Middle East Research Articles

A systematic review on the prevalence of a silent female disorder in Arabic-speaking countries and the Middle East: sexual dysfunctions and the role of culture.

Female sexual dysfunction (FSD) remains a silent problem, especially in Arabic-speaking countries and the Middle East and most of the data are from Western countries. Sociocultural determinants haven't been getting the same attention as biological and psychological factors when studying sexual health. To assess the prevalence of FSD in the Arab and Middle Eastern world and understand the sociocultural determinants related. On January 13, 2024, we searched electronic databases including Pubmed, Scielo, PsycArticles, Scopus, Cochrane Library and Google Scholar, Middle East Current Psychiatry, and Journal of Middle East Women's Studies, following PRISMA guidelines. Female participants, aged at least 16years old from Middle East or Arabic-speaking countries, including North Africa, and cross-sectional studies in Arabic, English, and/or French were included. After careful screening of titles, abstracts, and full texts, ineligible articles were excluded. A total of 19 papers were included in the present review. The most common FSD in each country were as follows: in Egypt, Turkey, Morocco, and Jordan, desire problems. In Iran, orgasm problems, and pain. In Palestine, pain. In Saudi Arabia, arousal. Sociocultural determinants such as language, poor sexual education, poor sexual self-awareness-and of partners-, lack of training, and help-seeking were related to FSD. FSD is prevalent in Arabic-speaking countries and the Middle East, yet little to no attention is given to this matter. Causes for FSD are mainly cultural, and Arab and Middle Eastern healthcare professionals lack training. Culturally sensitive, evidence-based studies regarding sexual health need to be conducted.

Assessing the Energy Efficiency of Saudi Arabia’s Relatively Middle Eastern Countries in the Context of Sustainable Development Goals

This paper employs a non-parametric approach to assess and compare the energy efficiency of Saudi Arabia with that of other Middle Eastern countries. An approach for evaluating the performance of each unit that utilizes optimization and linear programming is data envelopment analysis (DEA). A reference set for an inefficient unit is created to facilitate the comparison of various units against the efficiency boundary and enhance the efficiency of each unit. The research employs data envelopment analysis, incorporating three input and two output variables. This approach enables Middle Eastern countries to identify ineffective measures and recall essential actions necessary for enhancement. This study's findings suggest recommendations for the effective utilization of resources. This analysis indicates that Saudi Arabia, along with certain Middle Eastern nations, exhibits greater energy efficiency than most countries in the region. When analyzing the Middle East, Saudi Arabia, United Arab Emirates, Bahrain, Cyprus, Qatar, and Turkiye are notable examples of sustainable practices requiring further investigation. Furthermore, Yemen, Lebanon, and Syria require additional scrutiny to enhance effectiveness. The proposed study presents noteworthy conclusions concerning energy efficiency. The findings are anticipated to aid government agencies in pinpointing the factors influencing development and facilitating policymaking in Middle Eastern countries.

Worldwide trends in diabetes prevalence and treatment from 1990 to 2022: a pooled analysis of 1108 population-representative studies with 141 million participants.

