Over the past few decades, the profile of liver diseases in Africa and the Middle East has undergone significant changes. The incidence of metabolic dysfunction-associated fatty liver disease (MAFLD) has risen to alarming levels. Despite the seriousness of the situation, there is a scarcity of local or regional guidelines established to address it. This document presents the clinical practice guidelines from the African Middle East Association of Gastroenterology (AMAGE) related to the screening, diagnosis, and management of MAFLD. It addresses multiple aspects of managing this condition while taking into account local circumstances and the healthcare system's management requirements. These guidelines are intended for routine clinical use, with a specific focus on particular groups when needed.

Excessive dietary salt consumption is a significant public health concern, yet awareness and behaviors regarding salt intake remain underexplored in Saudi Arabia. This cross-sectional study evaluated the knowledge, attitudes, and behaviors related to salt intake among 1,308 adults residing in Saudi Arabia, surveyed online between December 2022 and May 2023. Most respondents (95.8%) recognized health risks associated with excessive salt intake, particularly hypertension (95.5%) and kidney disease (79.4%). However, awareness of its association with heart disease (50.5%) and stroke (28.3%) was considerably lower. Although nearly half acknowledged population-level salt overconsumption, only 25.9% were aware of the recommended daily salt limit, and just 17.5% considered their personal consumption excessive. Behaviorally, around 62% rarely or never checked sodium content on food labels, and over 75% rarely or never requested low-salt meals when dining out. Significant demographic variations emerged, with women and older adults displaying greater awareness and healthier practices. These findings underscore critical gaps in knowledge and self-awareness regarding salt intake among Saudi adults. Implementing clear front-of-pack nutrition labeling and strengthening public educational campaigns are vital steps. Moreover, targeted interventions involving food manufacturers and restaurants are crucial to effectively promote healthier salt intake behaviors and support national public health goals.

Fatty liver disease is one of the most common liver diseases in the Middle East and North Africa region, and globally. Unfortunately, there is a lack of awareness regarding this condition. The nomenclature changes for NAFLD (to MAFLD or MASLD) have gained considerable attention in the hepatology community. Here, we present our point of view on this ongoing change and debate.

