactamase-producing bacteria p. 257
Ahmad Abdullah Majrashi, Abdullah Saleh Alsultan, Bander Balkhi, Ali Mohammed Somily, Fahad Mohammad Almajid
DOI:10.4103/JNSM.JNSM_11_20  
Aim: The incidence of urinary tract infections (UTIs) due to extended-spectrum ß-lactamase (ESBL)-producing Escherichia coli is increasing worldwide. Infections with ESBL-producing E. coli are associated with prolonged length of hospital stay, cost, and need for parenteral therapy. This study was aimed to describe the prevalence and assess the risk factors of UTIs due to ESBL-producing E. coli and to describe the antimicrobial susceptibility patterns against E. coli. Methods: A retrospective, cross-sectional study was conducted at King Saud University Medical City from May 1, 2015, to May 1, 2016, and included all adult cases of UTIs caused by E. coli.Results: E. coli urine isolates were obtained from 301 patients; 107 (35.5%) isolates had ESBL-producing E. coli, and 194 (64.5%) had non-ESBL E. coli. On multivariate analysis, urinary catheterization (odds ratio [OR] 1.4, 95% confidence interval [CI] 1.17–1.55, P < 0.00), antibiotic use in the past 3 months, (OR 1.3, 95% CI 1.16–1.4, P < 0.00), and diabetes mellitus (OR 1.2, 95% CI 1.04–1.31, P < 0.00) were significantly associated with ESBL-producing E. coli. infection. As expected, these ESBL producing isolates demonstrated higher resistance compared to non-ESBL E. coli to trimethoprim/sulfamethoxazole (64.5% vs. 43.8%), ciprofloxacin (64.4% vs. 28.7%), and gentamycin (36.4% vs. 9.2%). Conclusion: About one-third of UTI patients with E. coli presented with ESBL-producing bacteria. Significant risk factors were urinary catheterizations, history of antibiotic use, and diabetes mellitus. However, the associated OR was low for all predictors indicating their limited value in identifying patients at risk of ESBL.
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The role of thiol–disulfide and ischemia-modified albumin in the differential diagnosis of ovarian pathologies in children p. 262
Can Ihsan Oztorun, Gamze Gok, Ahmet Erturk, Sabri Demir, Dogus Guney, Alkim Oden Akman, Salim Neselioglu, Mujdem Nur Azili, Emrah Senel
DOI:10.4103/JNSM.JNSM_8_20  
Introduction: The aim of this study was to evaluate the association between ovarian pathologies and oxidative stress in children via the new method of thiol/disulfide homeostasis. Materials and Methods: The study was conducted in our clinic and included 24 cases of ovarian cysts (OCs) followed by us and 23 cases of operated OC or torsion and monitored by pediatric surgical intensive care unit. The control group consisted of 24 girls who admitted to the pediatric surgery outpatient clinic because of not-incarcerated inguinal hernia. Serum native thiol, total thiol, dynamic disulfide, albumin, and ischemia-modified albumin (IMA) levels of the patients and healthy volunteers were evaluated. Results: Native thiol (P = 0.41), total thiol (P = 0.57), dynamic disulfide (P = 0.98), albumin (P = 0.54), and IMA (P = 0.98) levels of the patients with OC were found similar with the ovarian torsion (OT) group. However, there were statistically significant differences in native thiol (P < 0.001), total thiol (P < 0.001), albumin (P < 0.001), and IMA (P < 0.001) levels of OT group compared to the controls, whereas dynamic disulfide levels (P = 0.63) were not statistically different from that of controls. Conclusions: In children, the evaluation thiol/disulfide homeostasis might be helpful in the diagnosis of ovarian pathology. Nonetheless, it could not be helpful in the differential diagnosis of OT, which requires emergency surgery from the other ovarian pathologies. Measuring of IMA levels as well as thiol/disulfide homeostasis could increase the specificity of the test. Further studies with larger samples are needed to clarify this issue.