Diabetes can be detected at the primary health-care level, and effective treatments lower the risk of complications. There are insufficient data on the coverage of treatment for diabetes and how it has changed. We estimated trends from 1990 to 2022 in diabetes prevalence and treatment for 200 countries and territories. We used data from 1108 population-representative studies with 141 million participants aged 18 years and older with measurements of fasting glucose and glycated haemoglobin (HbA1c), and information on diabetes treatment. We defined diabetes as having a fasting plasma glucose (FPG) of 7·0 mmol/L or higher, having an HbA1c of 6·5% or higher, or taking medication for diabetes. We defined diabetes treatment as the proportion of people with diabetes who were taking medication for diabetes. We analysed the data in a Bayesian hierarchical meta-regression model to estimate diabetes prevalence and treatment. In 2022, an estimated 828 million (95% credible interval [CrI] 757-908) adults (those aged 18 years and older) had diabetes, an increase of 630 million (554-713) from 1990. From 1990 to 2022, the age-standardised prevalence of diabetes increased in 131 countries for women and in 155 countries for men with a posterior probability of more than 0·80. The largest increases were in low-income and middle-income countries in southeast Asia (eg, Malaysia), south Asia (eg, Pakistan), the Middle East and north Africa (eg, Egypt), and Latin America and the Caribbean (eg, Jamaica, Trinidad and Tobago, and Costa Rica). Age-standardised prevalence neither increased nor decreased with a posterior probability of more than 0·80 in some countries in western and central Europe, sub-Saharan Africa, east Asia and the Pacific, Canada, and some Pacific island nations where prevalence was already high in 1990; it decreased with a posterior probability of more than 0·80 in women in Japan, Spain, and France, and in men in Nauru. The lowest prevalence in the world in 2022 was in western Europe and east Africa for both sexes, and in Japan and Canada for women, and the highest prevalence in the world in 2022 was in countries in Polynesia and Micronesia, some countries in the Caribbean and the Middle East and north Africa, as well as Pakistan and Malaysia. In 2022, 445 million (95% CrI 401-496) adults aged 30 years or older with diabetes did not receive treatment (59% of adults aged 30 years or older with diabetes), 3·5 times the number in 1990. From 1990 to 2022, diabetes treatment coverage increased in 118 countries for women and 98 countries for men with a posterior probability of more than 0·80. The largest improvement in treatment coverage was in some countries from central and western Europe and Latin America (Mexico, Colombia, Chile, and Costa Rica), Canada, South Korea, Russia, Seychelles, and Jordan. There was no increase in treatment coverage in most countries in sub-Saharan Africa; the Caribbean; Pacific island nations; and south, southeast, and central Asia. In 2022, age-standardised treatment coverage was lowest in countries in sub-Saharan Africa and south Asia, and treatment coverage was less than 10% in some African countries. Treatment coverage was 55% or higher in South Korea, many high-income western countries, and some countries in central and eastern Europe (eg, Poland, Czechia, and Russia), Latin America (eg, Costa Rica, Chile, and Mexico), and the Middle East and north Africa (eg, Jordan, Qatar, and Kuwait). In most countries, especially in low-income and middle-income countries, diabetes treatment has not increased at all or has not increased sufficiently in comparison with the rise in prevalence. The burden of diabetes and untreated diabetes is increasingly borne by low-income and middle-income countries. The expansion of health insurance and primary health care should be accompanied with diabetes programmes that realign and resource health services to enhance the early detection and effective treatment of diabetes. UK Medical Research Council, UK Research and Innovation (Research England), and US Centers for Disease Control and Prevention.

Respiratory Disease Surveillance in the Middle East and Latin America during the COVID-19 Pandemic, 2020-2022.

Characterizing the epidemiology of circulating respiratory pathogens during the COVID-19 pandemic could clarify the burden of acute respiratory infections and monitor outbreaks of public health and military relevance. The US Department of Defense supported 2 regions for influenza-like illness and severe acute respiratory infections surveillance, one in the Middle East through US Naval Medical Research Unit EURAFCENT, and another in Latin America through US Naval Medical Research Unit SOUTH. During 2020‒2022, coinciding with the COVID-19 pandemic, we collected a total of 16,146 nasopharyngeal and oropharyngeal swab samples from sentinel sites in Jordan (n = 11,305) and Latin America (n = 4,841). Samples were tested for SARS-CoV-2, influenza, and other respiratory pathogens. SARS-CoV-2 was the most frequently detected pathogen during 2020; other respiratory pathogens had distinct temporal and frequency distributions according to geographic location. Our findings support the need for continued sentinel surveillance as a vital tool for assessing the burden of respiratory diseases globally.

Need for neurorehabilitation in the Middle East and North Africa from 1990 to 2021: an analysis based on the global burden of disease study.

This study will present the burden of diseases needing neurorehabilitation in Middle East and North Africa (MENA) countries and describe their epidemiology across age and sex groups. This study was conducted based on the Global Burden of Disease (GBD) 2021 findings. The authors used years of healthy life lost due to disability (YLD) as a proxy for the need for neurorehabilitation, and extracted the YLD rates and counts for neonatal encephalopathy due to birth asphyxia and trauma, stroke, neural tube defects, Parkinson's disease (PD), motor neuron disease, multiple sclerosis (MS), tension-type headache, other neurological disorders (except migraine, dementia, and epilepsy), head injuries, spinal injuries, nerve injury, and asphyxiation across age groups, sexes, and MENA countries. YLD rates of disorders needing neurorehabilitation in 1990 and 2021 were 408.08 and 496.19 per 100 000 people, respectively, indicating a 21.59% rise in YLD. Stroke had the highest YLD rates in both 1990 (150.19 per 100 000) and 2021 (192.75 per 100 000). Syria, Saudi Arabia, and the United Arab Emirates had the highest YLD rates for conditions needing neurorehabilitation. Considering the growing demand for neurorehabilitation with the aging of populations and the historical shortage of rehabilitation services in the region, the gap between the demand and supply may further increase in the coming years, leading to consequences for people living with neurological conditions in the region.