A multisociety Delphi consensus statement on new fatty liver disease nomenclatureJournal of HepatologyVol. 79Issue 6PreviewThe principal limitations of the terms NAFLD and NASH are the reliance on exclusionary confounder terms and the use of potentially stigmatising language. This study set out to determine if content experts and patient advocates were in favour of a change in nomenclature and/or definition. A modified Delphi process was led by three large pan-national liver associations. The consensus was defined a priori as a supermajority (67%) vote. An independent committee of experts external to the nomenclature process made the final recommendation on the acronym and its diagnostic criteria. Full-Text PDF Open Access In a tremendous conceptual advance, Eslam et al.1Eslam M. Newsome P.N. Sarin S.K. et al.A new definition for metabolic dysfunction-associated fatty liver disease: an international expert consensus statement.J Hepatol. 2020; 73: 202-209Abstract Full Text Full Text PDF PubMed Scopus (2259) Google Scholar, 2Eslam M. Sanyal A.J. George J. et al.MAFLD: a consensus-driven proposed nomenclature for metabolic associated fatty liver disease.Gastroenterology. 2020; 158: 1999-2014. e1Abstract Full Text Full Text PDF PubMed Scopus (1854) Google Scholar, 3Eslam M. Alkhouri N. Vajro P. et al.Defining paediatric metabolic (dysfunction)-associated fatty liver disease: an international expert consensus statement.Lancet Gastroenterol Hepatol. 2021; 6: 864-873Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar put forth two landmark articles that changed the narrative of fatty liver disease associated with metabolic dysfunction, including a correction in nomenclature from non-alcoholic fatty liver disease (NAFLD) to metabolic dysfunction-associated fatty liver disease (MAFLD) as a more apt term. They also introduced a set of simple and appropriate "positive" criteria for diagnosing the disease, independent of alcohol intake or other liver diseases. These criteria apply to both adults and children as the disease is a continuum across the lifespan. We were among the other societies and stakeholders that endorsed this proposal for a multitude of reasons,4Shiha G. Alswat K. Al Khatry M. et al.Nomenclature and definition of metabolic-associated fatty liver disease: a consensus from the Middle East and north Africa.Lancet Gastroenterol Hepatol. 2021; 6: 57-64Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar, 5Spearman C.W. Desalegn H. Ocama P. et al.The sub-Saharan Africa position statement on the redefinition of fatty liver disease: from NAFLD to MAFLD.J Hepatol. 2021; 74: 1256-1258Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 6Méndez-Sánchez N. Bugianesi E. Gish R.G. et al.Global multi-stakeholder endorsement of the MAFLD definition.Lancet Gastroenterol Hepatol. 2022; 7: 388-390Abstract Full Text Full Text PDF PubMed Scopus (147) Google Scholar including a) value the evidence: a wealth of data have provided unequivocal evidence for the superior utility of the MAFLD diagnostic criteria compared to the traditional NAFLD criteria across various outcomes.7Alharthi J. Gastaldelli A. Cua I.H. Ghazinian H. Eslam M. Metabolic dysfunction-associated fatty liver disease: a year in review.Curr Opin Gastroenterol. 2022; 38: 251-260Crossref PubMed Scopus (38) Google Scholar b) The simplicity and practicality of these criteria. c) Nomenclature that is devoid of any stigma and appropriately reflects the pathophysiology of the disease makes it easier to communicate with various stakeholders including patients, general practitioners, nurses, other non-hepatology specialists and policy makers.8Shiha G. Korenjak M. Eskridge W. et al.Redefining fatty liver disease: an international patient perspective.Lancet Gastroenterol Hepatol. 2021; 6: 73-79Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar, 9Clayton M. Fabrellas N. Luo J. et al.From NAFLD to MAFLD: nurse and allied health perspective.Liver Int. 2021; 41: 683-691Crossref PubMed Scopus (34) Google Scholar, 10Farahat T.M. Ungan M. Vilaseca J. et al.The paradigm shift from NAFLD to MAFLD: a global primary care viewpoint.Liver Int. 2022; 42: 1259-1267Crossref PubMed Scopus (14) Google Scholar, 11Eslam M. Ahmed A. Després J.-P. et al.Incorporating fatty liver disease in multidisciplinary care and novel clinical trial designs for patients with metabolic diseases.Lancet Gastroenterol Hepatol. 2021; 6: 743-753Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar Recently and after a lengthy and complex Delphi process that raised more questions than it resolved, an attempt was made to develop another consensus statement on fatty liver disease. A group of experts under the umbrella of three liver societies proposed using the term metabolic dysfunction-associated steatotic liver disease" (MASLD) and adopted diagnostic criteria from the definition of MAFLD.12Rinella M.E. Lazarus J.V. Ratziu V. et al.A multi-society Delphi consensus statement on new fatty liver disease nomenclature.Ann Hepatol. 2023; 101133PubMed Google Scholar As regional leaders, whose utmost priority is our patients, we spent several months analysing the new data and views on this proposal to determine our regional stance on it. Consequently, under the umbrella of the African Middle East Association of Gastroenterology (AMAGE), we, the undersigned, comprising over 100 signatories representing multiple stakeholders and regional key opinion leaders from over 31 countries, have decided to continue using the name MAFLD as an overarching term and its definition for fatty liver diseases associated with metabolic dysregulation as the official terminology in our region. We made this decision based on: 1) Emerging evidence suggesting that MAFLD more accurately reflects the underlying pathogenesis of the disease and is better at identifying those at high risk of disease outcomes than the proposed MASLD criteria. At a minimum, the MASLD criteria did not lead to any significant improvements that can justify the confusion that could be caused by this change.13Chen L. Tao X. Zeng M. Mi Y. Xu L. Clinical and histological features under different nomenclatures of fatty liver disease: NAFLD, MAFLD, MASLD and MetALD.J Hepatol. 2023; Google Scholar,14Zhao Q. Deng Y. Comparison of mortality outcomes in individuals with MASLD and/or MAFLD.J Hepatol. 2023; Abstract Full Text Full Text PDF Scopus (7) Google Scholar Additionally, numerous studies have demonstrated that the MASLD criteria lack granularity and specificity15Tanaka M. Mori K. Takahashi S. et al.Metabolic dysfunction–associated fatty liver disease predicts new onset of chronic kidney disease better than fatty liver or nonalcoholic fatty liver disease.Nephrol Dial Transplant. 2023; 38: 700-711Crossref PubMed Scopus (20) Google Scholar,16Anirvan P. Khatua C.R. Panigrahi M.K. Singh S.P. Definition of metabolic dysfunction: shifting goalposts.J Clin Exp Hepatol. 2023; Google Scholar. Therefore, the MAFLD definition is the only one that maintains the right balance between sensitivity and specificity. This finding is expected to have significant implications for health policy and cost-effective analysis. 2) The proposed change from MAFLD to MASLD is based on the argument that the term "fatty" can be stigmatising. However, multiple studies and statements have refuted this claim. This point has been accurately illustrated by liver patients' spokespeople, who have also highlighted that "in some cultures being fat is regarded as a sign of good health".17Shiha G. Korenjak M. Casanovas T. et al.MAFLD 2022: an ELPA/ALPA/EASO-ECPO joint statement on disease stigma.J Hepatol. 2022; 77: 1717-1719Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar A recent study also showed that the perception of NAFLD stigma varies significantly among patients, providers, geographic locations, and sub-specialties. Only 8% of patients perceived stigma compared to 38% of doctors.18Younossi Z.M. AlQahtani S.A. Alswat K. et al.Global survey of stigma among physicians and patients with nonalcoholic fatty liver disease.J Hepatol. 2023; Abstract Full Text Full Text PDF Scopus (12) Google Scholar Another study demonstrated that the term "fatty" is not necessarily stigmatising in all cultures.19Méndez-Sánchez N. Pal S.C. Fassio E. Díaz-Ferrer J. Prado-Robles J.A. MAFLD: perceived stigma—a single-center Mexican patient survey.Hepatol Int. 2023; 17: 507-508Crossref PubMed Scopus (6) Google Scholar We point out that "steatotic" and "fatty" have the same translation in the languages spoken in our region. We believe that the findings collectively weaken the argument for changing "fatty" to "steatotic". These findings can be a sufficient basis to avoid any abrupt changes in the nomenclature of fatty liver disease. Studies have shown that the transition to MAFLD has positive implications in increasing disease awareness among patients and healthcare providers. It also increases attention to MAFLD at conferences across countries and health systems.20Fouad Y. Gomaa A. Semida N. Ghany W.A. Attia D. Change from NAFLD to MAFLD increases the awareness of fatty liver disease in primary care physicians and specialists.J Hepatol. 2021; 74: 1254-1256Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar,21Fouad Y. Abdel Salam S. AbdAllah M. Attia D. The change from NAFLD to MAFLD expands fatty liver information flow.Hepatol Res. 2022; 52: 488-489Crossref PubMed Scopus (2) Google Scholar In conclusion, after considering the proposal for a new definition of fatty liver disease, the experts from the Middle East and North Africa, as well as Sub-Saharan Africa, have decided not to endorse the proposed definition. They have instead opted to continue using the existing definition of liver disease (MAFLD) as before. The Asian Pacific Association for the Study of the Liver (APASL) has also taken the same decision. Further studies to confirm the validity of the proposed MASLD definition are needed. No funding was obtained or required for this study. All authors have nothing to disclose relevant to this work. Please refer to the accompanying ICMJE disclosure forms for further details. All authors shared conceptualisation and designed the idea. Yasser Fouad wrote the initial draft. All authors revised the manuscript and approved the final version. Middle East and North Africa and sub-Saharan Africa position statement contributing authors list: Sherief M Abd-elsalam Tropical Medicine and Infectious Diseases Department, Faculty of Medicine, Tanta University, Tanta, Egypt. Mohamed AbdAllah Department of Gastroenterology, Hepatology, Medical Research Division, National Research Center, Egypt. Nermeen Abdeen Tropical Medicine Department, Faculty of Medicine, Alexandria University, Alexandria. Shereen Abdelaleem Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt. Yasser Abdelghani Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Minia University, Minia, Egypt. Wafaa Abdelhamid Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Minia University, Minia, Egypt. Haitham Abdel Hamid Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Minia University, Minia, Egypt. Nadia Abdelaaty Tropical Medicine Department, Ain Shams University, Egypt. Mostafa Abdellhalim Ministry of Health and population, Egypt. Ahmed Abdelmohsen Tropical Medicine and Gastroenterology Department, Assiut University, Assiut, Egypt. Doaa Abdeltawab Tropical Medicine and Gastroenterology Department, Assiut University, Assiut, Egypt. Mosaab Abdulkarim Department of Gastroenterology, Hepatology, Tripoli medical university, Libya. Bounena Abidine Department of Gastroenterology, Hepatology, Centre Hospitalier National de Nouakchott, Mauritania. Ahmed Aboalela Ministry of health and population, Egypt. YousryAboamer Hepatology, Gastroenterology and Infectious diseases Department, Mahala Hepatology Teaching Hospital, Egypt. Sayed Ahmed Tropical Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt. Mohammed Amer Department of Internal Medicine, Al-Azhar University, Cairo, Egypt. Kafya Akrouf Hepatology, Gastroenterology and Infectious diseases Department, Al-Amiri Hospital, Kuwait City, Kuwait. Hameed Al Jameel Department of Medicine, university of Kerbala, Iraq. Munira Al Tarrah Hepatology, Gastroenterology and Infectious diseases Department, Al-Amiri Hospital, Kuwait City, Kuwait. Abeer Al-Gharabally Hepatology, Gastroenterology and Infectious diseases Department, Al-Amiri Hospital, Kuwait City, Kuwait. Nourhan Alaa Ataa Ministry of Health and population, Egypt. Pezhman Alavinejad Department of Internal Medicine, School of Medicine, Alimentary Tract Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Khuzestan, Iran. Moussa Ali Mahamat Department of Internal Medicine and Gastroenterology, Chad. Alice Guingané Département d'Hépato-gastroentérologie, Centre Hospitalier Universitaire Yalgado Ouédraogo, Ouagadougou, Burkina Faso. Taha A. Alkarboly Alkarboly Kurdistan Center for Gastroenterology and Hepatology, Assulaymaniah, Kurdistan, Iraq. Nawal Alkhalidi Gastroenterology & Hepatology Teaching Hospital, Medical City, Ministry of Health and Environment, Baghdad, Iraq. Abdullah Alyouzbaki College of Medicine, University of Mosul, Iraq. Nazugum A. Ashimova Astana Medical University, Astana, Kazakhstan. Ahmed Badi Hamad medical corporation, Qatar. Ibrahim Halil Bahcecioglu Firat University, Faculty of Medicine, Department of Gastroenterology, Turkey. Shamardan Bazeed Department of Tropical Medicine and Gastroenterology, Faculty of Medicine, South Valley University, Qena, Egypt. Asad Dajani ADSC, Medcare Hospital and Saudi German Hospital, Sharjah, Al Khan, PO Box 6328, United Arab Emirates. Mahmoud Desoky Division of Gastroenterology and Hepatology, Sultan bin Abdulalaziz city, Saudi Arabia. Ibrahima Diallo Department of Internal Medicine and Hepatogastroenterology, Hôpital Principal de Dakar, Dakar, Senegal. Mohammed Elbadri Hamad Medical Corporation, Qatar. Amr M. Elsayed Gastroenterology and tropical medicine department, Minia University, Minia, Egypt. Aisha Elsharkawy Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt. Doaa Elwazzan Tropical Medicine Department, Alexandria University, Alexandria, Egypt. Eman Fares Gastroenterology and tropical medicine department, Fayoum University, Egypt. Manar Farhat Gastroenterology and tropical medicine department, Fayoum University, Egypt. Yasmine Gaber Endemic Medicine and Hepatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt. Manik Gemilyan Department of Gastroenterology and Hepatology, Yerevan State Medical University, Armenia. Yahya Ghanem Sanaa University, medical college, Yemen. Ahmed Gomaa Department of Hepatology, Gastroenterology and Endemic Medicine, Faculty of Medicine, Fayoum University, Fayoum, Egypt. Ibrahima Gueye Président Association Saafara Hépatites, Sénégal. Azaa Hafez Faculty of Nursing, Minia University, Minia, Egypt. Gagik Hakobyan Department of Gastroenterology and Hepatology, Yerevan State Medical University, Armenia. Adel Hasan Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Suez Canal University, Suez, Egypt. Fuad Hasan The Royale Hayat Hospital, Kuwait. Alshymaa Hassnine Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Minia University, Minia, Egypt. Taha M Hassanin Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Minia University, Minia, Egypt. Bilal Hotayt Khoury Hamra, Beirut, Lebanon. Alkassoum Salifou Abdou Moumouni University of Niamey, Niamey, Niger. Enas Kamal Gastroenterology and tropical medicine department, Minia University, Minia, Egypt. Qalandar Kasnazan Kurdistan Higher Council Fir Medical Specialities, KHCMS, Iraq. Rofida Khalifa Gastroenterology and tropical medicine department, Minia University, Minia, Egypt. Ashkhen Keryan Department of Hepatology, Nikomed Medical center, Armenia. Mohammed Khan King Abdulla Medical City, Mecca, Saudi Arabia. Saro Khemichyan Division of Gastrointestinal and liver Diseases, Keck Medical Center of USC, Armenia. Elmira K. Kuantay S.D. Asfendiyarov National Medical University, Kazakh Association for the Study of the Liver, Almaty, Kazakhstan. Dlovan Khoushnow DK radiology clinic, Erbil Governorate, Iraq. Alaa M Mostafa Gastroenterology and tropical medicine department, Minia University, Minia, Egypt. Reem Mahdy Gastroenterology and tropical medicine department, Assuit University, Minia, Egypt. Amna Mahmoud Gastroenterology and tropical medicine department, Minia University, Minia, Egypt. Saltanat S. Madenova S.D. Asfendiyarov National Medical University, Kazakh Association for the Study of the Liver, Almaty, Kazakhstan. Gayane Matsakyan Department of Gastroenterology and Hepatology, Yerevan State Medical University, Armenia. Nahed Makhlouf Gastroenterology and tropical medicine department, Assuit University, Assuit, Egypt. Mai Mehrez Department of Hepatology, Armed Forces College of Medicine, Egypt. Souraia Mezhoud Hamad medical corporation HMC, Qatar. Eileen Micah Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana. Safaa Mohamed Abdelhalim Gastroenterology and tropical medicine department, Minia University, Minia, Egypt. Menna Mostafa Kuwait medical centre, Kuwait. Shaymaa Nafady Department of Gastroenterology, Hepatology and Infectious Diseases, Faculty of Medicine, Beni-Suef University, Beni Suef, Egypt. Aren Nersisyan Nikomed Medical center, Armenia. Alexander V. Nersesov Department of Gastroenterology, S.D. Asfendiyarov Kazakh National Medical University, Kazakhstan. Kalys Nogoibaeva Kyrgyz State Medical Academi, Kyrgyzstan. Necati ORMECİ Department of Internal Medicine, Gastroenterology and Hepatology İstanbul Health and Technology University, Istanbul, Türkiye. Marian Muse Osman Somalia National Institute of Health, Somalia. Venera S. Rakhmetova Astana Medical University, Astana, Kazakhstan. Abdulfattah Rajab Medical department Central Tripoli Hospital, Libya. Aigul M. Raissova S.D. Asfendiyarov National Medical University, Kazakh Association for the Study of the Liver, Almaty, Kazakhstan. Ebada M Said Department of Gastroenterology, Hepatology and Infectious Diseases, Faculty of Medicine, Benha University, Benha, Egypt. Asmaa Salama Department of Gastroenterology, Hepatology and Infectious Diseases, Faculty of Medicine, Beni-Suef University, Beni Suef, Egypt. Eman Salama Gastroenterology and tropical medicine department, Minia University, Minia, Egypt. Ruzanna Safaryan Nikomed Medical center, Armenia. Violeta Sargsyan Violeta Medical center, Armenia. Nady Semeda Gastroenterology and tropical medicine department, Minia University, Minia, Egypt. Nara Stepanyan Nikomed Medical center, Armenia. Isaac Thom Shawa University of Malawi College of Medicine, Blantyre, Malawi. Aya Shazly Ministry of health, Saudi Arabia. Said Taharboucht Internal medicine department, CHU de Douera, University of Blida, Algiers, Algeria. Ali Tumi Central Hospital Tripoli Liya, Libya. Mariam Zaghloul Department of Hepatology, Gastroenterology and Infectious Diseases, Kafrelsheikh University,Egypt. Samy Zaky Department of Hepatogastroenterology and Infectious Diseases, Al-Azhar University, Cairo, Egypt. The following are the supplementary data to this article: Download .pdf (.95 MB) Help with pdf files Multimedia component 1