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Patient satisfaction with neurosurgical care at King Saud University Medical City p. 267
Nasser Almujaiwel, Ghadeer Alsager, Sarah Bin Abdulqader, Safdar Malik, Sherif Elwatidy
DOI:10.4103/JNSM.JNSM_26_20  
Objectives: The objectives of this study were to determine the extent of patient satisfaction with the care provided by the neurosurgery team in our institution. Methods: This cross-sectional study was conducted at King Saud University Medical City (KSUMC) in Riyadh, Saudi Arabia. Adult postoperative neurosurgical patients, who had elective surgery between January 2018 and March 2019, were included. Data were collected over 3 weeks during May 2019 through telephonic interviews. Ninety-three patients were included (47 cranial and 46 spinal cases). Results: A total of 85 questionnaires were completed. Sixty-nine percent of patients who underwent spinal surgeries did not seek a second opinion from another specialist, whereas 81.4% of the patients with cranial pathologies did. The mean for patient satisfaction for the cranial cases was 88.4%. Cranial patients were least satisfied with the consultant's explanations of the procedure and most satisfied with how their privacy was respected. Spinal patients were least satisfied with the availability of the resident and most satisfied with the availability of the nursing staff. Overall, 91.8% of the patients indicated that they were satisfied with the service that they received. Conclusion: The majority of the patients were satisfied with the care provided by the neurosurgery team at KSUMC and with the results of the surgery. The majority of the patients who underwent spinal surgery did not seek a second opinion from another neurosurgeon, whereas the majority of the cranial patients sought a second opinion.
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Knowledge and attitudes toward preventing hospital-acquired infections among nurses and residents at a university hospital p. 272
Mazin Barry, Ghada Alhadlaq, Reem Alsergani, Rana Almana, Nora Alshabib, Najd Altheeb
DOI:10.4103/JNSM.JNSM_19_20  
Introduction: Survey questionnaire hospital-acquired infections (HAIs) can be prevented through correct prevention and control measures. We assessed knowledge and attitudes of nurses and postgraduate residents in a developing country, by comparing knowledge on HAI and its prevention between internal medicine and surgery residents and between nurses in outpatient departments, wards, and intensive care units (ICUs) to assess need on more focused training. Methodology: This was a cross-sectional study measuring the knowledge and attitudes on HAI among 261 health-care workers. A questionnaire was adapted from the Centers for Disease Control and Prevention and World Health Organization. The association between knowledge score percentage and demographic and work-related factors was assessed using independent samples t-test or one-way analysis of variance when appropriate. The Chi-square test (Fisher's exact test when appropriate) was used to compare the percentage of correct answers between residents and nurses. Results: Nurses and residents did not meet the accepted level of knowledge, with mean scores of 71.2% among 160 nurses and 66% among 101 residents. Nurses' knowledge score was significantly associated with their department (P < 0.001). Nurses working in ICUs had a higher mean knowledge score (81.68%) than nurses working in outpatient (56.77%) or inpatient (72.5%) settings. Whereas, no significant difference is found among residents' mean knowledge score according to their departments. Conclusions: Residents and nurses had insufficient knowledge regarding HAI prevention varying by department. Corrective measures through increased education and training intensively targeting specified areas would be helpful in improving knowledge and preventing infections.
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Experience with the use of the navigation system for ear surgeries: A cohort study p. 280
Mariam Al-Amro, Manal Bin Manea, Hassan Al Shehri, Abdulrahman Hagr
DOI:10.4103/JNSM.JNSM_12_20  
Objectives: Image guidance has been well characterized in spinal, orthopedic, sinonasal, and skull base surgery, but there is limited information on the use of these systems in cochlear implant and ear surgery. The aim of this study was to evaluate the use of image guidance systems to facilitate cochlear and bone-anchored hearing aid (BAHA) implant surgery. Study Design: Cohort. Materials and Methods: Eleven patients, including 10 who underwent cochlear implantation and 1 who underwent BAHA implantation with the assistance of the navigation system, were included in the study. Patient's data (age, gender, type and cause of hearing loss, and type of surgery), preoperative computed tomography scan findings, accuracy of the navigation system, operating time, and postoperative complications were collected and analyzed. Results: All 11 patients underwent uneventful surgeries finding the desired sites for implantation with ease by using the navigation system. All surgeries were completed without any complications. Conclusion: Performing cochlear and BAHA implantation with the assistance of the navigation system is a safe way to treat patients with normal or abnormal anatomy. In particular, it is helpful for identifying the round window for electrode insertion in cochlear implantation and for choosing the site with the thickest bone for BAHA implantation.