Sexually transmitted infections in the middle east and North Africa: comprehensive systematic review and meta-analysis

BackgroundGlobally, sexually transmitted infections (STIs) collectively cause 2.3 million deaths and 1.2 million cases of cancer annually. However, the epidemiology of STIs in the Middle East and North Africa (MENA) is not well assessed because of various social and cultural factors.MethodsA systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and covering 23 MENA countries, 19 STIs, and data from 20,435,971 participants. PubMed, Embase, regional and international databases, and country-level reports were searched up to May 2024.ResultsThe analysis revealed significant regional variations in the prevalence of STIs within the MENA region. In North Africa, the most common STIs were bacterial vaginosis (31%), human papillomavirus (HPV, 23%), and Candida spp. (15%). In the Gulf Cooperation Council region and Yemen, Ureaplasma (25%), nongonococcal urethritis (NGU, 16%), and Mycoplasma spp. (12%) were the predominant infections. In the Levant region, the top STIs were HPV (20%), hepatitis B virus (HBV, 9%), and Candida spp. (9%). In Iran, Ureaplasma spp. (18%), HPV (17%), and cytomegalovirus (8%) were the most prevalent infections, whereas Ureaplasma spp. (20%), Candida spp. (18%), and HPV (16%) were most frequently detected in Türkiye. Gender-based disparities were observed, with a higher prevalence of Ureaplasma spp., Neisseria gonorrhoeae, and herpes in men and higher rates of Mycoplasma spp., HPV, HBV, and Candida spp. in women. Overall, high rates of nongonococcal urethritis (16.3%), Ureaplasma spp. (13.7%), HPV (12.7%), and Candida spp. (9.4%) were recorded in the MENA region.ConclusionsMost MENA countries lack national STI screening programs, and the reported data are primarily from symptomatic individuals. Establishing robust surveillance systems, addressing stigma and barriers to healthcare access, and expanding STIs screening and vaccination programs are crucial for accurately capturing the true burden of STIs in MENA countries.

Undergraduate dental curricula in Middle Eastern and Arabic-speaking African Nations − A cross-sectional study

PurposeTo evaluate the design of undergraduate curricula, teaching and learning practices, assessments, admission criteria and quality assurance in dental schools across Middle Eastern and Arab-speaking African nations. MethodologyA cross-sectional survey was sent to 40 dental colleges in the Middle East and African Arabic-speaking countries. A purposefully designed proforma consisting of 21 items divided into five sections based on admission criteria, curriculum delivery, teaching and learning practices, assessment methods, and quality assurance was used for data collection on Google forms. Participation in the survey was voluntary and all participants were consented before data collection. The data was analysed for descriptive statistics. ResultsA total of 28 dental institutions participated in the study yielding a response rate of 70 %. The data showed variations in the admission criteria, curricula, and assessment methods. The reliability statistics were satisfactory (Cronbach’s alpha = 0.89). ANOVA showed significant differences were noted in the clinical experience of students by country and curriculum design (p ≤ 0.001). Gaps were also identified in the quality assurance processes at some of the participating institutions. ConclusionThis study provides a snapshot of undergraduate dental education in the Middle East and Arabic speaking African countries. Although a majority of the institutions follow a student-centered approach, some in institutions still follow the traditional teacher-centered approach which is not consistent with the contemporary strategies in healthcare education. The admission criteria are based on high school grades albeit with some variations. The duration of dental programs is five years at most institutions with or without an additional foundation year. Variations were also noted in the assessment weightings, clinical targets and quality assurance procedures. Further collaboration is required to facilitate harmonization of dental curricula in the region, solicit international recognition and to better support their graduates in pursuing postgraduate studies and employment options.

Cognitive Difficulty in Middle Eastern and North African Adults Living in the United States Compared With Other Racial and Ethnic Categories, 2017-2021.