Background: Obesity is a common health problem that restricts people’s daily activities. Many observational studies found that diverticulosis is a common complication for obesity and the prevalence of diverticulosis is increasing. However, the correlation between obesity and diverticulosis remains controversial. Aim: The primary aim of our study was to assess the prevalence and the association between overweight or obesity and the rate of diverticulitis (as diagnosed by CT scans). Methods: Our study was based on reviewing the medical records in a single medical center in Saudi Arabia over a period of 3 years. 342 patients diagnosed with diverticulosis and confirmed by colonoscopy and CT scan were included, with those ages above 18 years old receiving a health examination, measurement of percentage of body fat, blood test and colonoscopy at King Abdulaziz University. Results: Women with body mass index (BMI 30) had a greater risk of developing diverticulosis (PR, 1.58; 95% CI, 1.05–2.06) when compared to women with normal BMI. By gender, in patients less than fifty-one, occurrence of colonic diverticulosis was less in female patients compared to males (29% vs 45%, P=.06). However, in older ages there wasn’t clear difference among male and female patients in the prevalence of diverticulosis. Conclusion: 342 patients who underwent screening colonoscopies for diverticulosis, were included in our analysis. We found that the risk of colonic diverticulosis has an obvious correlation to obesity especially in women with BMI 30. When comparing by age, colonic diverticulosis was less predominant in premenopausal-age women compared with similar-age men. These findings may be due to female sex hormones that enhance diverticulosis development. Key words: colonic diverticulosis, obesity, metabolic syndrome, Saudi Arabia

