Aims We hypothesized that the wide-awake local anaesthesia with no tourniquet (WALANT) technique is cost-effective, easy to use, safe, and reproducible, with a low learning curve towards mastery, having a high patient satisfaction rate. Furthermore, WALANT would be a suitable alternative for the austere and developing nation environments where lack of funds and resources are a common issue. Methods This was a randomized control trial of 169 patients who required surgery for closed isolated distal radius fractures. The study was performed between March 2016 and April 2019 at a public sector level 1 trauma centre. General anaesthesia was used in 56 patients, Bier’s block in 58 patients, and WALANT in 55 patients. Data were collected on pre-, peri-, and postoperative parameters, clinical outcome, hospital costs, and patient satisfaction. One-way analysis of variance (ANOVA) was used with a p-value of 0.05 being significant. Results Operations with WALANT proceeded sooner, and patients recovered faster, resulting in mean fewer missed working days (7.8 (SD 1.67)) compared with general anaesthesia (20.1 (SD 7.37)) or Bier’s block (14.1 (SD 7.65)) (p < 0.001). The WALANT patients did not develop complications, while the other patients did (p < 0.04). Clinical outcomes did not differ, nor did surgeon qualification affect clinical outcomes. Mean hospital costs were lower for WALANT ($428.50 (SD 77.71)) than for general anaesthesia ($630.63 (SD 114.77)) or Bier’s block ($734.00 (SD 37.54)) (p < 0.001). Patient satisfaction was also higher (p < 0.001). Conclusion WALANT for distal radius fractures results in a faster recovery, is more cost-effective, has similar clinical outcomes, and has fewer complications than general anaesthesia or Bier's block. This makes WALANT an attractive technique in any setting, but especially in middle- and low-income countries. Cite this article: Bone Joint Res 2020;9(7):429–439.

IntroductionThis survey evaluates knowledge, attitudes and practices of medical students towards use of antibiotics for upper respiratory infections (URTIs).MethodologyCross-sectional questionnaire study among 1042 randomly selected medical students in Saudi Arabia.ResultsRespondents were mostly Saudis (97.5%), had previous knowledge of antibiotics (99.7%) and their usage (98.3%) against bacterial infections (93.7%). 18.1% thought that they could be used for viral infections. Nearly all students (97.2%) used antibiotics themselves during the previous year and self-medication without a prescription was high at 49% of cases. Most antibiotics were taken for URTI symptoms (61.8%). Female medical students had better knowledge on antibiotic effectiveness against bacteria and viruses, and overall knowledge increased with study year. Health seeking behaviour rates for symptoms of RTI and associated estimated necessity for antibiotics varied but were highest for cough with yellow/green phlegm.ConclusionsThe depth of knowledge that healthcare professionals have in relation to the proper use of antibiotics is essential in spreading the right message within communities. This is the first large study among medical students in Saudi Arabia, shedding important light on areas for improvement in the medical curriculum as well as antibiotic practices of medical students themselves.

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Advanced glycation endproducts (AGEs) are believed to play a significant role in the pathophysiology of a variety of diseases including diabetes and cardiovascular diseases. Non-invasive skin autofluorescence (SAF) measurement serves as a proxy for tissue accumulation of AGEs. We assessed reference SAF and skin reflectance (SR) values in a Saudi population (n = 1,999) and evaluated the existing risk stratification scale. The mean SAF of the study cohort was 2.06 (SD = 0.57) arbitrary units (AU), which is considerably higher than the values reported for other populations. We show a previously unreported and significant difference in SAF values between men and women, with median (range) values of 1.77 AU (0.79–4.84 AU) and 2.20 AU (0.75–4.59 AU) respectively (p-value « 0.01). Age, presence of diabetes and BMI were the most influential variables in determining SAF values in men, whilst in female participants, SR was also highly correlated with SAF. Diabetes, hypertension and obesity all showed strong association with SAF, particularly when gender differences were taken into account. We propose an adjusted, gender-specific disease risk stratification scheme for Middle Eastern populations. SAF is a potentially valuable clinical screening tool for cardiovascular risk assessment but risk scores should take gender and ethnicity into consideration for accurate diagnosis.

Subcutaneous fat necrosis, though a rare phenomenon, can occur in patients of all ages. In newborns, it is an uncommon, self-limited panniculitis of traumatic origin, while in adults it is most commonly encountered among women presenting to breast clinics following a trivial or unnoticed injury sustained long ago. An acute presentation of fat necrosis as a large mass, however, is quite unusual and that may confuse the observer. History of trauma gives a clue to the diagnosis. We report an interesting case of traumatic subcutaneous fat necrosis because of massage therapy in a 66-year-old lady.