Objectives. To estimate the odds of having cognitive difficulties among Middle Eastern and North African (MENA) American adults and compare these odds with those of White, Black, Hispanic/Latino, Asian, American Indian or Alaska Native (AI/AN), and Native Hawaiian/Other Pacific Islander adults nationally and in the 4 states with the largest MENA populations (California, New York, Michigan, and Texas) after adjusting for sociodemographic factors. Methods. We analyzed 2017-2021 American Community Survey data (aged ≥ 45 years; n = 7 284 988), comparing presence of cognitive difficulties by race/ethnicity. Results. MENA adults had greater odds of reporting cognitive difficulties than did White (odds ratio [OR] = 1.49; 95% confidence interval [CI] = 1.42, 1.56), Black (OR = 1.20; 95% CI = 1.14, 1.26), Hispanic (OR = 1.46; 95% CI = 1.39, 1.53), Asian (OR = 1.31; 95% CI = 1.25, 1.38), and AI/AN (OR = 1.07; 95% CI = 1.01, 1.14) adults. In all 4 states, odds of having cognitive difficulties were higher among MENA than Asian adults. Other racial/ethnic comparisons differed by state. Conclusions. A separate checkbox for MENA Americans approved by the Office of Management and Budget is important so health outcomes can be studied in more detail and funds can be allocated for research and resources at state and national levels. (Am J Public Health. 2024;114(11):1265-1274. https://doi.org/10.2105/AJPH.2024.307803).

Getting sincere and efficient support: A grounded theory study of older spousal caregivers of people with alzheimer's disease

Despite the importance of supporting older spousal caregivers (OSCs) of people with Alzheimer's Disease (PWAD), little evidence is available about the process of its occurrence in Middle Eastern countries, such as Iran. Understanding this process will help support more effectively. This study explored the support process for OSCs of PWAD using the grounded theory approach of Corbin and Strauss (2015). A total of 16 participants (10 caregivers, six formal and informal resources) were recruited using purposive and theoretical sampling methods, and in-depth interviews were conducted with them. Getting sincere and efficient support was the core category and was achieved through four strategies, which were thoughtful support-seeking, informal support-getting, formal seasonal support-getting, and informal support-devoting. Despite OSCs' vital need for multiple support, specific factors and conditions impair the support process. Healthcare providers and policymakers can use the results to make informed decisions and provide more practical support for these older caregivers.

Comparison of the Diagnostic Performance of Antigen B Purified from Sheep Hydatid Cyst Fluid (HCF) with Commercial ELISA Kit.

Cystic echinococcosis (CE) is a zoonotic parasitic disease caused by the metacestode of Echinococcus granulosus. CE is a health problem in Middle Eastern countries, such as Iran. The purpose of this study was to purify subunit 8 KDa antigen B from crude sheep hydatid cyst fluid (HCF) and compare its sensitivity and specificity with a commercial human ELISA kit (PT-Hydatid-96). 28 sera samples were collected from hydatid cyst patients who had surgery for a hydatid cyst and had their disease confirmed by pathology after the surgery. Furthermore, 35 samples of healthy individuals with no history of hydatid cysts were collected, as were nine serum samples from parasite-infected non-CE patients. HCF was obtained from sheep fertile cysts at a Sari slaughterhouse and used as an antigen. In an indirect ELISA test, the B antigen was employed, and the results were compared to those from a commercial ELISA kit. The results of this study were analyzed using the Kappa test. The commercial ELISA kit showed 17 cases (23.6%) positive, 44 cases (61.1%) negative, and 11 cases (15.3%) borderline. B antigen showed that 18 (25%), 43 (59.7 %), and 11 (15.3%) were positive, negative, and borderline, respectively. One sample (1.4% of 72 total samples) of 35 serum samples from healthy individuals was positive using B antigen-based ELISA. In addition, all nine serum samples from parasite-infected non-CE patients were negative for both tests. The sensitivity and specificity of the commercial ELISA kit have been evaluated at 60.7% and 100%, respectively. For B antigenbased ELISA, these values are 64.3 and 97.7%, respectively. Antigen B produced from hydatid cyst fluid is a promising option for serological identification of hydatid cysts in both infected and healthy individuals. In an indirect ELISA test, hydatid fluid antigen could be used as a precise source of detection.