Background: Evidence for the effectiveness of enteral nutrition (EN) for the management of patients with inflammatory bowel disease (IBD) is well-established. However, there is considerable global variation in EN practices. This study aimed to characterize the practices and perceptions of gastroenterologists regarding the use of EN in patients with IBD in one of the largest countries in the Gulf region. Methods: A cross-sectional study was conducted on pediatric and adult gastroenterologists working in Saudi Arabia who are involved in IBD management. A self-administered web-based survey was distributed via social media platforms and mailing lists of national gastroenterology societies. Results: A total of 80 gastroenterologists completed the survey. However, only 55 reported that they were currently practicing EN in any form. EN was mostly indicated by gastroenterologists who “sometimes” recommend EN for: the prevention and correction of undernutrition (50.9%), preoperative optimization (50.9%), and the induction of remission in patients with active and long-standing CD (36.4%), at initial diagnosis (34.5%), during the management of complications (61.8%), and after failing to respond to pharmacological therapy (58.2%). Exclusive enteral nutrition (EEN) is regularly recommended by 14.5% of gastroenterologists. The prescription of EEN was significantly associated with the pediatric profession (p < 0.01), IBD specialty (p < 0.05), level of nutrition education during training (p < 0.01), and previous training in a unit with regular EN use (p < 0.01). The most reported barriers to using EN were patients’ lack of acceptance (73.8%) and poor adherence (65%). A lack of dietitian support and a lack of standardized protocols were also reported as barriers by many physicians. Pediatric gastroenterologists were more likely to use at least one assessment method to evaluate EN success. Conclusion: EN practices differ between gastroenterologists working in Saudi Arabia. Future EN protocols should be optimized to support both children and adults with IBD. Gastroenterology training programs should offer nutrition support-focused training to help physicians better utilize EN.