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The neurobehavioral outcomes of very low birth weight infants with intraventricular hemorrhage at corrected age of 24–36 months p. 286
Khalid A Altirkawi, Badr Sobaih, Abdulrahman Altuwaym, Alhanouf Almuhanna, Rasha Bassas, Rozina Banoo, Amull Fariss
DOI:10.4103/JNSM.JNSM_53_20  
Objectives: A proper neurobehavioral development is important for acquiring the skills of a healthy and productive life. Determining intraventricular hemorrhage (IVH) impact on different aspects of development may help in mitigation, and probably, prevention of the developmental delays. Materials and Methods: We evaluated the developmental quotients (DQ) of very low birth weight (VLBW) infants, who experienced IVH during neonatal period, at 24–36 months of their corrected age, using Gesell schedules of child development. Furthermore, we assessed the relationship between the severity, extent and sidedness of IVH, and total DQ, its subdomains, and common neurological and non-neurological comorbidities. Results: The study included 54 patients (36 males and 18 females). Bilateral IVH was more common in females, who exhibited also a trend toward left-sided IVH. Patient's sex, birth-weight, and gestational age, however, have not shown significant associations with the total DQ, or its subdomains. Severe IVH was significantly associated with both cerebral palsy, and reduction in total DQ, but not in its personal-social subdomain. Left-sided IVH was associated with a significant reduction in total DQ, but right-sidedness showed no such association. Periventricular leukomalacia was significantly associated with reduction in total DQ and in its personal-social subdomain. No significant associations were detected in patients with the non-neurological comorbidities. Conclusions: VLBW infants with left-sided, bilateral or severe IVH are at higher risk of worse neurobehavioral outcomes at 24–36 months of age. Non-neurological comorbidities seem to have little impact on the DQ and its subdomains assessed at this age.
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Assessment of dental health status, knowledge, and practice among Saudi diabetic patients attending general practice Clinic p. 292
Aljohara Saud Almeneessier, Nouf Saud Almunaiseer, Banna M Alnufaiy, Shaima O Bahammam, Nada A Alyousefi, Mohammed A Batais, Abdulaziz A Alodhayani, Turky H Almigbal, Rawan K Alkhalaf
DOI:10.4103/JNSM.JNSM_64_20  
Objective: Diabetic quality indicators are missing a major part of diabetes care management. We aimed to explore the diabetic patients' knowledge of oral health care and identify the periodontal health status among them. Materials and Methods: This study was a cross-sectional study on diabetic patients at a diabetic care clinic in the primary care setting. Data collection instrument was structured to measure knowledge and dental hygiene practice. Clinical examination was done to assess dental health using the Simplified Oral Hygiene Index (OHI-S) and Periodontal Screening and Recording. Data were analyzed using Statistical Package for the Social Sciences (SPSS 22). Results: One hundred and ninety-five individuals were included in the study, with a mean age of 54.32 ± 11.58. Knowledge assessment showed that 47.2% of the respondents answered ≥50% of the questions. Dental hygiene behavior showed that 58.6% brushed teeth one to two times per day, 66.8% never used flossing, and 14% never visited a dental care clinic. Forty-seven individuals had dental examination. The mean OHI was 1.71 ± 1.06. The relationship between OHI and glycated hemoglobin, fasting blood sugar, diabetes duration, brushing, flossing, and vegetable and fruit consumption could not be detected with P= 0.61, 0.78, 0.93, 0.97, 0.86, 0.98, and 0.7, respectively. Patients' perception of dental health status is positively correlated with the clinical dental examination and statistically significant with P= 0.004. Conclusions: Oral health literacy should be improved with implementation of educational intervention. A positive correlation between patient perception and dental examination will help the health-care provider in diabetic care adoption of oral health care within diabetic management at the primary care setting, which will improve the quality of diabetic care.