Air Quality Near Middle East's Large Dried Lake: Heavy Metal Emissions, Machine learning Analysis, and Health Risks

The present study aimed to measure the concentrations and chemical compositions of suspended particulate matters smaller than 10 μm (PM10) in the ambient air of Bakhtegan Lake and to assess the health risks associated with exposure to metal elements through inhalation. Ambient air samples were collected from a rural area close to the lake. The levels of metal elements bonded to PM10 were measured by the Inductively Coupled Plasma Mass Spectrometry (ICP-MS). The mean ambient PM10 concentration around the studied lake (78.12 μg/m3) was higher than the 24 hours guidelines PM10 standards proposed by World Health Organization (WHO) (50 μg/m3). The highest and lowest concentrations were related to Fe and V, respectively. Lifetime Cancer Risk (LCR) was higher for adults than for children. Additionally, the LCR value was higher for As compared to other metals, indicating that the cancer risk in the adults group was mainly due to As. Besides, health risk assessments indicated that adults suffered from higher cancer risks compared to children, while both adults and children did not suffer from non-carcinogenic risks. Through Principal component analysis (PCA) and random forest (RF) analysis, it was determined that metallic concentrations in the air samples are influenced by both natural and anthropogenic sources, with copper and lead identified as pivotal predictors for nickel levels. Therefore, monitoring and addressing such metal-induced pollution is essential for regional public health.

Towards cleaner desalination systems utilizing waste heat: a bibliometric analysis

Water scarcity is a global issue facing the coming generations. Desalination is a dependable, nonconventional freshwater method. However, desalination is an energy-intensive water treatment method. The primary energy source used to power various desalination processes for thermal and electrical energy consumption is fossil fuels, such as coal, oil, and gas. The widespread use of fossil fuels has been linked to climate change and global warming, leading to numerous demands to reduce their usage and energy utilization. Waste heat has an excellent potential for energy recovery that can reduce the consumption of fossil fuels. This research study has been conducted to evaluate related waste heat desalination literature with data analysis, bibliometric, and clustering methods. Based on articles published between 2013 and 2023, the current study analyzed existing trends, distribution of publication subjects, journals' performances, countries' collaborations, affiliations' performances, most cited publications, authors' contributions, keyword analysis, and future perspectives on waste heat desalination systems. The findings showed that the most active journal in this field is Desalination, with 133 publications and 6332 citations. China led in publications with 242, while the United States topped the list of citations with 3598. Also, King Abdullah University of Science and Technology in Saudi Arabia published 50 documents. The top 10 institutions in this field of research are in the Middle East and North Africa (MENA) region and Asia, particularly in Saudi Arabia, China, Iran, Egypt, and Singapore. Moreover, the most frequently used terms are analyzed and clustered into three main topics. The top 3 clusters are solar-powered desalination technologies, membrane-powered desalination technologies, and power cycles driving desalination technologies.

Effectiveness of 8-week TReatment with vortioxetine on depressive symptoms in major depressive disorder patients with comorbid generalized anxiety disorder in UAE (TRUE)

BackgroundMajor Depressive Disorder (MDD) is a leading cause of disability and results in excessive utilization of healthcare resources worldwide. The Middle East and North Africa (MENA) region shows a high prevalence of depressive disorders. Generalized Anxiety Disorder (GAD) and MDD have the highest rate of comorbidity of all mood and anxiety disorders, ranging from 40 to 98% in drug studies. Comorbid GAD results in more significant impairment in MDD and increases the severity of symptoms. Although several clinical trials supported the safety and effectiveness of vortioxetine, no data regarding these aspects has been revealed in the MENA region. This study aimed to assess the safety and efficacy of vortioxetine in patients with comorbid GAD in the United Arab Emirates (UAE).MethodIn a multicenter observational study, 118 patients with confirmed anxiety and depressive disorders were evaluated over four visits (baseline visit, two weeks, four weeks, and eight weeks) using MADRS and HAM-A scales to assess depression and anxiety severity, respectively by calculating mean change and the percent using Kendall’s W test.ResultsA significant mean difference in MADRS score was observed, with a gradual decrease of mean MADRS total scores over the assessment weeks (p < 0.001) as well as in HAM-A scores, from severe to moderate-severe anxiety through the four visits (p < 0.001). Furthermore, only one case was reported as a serious side effect. Nausea and insomnia were the most predominant side effects reported among the studied population.ConclusionVortioxetine was found effective and safe among patients with MDD and comorbid GAD.