Background Assessment of mucosal visualization during esophagogastroduodenoscopy (EGD) can be improved with a standardized scoring system. To address this need, we created the Toronto Upper Gastrointestinal Cleaning Score (TUGCS). Methods We developed the TUGCS using Delphi methodology, whereby an international group of endoscopy experts iteratively rated their agreement with proposed TUGCS items and anchors on a 5-point Likert scale. After each Delphi round, we analyzed responses and refined the TUGCS using an 80 % agreement threshold for consensus. We used the intraclass correlation coefficient (ICC) to assess inter-rater and test–retest reliability. We assessed internal consistency with Cronbach’s alpha and item-total and inter-item correlations with Pearson’s correlation coefficient. We compared TUGCS ratings with an independent endoscopist’s global rating of mucosal visualization using Spearman’s ρ. Results We achieved consensus with 14 invited participants after three Delphi rounds. Inter-rater reliability was high at 0.79 (95 %CI 0.64–0.88). Test–retest reliability was excellent at 0.83 (95 %CI 0.77–0.87). Cronbach’s α was 0.81, item-total correlation range was 0.52–0.70, and inter-item correlation range was 0.38–0.74. There was a positive correlation between TUGCS ratings and a global rating of visualization (r = 0.41, P = 0.002). TUGCS ratings for EGDs with global ratings of excellent were significantly higher than those for EGDs with global ratings of fair (P = 0.01). Conclusion The TUGCS had strong evidence of validity in the clinical setting. The international group of assessors, broad variety of EGD indications, and minimal assessor training improves the potential for dissemination.

Abstract Background High quality esophagogastroduodenoscopy (EGD) depends on the ability to appropriately visualize upper gastrointestinal (GI) mucosa pathology. Evaluation can be limited by the presence of mucus, foam, bubbles and solid materials. Currently, there is no standardized method to assess mucosal visualization for use in clinical or research settings. Aims To develop and establish the content validity of the Toronto Upper Gastrointestinal Cleaning Score (TUGCS) and evaluate its interrater reliability. Methods An international panel of endoscopy experts rated potential items and their associated anchors for importance as indicators of adequacy of mucosal visualization during EGD. The survey utilized a Likert scale (1 (strongly disagree) to 5 (strongly agree)). The Delphi process was repeated until consensus was reached. Consensus was defined priori as ≥80% of experts in a given round scoring ≥4 on all survey items. To assess content validity, 48 EGD procedures were evaluated in real-time by two endoscopist reviewers using the TUGCS at a single institution. The interrater agreement between assessments was calculated for TUGCS total scores using intraclass correlation coefficient, one-way random effects model (ICC 1,1). Results Fourteen experts agreed to be part of the Delphi panel. An anatomical framework representing the upper GI mucosa and anchors for each mucosal portion representing various levels of visibility was generated through systematic review. Three survey rounds, with response rates of 100%, 100% and 71% respectively, achieved consensus. The final TUGCS includes four anatomical areas (fundus, body, antrum, duodenum) and mucosal visualization anchors ranging from 0 to 3 (Figure 1). TUGCS was used to assess foregut cleaning in 48 procedures (Table 1). The mean TUGCS for staff and trainee were 8.1 (±2.4) and 8.1 (±2.6), respectively. The ICC was 0.78 (95% confidence interval 0.62–0.88) indicating good reliability. Conclusions We developed and generated content validity evidence for the TUGCS through rigorous Delphi methodology, reflective of practice across different centres. Planned as future research is a video survey distributed to endoscopists internationally to further validate the TUGCS to create a tool that may be used to judge mucosal visualization for EGD in research and clinical settings. Table 1. Patient Characteristics (n=48) Age, mean (±SD) 55.4 (18.6) Sex, n Male 20 Female 28 Fasting duration (hours), mean (±SD) 14.9 (10.5) Procedure type Elective 47 Acute 1 Figure 1. TUGCS tool Funding Agencies None

Objective: The COVID-19 pandemic is still continuing throughout the world, with newer genetic variants regularly appearing from different parts of the world. Considering the waning of immunity against COVID-19 infection even with two doses of the COVID-19 vaccine, regulatory authorities have authorised booster COVID-19 vaccination in many countries, especially for vulnerable populations, including healthcare workers. The current study analysed factors predicting the third (booster) dose of COVID-19 vaccine intention, including the health belief model (HBM), among the healthcare workers in Saudi Arabia. Methods: The current study was a cross-sectional online survey performed from 1st October 2021 to 30th November 2021, using a questionnaire prepared in GoogleTM form among healthcare workers in Saudi Arabia. The questionnaire asked demographic factors, COVID-19 experience of participants, subjective assessment of health, intention of COVID-19 booster dose vaccination, preferences for local/foreign-made vaccines, and health belief of the study population related to COVID-19 infection and COVID-19 booster dose. Results: This study received 2059 complete responses. The study population reported mixed health belief with respect to the susceptibility of COVID-19 infection, and higher health belief perception regarding the severity. The perceptions of the study participants regarding the benefits of COVID-19 booster dose were positive. There were few barriers to COVID-19 booster dose expressed by study participants. A total of 1464 (71.1%) study participants reported positive intent for receiving a COVID-19 booster dose. The study showed significant association between definite intention to receive a booster dose and nationality (p = 0.001), marital status (p = 0.017), gender (p < 0.001), education level (p = 0.001), monthly income (p < 0.001), and co-morbid medical illness (p = 0.045). The perception of the COVID-19 booster vaccine as a good idea to minimise worries about getting COVID-19 (OR = 2.28, CI 1.89–2.76), and perceptions that receiving the third (booster) dose reduces the risk of COVID-19 infection and associated complications (OR= 2.69, CI = 2.17–3.34), of the perceived benefit construct of HBM, predicted significantly higher definite intention to receive a booster dose. The concern with the safety of the vaccine (OR= 0.40, CI 0.34–0.47) under the perceived barriers construct of HBM predicted as significantly higher no definite intention to receive a booster dose. Conclusions: The results of the present study can guide policy makers in their efforts to promote booster doses of COVID-19 vaccination among the healthcare workers in Saudi Arabia.