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Stress and psychological consequences of COVID-19 on health-care workers p. 299
Nevin F W. Zaki, Mohammad Sidiq, Mohammad Qasim, Brenda Aranas, Ali Hakamy, Nabil Abdelaziz Ruwais, Hussain Alanezi, Dib Abdul-Aziz Al Saudi, Raad Bin Saeed Alshahrani, Abdullah Bin Ali Al-Thomali, Md Dilshad Manzar, Ahmed S BaHammam, Abdelaziz F Al-Kaabba, Seithikurippu R Pandi-Perumal
DOI:10.4103/JNSM.JNSM_86_20  
Background: The wide scope and spread of Coronavirus Disease 2019 (COVID-19) could lead to a true mental health disaster, especially in countries with high caseloads. Very few studies have assessed the impact on hospital staff. This study aimed to assess mental health changes in health-care workers (Northern Area Armed Forces Hospital-Kingdom of Saudi Arabia). Materials and Methods: This is a cross-sectional study. A survey questionnaire was designed and distributed among the participants, and the survey contained demographic questions and questions related to anxiety, worries, and fears, in addition to depressive symptoms and basic sleep profile. In addition, the psychological impacts, feelings, fears of developing COVID-19, and symptoms of posttraumatic stress disorder were assessed using the Impact of Events Scale-Revised (IES-R). Results: The mean age of the staff was 38.2 years. The examined staffs showed high levels of anxiety and depressive features: 19.3% had crying and depressed mood and 2.4% had loss of motivation; they depended mainly on social media as a source of COVID-19 information. Moreover, these features correlated positively with their Post-Traumatic features measured by the IES-R. Nearly 27.3% of the participants had their duty impacted by COVID-19 and 40.6% were affected financially. Conclusion: Our study identified a vulnerable group susceptible to psychological distress. Psychological support could also be included as counseling services and development of support systems among colleagues.
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Views of faculty members on the use of e-learning in Saudi medical and health colleges during COVID-19 pandemic p. 308
Ahmad A Alanazi, Ziad M Alshaalan
DOI:10.4103/JNSM.JNSM_82_20  
Objective: The significant impact of COVID-19 pandemic may change the future of education. There was an abrupt obligatory transformation into e-learning. This study aimed to examine views of faculty members on the use of e-learning in Saudi medical and health colleges during COVID-19 pandemic, and their preparedness for e-learning in the light of the complete lockdown due to the pandemic. Materials and Methods: A descriptive cross-sectional study design was conducted in two parts. The first part was a pilot study aimed to provide valuable validation of the content of the major questionnaire study. The second part was a full-scale study designed to address the aim. An electronic questionnaire was prepared and distributed to reach a large number of faculties and primarily focused on three sections demographic information, experience with e-learning before and after COVID-19 pandemic, and preparedness for e-learning. Results: A total of 38 and 220 faculty members participated in the pilot and full-scale studies, respectively. The majority of respondents to the main questionnaire were male (73.2%), from Riyadh (42.7%), worked in governmental colleges (96.3%), and had different academic ranking and teaching experiences. Faculty members showed positive attitudes towards the use of e-learning which was tremendously increased post-COVID-19 (91.9%) compared to pre-COVID-19 (45.9%). Most of the participants were enthusiastic (82.3%) about and confident in using e-learning in teaching and learning. Yet, e-learning was not entirely used as a substitute for hands-on skill training and assessment. Conclusions: This study provides stakeholders with valuable standpoints indispensability of e-learning and the positive attitude and proficiency of teaching staff toward it. This urges furthering our institutional e-learning preparedness and engagement through resolving some appeared individual and infrastructural shortcomings. It is an appropriate time for overcoming barriers to e-learning/teaching as an integral teaching modality in medical and health colleges.
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VIEWPOINT Top

Lockdowns for community containment of COVID-19: Present challenges in the absence of interim guidelines p. 318
Md Dilshad Manzar, Seithikurippu R Pandi-Perumal, Ahmed S Bahammam
DOI:10.4103/JNSM.JNSM_68_20  
The implementation of lockdown as a method of community containment is complex and affects the several aspects of daily living. There is an urgent need for the development of guidelines for lockdowns as community containment methods to prevent pandemics. This opinion presents five broad areas of concern affecting community-containment strategies. This viewpoint may help in the development of an interim guide for the adequate implementation of community containment strategies. The presence of the COVID-19 pandemic, which now influences nearly every country, emphasizes the urgency of adopting meaningful and doable-threat reduction strategies that will fulfill the need of the local populations.