Toscana virus - an emerging Mediterranean arbovirus transmitted by sand flies.

Toscana virus (TOSV) is an emerging arthropod-borne virus (arbovirus) of medical importance that is increasing its range across much of the Mediterranean Basin, Europe and the Middle East. Transmitted by Phlebotomus spp. sand flies, it is the most clinically relevant sand fly-borne phlebovirus. Initially isolated in the Tuscany region of Central Italy, it has now been detected in multiple countries that surround this geographical area. Infection of the vertebrate host can cause fever and neurological disease, following the dissemination of the virus to the brain. The prevalence is high in some regions, with a notable percentage of individuals showing seroconversion. TOSV can be a leading cause of acute meningitis and encephalitis (AME) during the summer months. In this comprehensive review, we will focus on several key topics. We discuss how TOSV has spread to establish outbreaks of infection in both humans and animals around the Mediterranean and the wider region. Clinical aspects of TOSV infection in humans are described, along with the best standards in diagnosis. Finally, we focus our discussion on the role of the sand fly vector, describing their biology, vector competency, implications for putative vertebrate reservoirs, the effect of the climate emergency on sand fly distribution and the putative role that sand fly-derived salivary factors may have on modulating host susceptibility to TOSV infection.

P23 A case of visceral leishmaniasis presenting as seropositive erosive rheumatoid arthritis in an immunocompromised patient

Abstract Introduction Visceral leishmaniasis (VL) is a potentially fatal parasitic infection occurring primarily in the tropics, subtropics, and southern Europe. A strong humoral response can be observed in VL due to polyclonal activation of B-lymphocytes, and it can also result in the production of rheumatoid factor (RF), anti-CCP and anti-nuclear antibodies. We present this case here of visceral leishmaniasis presenting as seropositive RA on the background of HIV and hepatitis B infection. Case description We present a case of a 46-year-old Caucasian male with a two-year history of skin nodules, symmetrical arthralgia and weight loss. He was diagnosed with HIV a decade ago which was well controlled with bictegravir, emtricitabine and tenofovir alafenamide. He received pulmonary tuberculosis (TB) treatment in 2012 and had chronic e-antigen-positive hepatitis B. He previously resided in Ukraine and travelled frequently to Crimea and the Middle East. There was no history of Raynaud’s, chest pain, shortness of breath, sicca symptoms, mouth ulcers, genital ulcers, hair loss or photosensitivity. On examination, he was cachectic with generalised lymphadenopathy and multiple subcutaneous (1-2cm, firm, mildly tender, non-ulcerating) forearm nodules. There was synovitis on two joints but no tenosynovitis or joint deformity. Initial investigations revealed pancytopenia, hyperuricemia, proteinuria, positive RF (&amp;gt;200 IU/ml) and anti-CCP, positive ANA and anti-Ro antibody and erosion of proximal phalanx of the big toe bilaterally. His CD4 count was 166 (33%) with undetectable HIV viral load. Imaging showed lymphadenopathy and splenomegaly (17.5cm). A diagnosis of rheumatoid arthritis with possible connective tissue disease overlap was made and he was initiated on hydroxychloroquine. Because of systemic symptoms and atypical skin nodules, further investigation was undertaken including lymph node, bone marrow and skin biopsies, all of which confirmed a diagnosis of leishmaniasis. Blood PCR was positive for L. donovani complex, and serological analysis showed direct agglutination test and k39 Ag positivity. Treatment was initiated by the infectious diseases team initially with amphotericin B 40 mg/kg monotherapy, later on further amphotericin B 30 mg/kg and miltefisone. He responded well as evidenced by reduced splenomegaly, resolution of skin nodules and improvement in cytopenia. His joint symptoms also improved except for the recurrence of ankle pain for which he received intra-articular steroids. Discussion It has been widely reported in literature that leishmaniasis can trigger autoimmune diseases such as rheumatoid arthritis and systemic lupus erythematosis. There have also been multiple studies confirming the presence of rheumatoid factor, anti-CCP and ANA in patients with leishmaniasis without any presence of symptomatic autoimmune disease. The mechanisms involved in the pathophysiology of autoantibody productions are not yet fully understood. There is some evidence that these are related to activation of polyclonal B cells due to a decreased regulatory T cell activity. Another possible mechanism would be production of autoantigen in response to cross reaction between the parasite and the hoarse tissue antigens. There have been multiple case reports of leishmaniasis in patients with rheumatoid arthritis who were taking anti-TNF biologics. This represents the reactivation of leishmaniasis due to immunosuppression. There has been a long-known link between HIV infection and leishmaniasis. Our patient was a known case of HIV. Interestingly, not only did he have significantly positive rheumatoid factor, anti-CCP, ANA and anti-Ro antibodies, but he also had active synovitis on his joints and even erosions were seen on the X-ray. He fulfilled the criteria for rheumatoid arthritis. Our case was unique in the sense that this is a case of visceral leishmaniasis in an HIV patient who presented with rheumatoid arthritis. Skin nodules in this patient were appearing similar to rheumatoid nodules. Later on, the biopsy confirmed that these were due to leishmaniasis. It is also a challenge to manage RA in patients with HIV especially when have already an opportunistic infection like leishmaniasis. A high prevalence of hyperuricemia in HIV infection has been reported in multiple studies. Our case did have raised urate but his disease was not consistent with gout clinically. Key learning points • This is a rare case showing seropositive erosive RA coexisting with VL in an HIV patient, underscoring the link between autoimmune diseases and chronic infections. Chronic infections are always considered an important differential in inflammatory arthritis or connective tissue disease especially when they present with systemic features of fever, weight loss and organomegaly. • Although this disease is considered rare in the Western hemisphere, in the diverse, multiethnic and immigrant UK population this should be considered an important differential diagnosis. Another key element in clenching these diagnoses is detailed travel history. Multidisciplinary approach is key in managing such difficult cases. Our case was managed jointly by the rheumatology, dermatology and infectious disease teams, and the national leishmaniasis multidisciplinary team from University College London Hospitals. • It is important to do a holistic assessment for these patients and get help from other specialities especially in such challenging cases.