Patients with chronic liver disease (CLD) and liver transplant recipients are at increased risk of morbidity and mortality from coronavirus disease 2019 (COVID-19). Although several studies demonstrated the safety and efficacy of COVID-19 vaccines in the general population, data in CLD patients and liver transplant recipients are lacking. Two COVID-19 vaccines were approved by the Saudi Food and Drug Authority and rolled out to several million recipients in Saudi Arabia. These vaccines are mRNA-based vaccine BNT162b2 from Pfizer/BioNTech and adenovirus-based AZD1222 from Oxford/AstraZeneca from three manufacturing sites (EU Nodes, Serum Institute of India, and South Korea Bio). The Saudi Association for the Study of Liver diseases and Transplantation (SASLT) has reviewed the available evidence and issued interim recommendations for COVID-19 vaccination in CLD and liver transplant recipients. Since there is no evidence contradicting the safety and immunogenicity of the currently approved COVID-19 vaccines in patients with CLD and hepatobiliary cancer and liver transplant recipients, the SASLT recommends vaccination in those patient populations. CLD and hepatobiliary cancer patients and liver transplant recipients should be prioritized depending on the risk factors for severe COVID-19. In transplant recipients, the optimal timing of vaccination remains unknown; however, immunization is recommended after the initial immunosuppression phase. Patients with CLD and liver transplant candidates or recipients should be closely monitored after COVID-19 vaccination. These patient populations should be included in future clinical trials to provide further evidence on the efficacy and safety of COVID-19 vaccines.

A 22-year-old male with long standing, active Crohn's disease on Adalimumab had presented with increasing levels of his transaminases. A full workup was conducted and the patient was found to have hepatitis C (HCV) based on a positive HCV antibody, polymerase chain reaction (PCR) and genotyping. He was started on a regimen of Glecaprevir/Pibrentasvir with excellent response defined by complete normalization of his transaminitis and an undetectable PCR at the end of 8 weeks of treatment and achieved sustained viral response at 12 weeks of treatment. This is the first case reporting the use of a combination of Glecaprevir/Pibrentasvir and Adalimumab in a patient with HCV and Crohn's disease.

BACKGROUND AND AIMS:The Middle East (ME) has a high prevalence of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH), driven by obesity and type-2 diabetes mellitus (T2DM). Studies in Saudi Arabia (KSA) and United Arab Emirates (UAE) predict an escalating impact of NAFLD/NASH, particularly advanced fibrosis due to NASH (AF-NASH), increasing cases of cirrhosis, liver cancer and death. The scale of this burden in other ME countries is unknown with no reports of NAFLD/NASH healthcare resource utilization (HCRU) or costs. We estimated the clinical and economic burden of NAFLD/NASH in KSA, UAE and Kuwait. METHODS:Markov models populated with country-specific obesity and T2DM prevalence data estimated numbers and progression of NAFLD/NASH patients from 2018 to 2030. Model inputs, assumptions and outputs were collected from literature, national statistics, and expert consensus. RESULTS:Over 13 years, the KSA model estimated cases increasing as follows: patients with fibrosis F0-3 doubled to 2.5 m, compensated and decompensated cirrhosis and hepatocellular carcinoma trebled to 212,000; liver failure or transplant patients increased four-fold to 4,086 and liver-related death escalated from < 10,000 to > 200,000. Similar trends occurred in UAE and Kuwait. Discounted lifetime costs of NASH standard-care increased totaling USD40.41 bn, 1.59 bn and 6.36 bn in KSA, UAE (Emiratis only) and Kuwait, respectively. NASH-related costs in 2019 comprised, respectively, 5.83%, 5.80% and 7.66% of national healthcare spending. CONCLUSIONS:NASH, especially AF-NASH, should be considered a higher priority in ME Public Health policy. Our analyses should inform health policy makers to mitigate the enormity of this escalating regional burden.

Objectives To determine how self-reported level of exposure to patients with novel coronavirus 2019 (COVID-19) affected the perceived safety, training and well-being of residents and fellows. Methods We administered an anonymous, voluntary, web-based survey to a convenience sample of trainees worldwide. The survey was distributed by email and social media posts from April 20th to May 11th, 2020. Respondents were asked to estimate the number of patients with COVID-19 they cared for in March and April 2020 (0, 1-30, 31-60, >60). Survey questions addressed (1) safety and access to personal protective equipment (PPE), (2) training and professional development and (3) well-being and burnout. Results Surveys were completed by 1420 trainees (73% residents, 27% fellows), most commonly from the USA (n=670), China (n=150), Saudi Arabia (n=76) and Taiwan (n=75). Trainees who cared for a greater number of patients with COVID-19 were more likely to report limited access to PPE and COVID-19 testing and more likely to test positive for COVID-19. Compared with trainees who did not take care of patients with COVID-19 , those who took care of 1-30 patients (adjusted OR [AOR] 1.80, 95% CI 1.29 to 2.51), 31-60 patients (AOR 3.30, 95% CI 1.86 to 5.88) and >60 patients (AOR 4.03, 95% CI 2.12 to 7.63) were increasingly more likely to report burnout. Trainees were very concerned about the negative effects on training opportunities and professional development irrespective of the number of patients with COVID-19 they cared for. Conclusion Exposure to patients with COVID-19 is significantly associated with higher burnout rates in physician trainees.

Introduction: Esophagogastroduodenoscopy (EGD) is essential for the evaluation of the foregut and is dependent on visualization of the upper gastrointestinal (GI) mucosa pathology. Foregut evaluation can be limited by the presence of mucus, foam, bubbles, and solid materials. Inadequate visualization may necessitate repeat endoscopy, exposing the patient to additional procedural risk. Currently, there is no standardized method to assess mucosal visualization for use in clinical or research settings. By using Delphi methodology, we aimed to develop and establish the content validity of the Toronto Upper Gastrointestinal Cleaning Score (TUGCS). Methods: We invited an international panel of endoscopy experts and educators to rate potential anatomical items and their associated anchors for importance as indicators of adequacy of mucosal visualization during EGD. The survey included questions regarding the TUGCS with Likert scales, wherein each participant reported their agreement with given statements on a scale of 1 (I strongly disagree with this statement) to 5 (I strongly agree with this statement). After each round in the Delphi process, we evaluated agreement for each survey item and sent back a revised version of the TUGCS to the expert panel for further ratings until we reached a consensus. We defined consensus a priori as ≥80% of experts in a given round, scoring ≥4 on all survey items. Results: Fourteen experts agreed to be part of the Delphi panel. We initially generated an anatomical framework to represent the upper GI mucosa and anchors for each mucosal portion to represent various levels of visibility through a systematic review. After three rounds of surveys, with response rates of 100%, 100%, and 71% respectively, consensus was achieved. The final TUGCS includes four anatomical areas (fundus, body, antrum, duodenum) and mucosal visualization anchors ranging from 0 (any solid food, blood or blood clots, or other content that could not be suctioned or washed, or an obstruction that prevented adequate visualization of the majority of an anatomical area) to 3 (entire mucosa well seen without the need for suctioning or washing) (Figure 1). Conclusion: We developed and generated content validity evidence for the TUGCS through rigorous Delphi methodology, reflective of practice across different centers. We are currently gathering validity evidence for the TUGCS in the effort of creating a tool that may be used to judge mucosal visualization for EGD in research and clinical settings.Figure 1.: Toronto Upper Gastrointestinal Cleaning Score