Metabolic phenotyping of obese populations can shed light on understanding environmental interactions underpinning obesogenesis. Obesity and its comorbidities are a major health and socioeconomic concern globally and are highly prevalent in the Middle East. We employed nuclear magnetic resonance spectroscopy to characterize the metabolic signature of urine and blood plasma for a cohort of obese (n = 50) compared to non-obese (n = 48) Saudi participants. The urinary metabolic phenotype of obesity was characterized by higher concentrations of N-acetyl glycoprotein fragments, bile acids, lysine, and methylamines and lower concentrations of tricarboxylic acid cycle intermediates, glycine, and gut microbial metabolites. The plasma metabolic phenotype of obesity was dominated by sugars, branched chain amino acids, and lipids, particularly unsaturated lipids, with lower levels of plasma phosphorylcholine and HDL. Serum hepatic enzymes, triglycerides, and cholesterol mapped to specific metabolic phenotypes, potentially indicating the dysregulation of multiple distinct obesity-related pathways. Differences between urine and plasma phenotypes of obesity for this Saudi population and that reported for Caucasian individuals indicate population disparities in pathways relating to ketogenesis (more apparent in the Saudi obese population), dysregulated liver function, and the gut microbiome. Mapping population-specific metabolic perturbations may hold promise in establishing population differences relevant to disease risk and stratification of individuals with respect to discovery of new therapeutic targets.

The success of a plant breeding program is linked with the rapid screening of crop germplasm. In the following study, the germination stage of rice seeds has been examined for the rapid screening of drought-tolerant genotypes. The rice genotypes (10 drought tolerant, 5 moderately drought tolerant, and 5 drought susceptible) were sown in Petri dishes under control and osmotic stress of 15% PEG6000. Data were recorded after four days of sowing for the osmotic stress-induced change in imbibition rate, speed of germination, radical and plumule length, radical and plumule total fresh and dry weight, proline contents, total antioxidant capacity, and malondialdehyde level in radical and plumule of seeds. Moreover, the change in expression of OsP5CS gene was also recorded in one of each drought tolerant, moderately drought tolerant, and drought susceptible genotypes. Under osmotic stress, the level of proline, total antioxidant capacity, and the expression of OsP5CS were increased in drought-tolerant genotypes as compared to moderately drought tolerant and drought susceptible genotypes. While, the change in imbibition rate, speed of germination, radical and plumule length, and fresh and dry weight were not symmetrical in drought tolerant, moderately drought tolerant, and drought susceptible genotypes. In short, the symmetrical change in proline, total antioxidant capacity, and expression of OsP5CS gene within radical and plumule of drought tolerant, moderately drought tolerant, and drought susceptible genotypes can help rapid screening of drought-tolerant rice genotypes.

Skin auto fluorescence (SAF) is used as a proxy for the accumulation of advanced glycation end products (AGEs) and has been proposed to stratify patients into cardiovascular disease (CVD) and diabetes mellitus (DM) risk groups. This study evaluates the effects of seven different ethnicities (Arab, Central-East African, Eastern Mediterranean, European, North African, South Asian and Southeast Asian) and gender on SAF as well as validating SAF assessment as a risk estimation tool for CVD and DM in an Arabian cohort. SAF data from self-reported healthy 2,780 individuals, collated from three independent studies, has been linear modelled using age and gender as a covariate. A cross-study harmonized effect size (Cohens’d) is provided for each ethnicity. Furthermore, new data has been collected from a clinically well-defined patient group of 235 individuals, to evaluate SAF as a clinical tool for DM and CVD-risk estimation in an Arab cohort. In an Arab population, SAF-based CVD and/or DM risk-estimation can be improved by referencing to ethnicity and gender-specific SAF values. Highest SAF values were observed for the North African population, followed by East Mediterranean, Arab, South Asian and European populations. The South Asian population had a slightly steeper slope in SAF values with age compared to other ethnic groups. All ethnic groups except Europeans showed a significant gender effect. When compared with a European group, effect size was highest for Eastern Mediterranean group and lowest for South Asian group. The Central-East African and Southeast Asian ethnicity matched closest to the Arab and Eastern Mediterranean ethnicities, respectively. Ethnic and gender-specific data improves performance in SAF-based CVD and DM risk estimation. The provided harmonized effect size allows a direct comparison of SAF in different ethnicities. For the first time, gender differences in SAF are described for North African and East Mediterranean populations.