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REVIEW ARTICLES Top

Mesenchymal stem cell infusion as a promising therapeutic approach to treat coronavirus disease 2019 patients p. 322
Nihal AlMuraikhi
DOI:10.4103/JNSM.JNSM_46_20  
Coronavirus disease 2019 (COVID-19) is a highly contagious respiratory infection that emerges as a serious healthcare problem and becomes a global pandemic. The disease is caused by a novel virus called SARS-CoV-2. The initial site of infection is the pulmonary epithelial cells when the surface spike protein of the virus binds to their angiotensin I converting enzyme 2 receptor receptor triggering the immune system to release a huge number of inflammatory cytokines that may result in a cytokine storm. The clinical spectrum of the infections ranges from asymptomatic cases to severe viral pneumonia with multiple organ dysfunction that may lead to death. Currently, no specific antiviral drugs or vaccine has been confirmed to cure COVID-19. Mesenchymal stem cells (MSCs) present a potential therapeutic approach for treating COVID-19 patients through their regeneration of damaged tissues, anti-inflammatory, and immunomodulatory features. Preclinical data suggest that they can reduce pro-inflammatory cytokines, mitigate cytokine storm, and repair microenvironment of damaged tissues. MSCs are allogeneic stem cells that mainly get trapped in the lung when they are infused intravenously. Since the lung is the main affected organ in COVID-19 patients, this therapeutic approach seems to be advantageous. In this manuscript, we are describing this novel disease and its mechanism of infection, and stating the urgent need for treatment. Although many treatments are now being investigated for their effectiveness, this review has been dedicated to introducing all the supportive evidence in favor of utilizing the MSC therapy as a powerful therapeutic approach to improve the immunological response of COVID-19 patients.
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Current understanding of probiotics and sinonasal inflammation: A review p. 329
Saud Romaih Alromaih, Nouf Mohammad Aloraini
DOI:10.4103/JNSM.JNSM_14_20  
The complex interplay between commensal sinonasal microbiota and pathogenic bacteria contributes to the development of sinonasal inflammatory diseases. This review describes the rationale, effectiveness, and safety of probiotics in sinonasal inflammatory diseases. In vitro and animal clinical trials demonstrated a promising effect of probiotics in decreasing inflammation and the proportion of pathologic bacteria and improving the outcome. However, human studies involving chronic rhinosinusitis (CRS) patients did not exert any significant effect in reducing the symptoms, except in one study reported improvements in CRS exacerbations. This review concluded that up to now, the value of probiotics usage is not well understood, and future research aiming to extend the understanding of it will contribute to enhance the effectiveness of probiotic use in sinonasal inflammatory diseases.
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Demystifying bioethics: The past, present, and future of a flourishing discipline p. 334
Ruaim A Muaygil
DOI:10.4103/JNSM.JNSM_62_20  
Despite interest in bioethics being arguably at its highest, the history, development, and tasks of this practice remain elusive to many medical practitioners. This ambiguity is not without good reason; unlike its clinical counterparts, bioethics is not exclusively a child of medicine. Rather, bioethics also belongs to theology, philosophy, sociology, and the law. Its intellectual assumptions are multi-disciplinary and wide-reaching, in contrast to those of medicine-neatly delineated and perfected by the scientific method. Indeed, bioethics is contemplative where medicine is active, inquisitive where medicine is decisive, and measured where medicine is efficient. Although at first glance, bioethics may not appear to share much with medicine, the discipline has become an essential conduit of moral medical practice. This manuscript gives an account of the history and development of contemporary bioethics in both the Islamic and Western world, its current state of affairs, its tasks, and its future. Ultimately, it is hoped that this work will demystify the practice of bioethics and elucidate the role of the bioethicist as a partner to the practitioner, an ally to the patient, and an advocate for the moral practice of medicine.
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2020 Updates on tocilizumab indications for clinicians managing patients with severe acute respiratory syndrome coronavirus 2 p. 344
Mohammed A Omair, Waleed Hafiz, Mohammad Mustafa, Leen Ghoniam, Abdulrahman Alreshaid, Ibrahim Almaghlouth, Mazin Barry
DOI:10.4103/JNSM.JNSM_85_20  
In March 2020, the World Health Organization declared coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2, as a global pandemic. The number of infected individuals has grown exponentially, and no vaccine candidate is currently available. Hence, various drugs are being considered for the treatment of patients with COVID-19. Tocilizumab, a novel humanized monoclonal antibody targeting interleukin-6 (IL-6) receptor, has been approved for the treatment of various inflammatory conditions, including moderate-to-severe rheumatoid arthritis, giant cell arteritis, active polyarticular and systemic juvenile idiopathic arthritis in patients aged ≥2 years, and Castleman disease. Given that patients with severe COVID-19 show features of an accentuated immune response and increased release of many proinflammatory cytokines, including IL-6, tocilizumab has been repurposed as a possible COVID-19 therapy. This review provides clinicians managing patients with COVID-19 with an overview of the IL-6 pathway, its blockade by tocilizumab, and the effects of this drug in various inflammatory conditions, including current understanding of its effects in patients with COVID-19. Tocilizumab is listed as an option for treating severe or critical cases of COVID-19 with elevated IL-6 in the 7th edition of the National Health Commission of the People's Republic of China COVID-19 Diagnosis and Treatment Guide. A systematic review of six small observational studies and case reports on the supportive use of tocilizumab in patients with COVID-19 suggested some benefits of the treatment but did not allow solid conclusions; further clinical trials are currently evaluating the impact of adding tocilizumab to the treatment regimen for these patients.