The global health sector strategy (GHSS) on viral hepatitis 2016-20211 set the stage for bold action to eliminate the hepatitis B virus (HBV) and hepatitis C virus (HCV) as public health threats by 2030. The strategy provided a roadmap setting out tangible targets on diagnosis, prevention and treatment. Recently, the World Health Assembly approved the development of a new global health sector strategy on viral hepatitis for 2022-2030. The new strategy comes at a critical time as countries need to make a strong push to eliminate HBV and HBC by 2030. Despite substantial progress, numerous challenges remain to HBV elimination across policy and practice.2 Here, we reflect on the successes and challenges towards HBV elimination in the six Gulf Cooperation Council (GCC) states: Bahrain, Kuwait, Oman, Qatar, the Kingdom of Saudi Arabia (KSA) and the United Arab Emirates (UAE). We also set out how the new health sector strategy can drive the field towards achieving the 2030 targets. At the turn of the twenty-first century, GCC states had high to medium endemicity of HBV. Over the following decades the burden fell, and in 2016 the prevalence of HBsAg in the Middle East and North Africa region was estimated at 2.1% (1.6-2.6). Within GCC states the prevalence varied; Bahrain and the UAE had the lowest estimated prevalence at around 1%, while Oman had the highest at 2.5%.3 Successful HBV vaccination programmes have driven much of the progress. GCC countries incorporated the HBV vaccine into their national immunisation programmes around 1990-1991, with progressive increases in the coverage over time. Data from the World Health Organization (WHO) vaccine monitoring system show that in recent years over 90% of children received an HBV birth-dose and the required three doses of HBV vaccine before the age of 5 years in all six GCC states.4 The viral hepatitis GHSS set the target of reducing the incidence of new cases of HBV by 30% between 2015 and 2020 and 90% by 2030, the latter being equivalent to a prevalence of 0.1% HBsAg among children.1 GCC states have already taken great strides to meet this target and in 2016, Bahrain, Kuwait, KSA and UAE had already achieved the goal, while Oman and Qatar had a prevalence of 0.2%.3 Despite successes in driving down the prevalence of HBV in GCC states, numerous challenges remain to its elimination, from a lack of resourcing to the absence of national and regional disease registries. Here we outline three priorities for achieving the goal of HBV elimination in GCC states by 2030. A lack of public knowledge of HBV and the social stigma associated with the condition have been long-standing barriers to elimination. Recently we engaged YouGov to conduct an online survey exploring public knowledge and perspectives of HBV amongst 1003 people in the KSA (698 Saudi, 305 expatriates) and 1022 in the UAE (118 Emirati, 904 expatriates). The survey employed a close-ended self-administered quantitative questionnaire in both English and Arabic. Just over half of the people surveyed in both countries were aware of HBV, while around a quarter knew that HBV results in serious health consequences. Less than 1 in 5 people reported knowing how HBV can be transmitted or prevented (Table 1). The lack of knowledge around HBV, including on the risk factors and consequences of the disease, coupled with social stigma which prevents people from seeking advice and care, present major barriers for diagnosing people and linking them to care. Globally, only 10% of people living with chronic HBV are diagnosed, and only 22% of these receive treatment.5 In the GCC states, in 2016 the percentage of people with HBV who received a diagnosis varied from 18% in Qatar to 3% in Bahrain and the UAE.3 United Arab Emirates n (%)a Kingdom of Saudi Arabia n (%)b Increasing the general public's awareness and knowledge and tackling social stigma should be at the centre of efforts to scale up prevention programmes and improve HBV diagnosis and treatment. Targeted approaches, including in high-risk groups for transmission, are likely to be most effective. Yet, in GCC states, policies and strategies focusing on vulnerable or marginalised groups, including people who inject drugs, remain suboptimal.6 These challenges are not limited to the Gulf region. In Europe, WHO policy recommendations targeting the most vulnerable are less requently in place and where they are in place, are more often poorly implemented.7 Sustained efforts to increase awareness and improve knowledge, including HBV risk factors and the consequences of chronic liver disease, will be important. These efforts must be directed not just to the community at large, but also towards primary care physicians. At-risk groups should also be prioritised for health education, including on the benefits of screening.2 Continuing education programs and awareness campaigns are important, as well as the development and adaptation of regional clinical practice guidelines.8 The role of primary care physicians, the implementation of community-based initiatives and the role of civil society in HBV education, prevention, diagnosis and management are also key considerations. The new WHO strategy should reflect the need to employ an equity lens to all HBV programmes, from public health policies to prevention, diagnosis and treatment. Building trust among impacted communities and providing opportunities for them to engage in the development of programmes for their own benefit will be key to achieving sustained impact. All stakeholders play a critical role, from government institutions, clinicians and professional associations to the private sector and civil society. In most countries, however, there is limited engagement between stakeholders or platforms for coordinating activities.6 Strengthened coordination and communication mechanisms will enable different actors to work together toward achieving shared goals. New criteria from the WHO will assist countries to validate the impact and programmatic targets set out in the GHSS. Knowledge sharing initiatives between countries can also help to ensure best practices are replicated. Reducing the burden of HBV will also require improving how people living with HBV access services along the care cascade. Receiving a diagnosis is one of the most critical steps in a patient's journey. Health professionals need to use clear, non-stigmatizing language to explain the diagnosis and set out the management plan. Continuity of care enables a patient to build a trusting relationship with their physician. The YouGov survey asked respondents how important it is for patients to express their views during different stages of their care (Table 2). Most respondents thought it was very, or somewhat important to express their views when starting or stopping a treatment, when treatment may impact their social life or when the condition is stigmatising. The results highlight the need for care providers to create space for patients to engage in critical discussions regarding decision-making processes. Point-of-care diagnostics and linkage to care following diagnosis are challenges in the Gulf, as is ensuring patients remain in care. Previous efforts to simplify models of care for HCV can deem useful models for HBV.9 The role of allied health professions, such as counsellors, should also be considered as they play an important role in helping patients to adjust to the realities of long-term treatment. Patient monitoring is an often-overlooked aspect of long-term care but is critical in HBV management; improved systems that track patients along the care pathway will help to maintain continuity of care and ensure better outcomes. Finally, integrating HBV into the continuing medical education of all health providers who will engage with HBV risk populations can help to ensure consistent quality care across the health system. While GCC states have succeeded in driving down the prevalence of HBV, particularly among children, it is important to recognise the fragility of these gains. The COVID-19 pandemic has highlighted the vulnerability of health systems with disruption to services presenting very real risks for people requiring long-term chronic disease management. There is emerging evidence of disruptions to routine childhood immunisations in GCC states which directly threaten recent progress on HBV and other vaccine-preventable diseases.10 The impact of this is likely to be uneven. Prior to the pandemic, HBV vaccination coverage in GCC states was suboptimal among the most at-risk populations.6 Now, more than ever, all stakeholders must work towards establishing and strengthening policies and strategies that directly meet the needs of the most vulnerable and ensure optimal clinical care by, for example, reducing late diagnosis. As the burden of COVID-19 subsides, health systems will face enormous challenges to address the backlog of unmet needs, including missed routine vaccinations. We urge countries to take immediate steps to develop plans and strategies to minimising the impact of healthcare disruptions, ensuring that future generations do not suffer needlessly from vaccine-preventable conditions such as HBV. In many countries, HBV elimination is a distant reality,2 yet after decades of progress GCC states are on the brink of achieving this goal. The final step in the journey may prove the hardest yet, but with continued commitment from all stakeholders an HBV-free future is a real possibility. HEM reports receiving consulting fees from ISGlobal related to this work. The remaining authors report no relevant conflict of interest. The data are available upon request from the corresponding author.