The lifetime risk of maternal near miss morbidity in Asia, Africa, the Middle East, and Latin America: a cross-country systematic analysis

Life-threatening maternal near miss (MNM) morbidity can have long-term consequences for the physical, psychological, sexual, social, and economic wellbeing of female individuals. The lifetime risk of MNM (LTR-MNM) quantifies the probability that a female individual aged 15 years will have an MNM before age 50 years, given current mortality and fertility rates. We compare the LTR-MNM globally to reveal inequities in the cumulative burden of severe maternal morbidity across the reproductive life course. We estimated the LTR-MNM for 40 countries with multifacility, regional, or national data on the prevalence of MNM morbidity measured using WHO or modified WHO criteria of organ dysfunction from 2010 onwards (Central and Southern Asia=6, Eastern and Southeastern Asia=9, Latin America and the Caribbean=10, Northern Africa and Western Asia=2, sub-Saharan Africa=13). We also calculated the lifetime risk of severe maternal outcome (LTR-SMO) as the lifetime risk of maternal death or MNM. The LTR-MNM ranges from a 1 in 269 risk in Viet Nam (2010) to 1 in 6 in Guatemala (2016), whereas the LTR-SMO ranges from a 1 in 201 risk in Malaysia (2014) to 1 in 5 in Guatemala (2016). The LTR-MNM is a 1 in 20 risk or higher in nine countries, seven of which are in sub-Saharan Africa. The LTR-SMO is a 1 in 20 risk or higher in 11 countries, eight of which are in sub-Saharan Africa. The relative contribution of the LTR-MNM to the LTR-SMO ranges from 42% in Angola to 99% in Japan. There exist substantial global and regional disparities in the cumulative burden of severe maternal morbidity across the reproductive life course. The LTR-MNM is an important indicator to highlight the magnitude of inequalities in MNM morbidity, once accounting for obstetric risk, fertility rates, and mortality rates. The LTR-SMO can be used to highlight variation in the relative importance of morbidity to the overall burden of maternal ill-health across the female reproductive life course, given countries' stage in the obstetric transition. Both the LTR-MNM and LTR-SMO can serve as important indicators to advocate for further global commitment to end preventable maternal morbidity and mortality. UK Economic and Social Research Council, EU Horizon 2020 Marie Curie Fellowship, and Leverhulme Trust Large Centre Grant.