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HOT TOPIC Top

Staying safe and saving precious lives: Pediatric life support during COVID-19 pandemic and beyond p. 356
Mohamad-Hani Temsah
DOI:10.4103/JNSM.JNSM_79_20  
As COVID-19 was declared a pandemic by the World Health Organization in March 2020, the global community became on the alert toward optimizing patients' outcomes while maintaining the safety of health-care workers (HCWs). Providing cardiopulmonary resuscitation (CPR) to COVID-19 victims is further challenging, especially in the pediatric age group. This review describes the changes in the pediatric CPR guidelines after COVID-19, as well as potential resources to improve the patients' outcomes while maintaining HCWs' safety. We conducted a literature review on PubMed for all peer-reviewed publications on CPR in children with confirmed or suspected COVID-19. The search on June 25, 2020, retrieved the following results: “pediatric life support” AND COVID-19 (30 papers); CPR AND children AND COVID-19 (6 papers) CPR devise AND COVID-19 (11 papers). Twenty-four papers were retrieved after accounting for duplications. All the reviewed CPR guidelines in suspected or confirmed COVID-19 pediatric patients emphasize balancing the immediate needs of the victims with the priority of HCWs' own safety. Furthermore, in the pediatric age group, the rapid initiation of respiratory support is key to improving the outcome. We, therefore, recommend early recognition of the rapidly deteriorating child, such as through the Pediatric Rapid Response Team (PRRT), since such proactive measures could avoid risky CPR. This proactive PRRT would be much needed in the coming winter season, when more children may require critical care services. Implications of key findings: Early recognition of the rapidly deteriorating child to avoid or quickly prepare for possible CPR is advisable. Planning for the pediatric code teams before the next winter season is warranted.
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BRIEF REPORT Top

Saudi Arabia stands as one of the leading countries for COVID-19 containment p. 362
Fadilah Sfouq Aleanizy, Fulwah Yahya Alqahtani, Jouri Alanazi, Hajar AlQahtani, Marzouqah Alanazi
DOI:10.4103/JNSM.JNSM_51_20  
Objective: Coronavirus disease 2019 (COVID-19) has emerged in China at the end of the year 2019 and a few weeks later it has out broken globally. There are obvious geographical variations in the mortality rates of COVID-19 according to the data published by the World Health Organization and Centers for Disease Control and Prevention. This paper aims to estimate where Saudi Arabia stands in comparison to other countries in regard to aspects such as recovery and death percentage among the top 15 countries which have reported the highest number of cases globally. Methods: The percentage of death and recovery from COVID-19 in 15 countries until May 24, 2020, was calculated using data released from the world meter. Results: The highest number of cases was reported in the United States and the lowest cases were in Saudi Arabia. Saudi Arabia demonstrated the lowest number of the death rate which was 0.54%, on the other hand, France ranked first in the mortality rate which was 15.54%. Conclusion: All of the guidelines, precautionary approaches, and instructions included in the orders in addition to the application of the restrictive measures, as well as and high capacity of Saudi hospitals, collectively helped Saudi Arabia to be the leader in achieving the lowest death rate.
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LETTER TO EDITOR Top

Lessons learned from China's response to coronavirus disease 2019 pandemic and implications for the rest of the world p. 366
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/JNSM.JNSM_70_20  
The coronavirus disease-2019 (COVID-19) outbreak, which started from a single city in China has been designated as a public health emergency of international concern. Despite being the most affected nation for close to 2 months, the situation has reversed in China and at present, the nation accounts for only 1% of global caseload and 1% of global deaths. All these estimates are very much suggestive that China has been successful in containing the outbreak in their settings. However, it will not be wise to expect that the outbreak is totally under control as long as the pandemic is going on. The most important lesson from the containment efforts in China was that a single approach will not be right in all the settings. In conclusion, China has been successful in containing the COVID-19 infection and the experience from China should be utilized by other nations who are fighting against the infection. On the contrary, China should not be relaxed and prepare themselves for a fresh wave of infection and also address the special needs during the recovery phase of the disease.
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