Luigi Balugani l’esplora(pit)tore alle sorgenti del Nilo

In the second half of the 18th century, the Bolognese draftsman Luigi Balugani joined the explorer James Bruce in an expedition aiming to document the antiquities of North Africa. Having been the first to utilize a “camera obscura” on the field, Bruce and Balugani can be considered pioneers of photoreportage, since they created the first visual documentation of this kind in history. Today these drawings are housed in the Royal Collection at Windsor. Later, the expedition ventured into the Middle East before shifting its focus toward the source of the Nile river. Travelling through Egypt, Arabia, and Abyssinia, Balugani produced over 300 drawings of plants and animals, which are now preserved at the Center for British Art at Yale University. Bruce and Balugani reached the source of the Blue Nile on November 4th, 1770, but in March 1771 the untimely death of Balugani left all the honors to Bruce, who did not fully recognize the talent and contributions of the Bolognese draftsman.

Study of the Performance of Warm-Mix Asphalt Containing Recycled Concrete as a Coarse Aggregate in Egypt and the Middle East

Study of the Performance of Warm-Mix Asphalt Containing Recycled Concrete as a Coarse Aggregate in Egypt and the Middle East

Arab founder variants: Contributions to clinical genomics and precision medicine.

Founder variants are ancestral variants shared by individuals who are not closely related. The large effect size of some of these variants in the context of Mendelian disorders offers numerous precision medicine opportunities. Using one of the largest datasets on Mendelian disorders in the Middle East, we identified 2,908 medically relevant founder variants derived from 18,360 exomes and genomes and investigated their contribution to the clinical annotation of the human genome. Strikingly, ∼34% of Arab founder variants are absent in gnomAD. We found a strong contribution of Arab founder variants to the identification of novel gene-disease links (n= 224) and the support/dispute (n= 81 support, n= 101 dispute) of previously reported candidate gene-disease links. The powerful segregation evidence generated by Arab founder variants allowed many ClinVar and Human Gene Mutation Database variants to be reclassified. Overall, 39.5% of diagnostic reports from our clinical lab are based on founder variants, and 19.41% of tested individuals carry at least one pathogenic founder variant. The presumptive loss-of-function mechanism that typically underlies autosomal recessive diseases means that Arab founder variants also offer unique opportunities in "druggable genome" research. Arab founder variants were also informative of migration patterns in the Middle East consistent with documented historical accounts. We highlight the contribution of founder variants from an under-represented population group to precision medicine and inform future prevention programs. Our study also sheds light on the added value of these variants in supplementing other lines of research in tracing population history. There is no funding for this work.

Exploring the knowledge and attitudes towards metabolic dysfunction associated fatty liver disease (MAFLD): Validation and correlations of MAFLD-knowledge questionnaire and MAFLD-attitude questionnaire

BackgroundMetabolic dysfunction associated fatty liver disease (MAFLD) is a highly prevalent non-communicable disease whose prevalence is reaching pandemic proportions. Its implications constitute a major public health concern. To date, no validated tool measures knowledge and attitudes towards MAFLD in young adults in the Middle East and North Africa region. ObjectiveTo establish and validate questionnaires that measure knowledge and attitudes towards MAFLD. MethodsMAFLD-Knowledge Questionnaire (KQ) and MAFLD-Attitudes Questionnaire (AQ) were developed by disease content experts and piloted on a group of 20 students. The questionnaire was next administered to 406 university students aged 18–24 years. The dimensionality of the instrument was tested using exploratory factor analysis and consistency with Cronbach's alpha. Finally, known-group validity was assessed by comparing the knowledge and attitudes of those with poor versus good knowledge. ResultsFor the knowledge questionnaire, 28 out of 32 questions had good loading and were thus included. Based on Exploratory Factor Analysis (EFA), there were 4 domains with Kaiser–Meyer–Olkin (KMO) 0.95 and Bartlett test with P < 0.001, with very good internal consistency (Cronbach's alpha 0.88). For the attitudes questionnaire, 17 items were extracted all with adequate loading. EFA revealed 3 domains with KMO of 0.95 and very good internal consistency (Cronbach's alpha 0.81). Known group validity showed a significant difference between the attitudes of subjects with poor and moderate knowledge and poor and high knowledge scores but not between moderate and high knowledge scores. ConclusionWe developed and validated two questionnaires, one for the assessment of knowledge and the other for attitudes towards MAFLD in young adults. Further studies are needed to confirm dimensionality and reproducibility in different populations and age groups.