Background: During the novel coronavirus-2019 (COVID-19) pandemic, physicians in residency and fellowship training programs are serving as essential healthcare workers while also attempting to continue their preparation for eventual independent practice in their field. The aim of this study was to determine how the COVID-19 pandemic affected the safety, training, and well-being of medical trainees during March and April 2020. Methods: We administered an anonymous, voluntary, web-based survey to physicians enrolled in residency or fellowship training programs in any specialty worldwide. A convenience sampling of trainees was obtained through distribution of the survey by email and social media posts. Findings: Surveys were completed by 1420 trainees, of whom 1031 (73%) were residents. Trainees who cared for a greater number of COVID-19 patients were more likely to report limited access to PPE and COVID-19 testing and more likely to report testing positive for COVID-19. Compared to trainees who did not take care of COVID-19 patients, those who took care of 1-30 patients (adjusted odds ratio [AOR] 1.80, 95% CI 1.29-2.51), 31-60 patients (AOR 3.30, 95% CI 1.86-5.88) and >60 patients (AOR 4.03, 95% CI 2.12-7.63) were increasingly more likely to report burnout. More than half (835, 58%) of trainees reported concern about their future preparedness for independent practice. Interpretation: Physician trainees who were involved in the care of patients with COVID-19 reported unsafe working conditions and suffered from higher rates of physician burnout. Trainees were concerned about the effects of lost training opportunities on their professional development.Funding Statement: The study was supported in part by VA CSR&D grant COVID19-8900-11 to GNI.Declaration of Interests: None.Ethics Approval Statement: The study was approved and considered exempt by the Institutional Review Board at the University of Washington prior to dissemination.

Overview Successful medical care depends on the trust developed between a physician and his patient. Professionally dressed doctors are likely to achieve a higher level of trust from their patients than those with a non-professional appearance. For many years, the physician’s famous white coat has been the standard professional wear around the world. Few studies in Saudi Arabia have been conducted to analyze what kind of physician outfits patients prefer and whether the choice of attire affects the patient’s level of trust. These studies were either done in a single health institute, or in few primary healthcare clinics in one city. This study aims to analyze whether the type of clothing worn by a physician improves the level of trust between a patient and a doctor. Participants were asked about different styles of clothing, including Western business attire, traditional Saudi outfits, and surgical scrubs, and whether wearing the white coat was preferred. Moreover, we sought to establish if differences in age, gender, nationality, or educational background affected the responses. Methods This cross-sectional study was carried out in August and September 2018. Participants living in Saudi Arabia anonymously filled out an electronic questionnaire, distributed by social media, which measured the effect of male physicians’ outfits on the general population's perception in Saudi Arabia. Participants were shown photographs of possible dress styles for physicians. Data were collected on the participants’ demographics, their most and least preferred doctor’s outfits, and the effect of the physician’s attire on their level of trust. Results A total of 8231 participants were included in the survey: 53% males, 87.9% with university-level education or higher, and 93.5% of Saudi nationality; 76.1% of the participants responded “yes” saying that the outfit would have an effect on how a patient might receive medical advice and follow the doctor’s recommendations. The most preferred outfits chosen by the participants were surgical scrubs with a white coat (39.3%), followed by a Western shirt and tie with a white coat (30.3%). The least preferred outfit was the full (traditional) Saudi outfit with a white coat (25.4%), followed by a Western business suit without a white coat (23.2%). The choices of most and least preferred attire were found to be impacted by different demographic factors, such as age, gender, and nationality, but not the educational background. Conclusion Physicians practicing in Saudi Arabia should note that their attire will earn the patient’s trust and encourage compliance with advice or treatment. The most preferred outfits were surgical scrubs with a white coat and a Western shirt and tie worn with a white coat, whereas the least preferred ones were the traditional Saudi thobe, with and without shemagh or ghutra, and the Western business suit without a white coat.

In December 2019, a novel coronavirus was identified in patients in Wuhan, China. The virus, subsequently named severe acute respiratory syndrome coronavirus-2, spread worldwide and the disease (coronavirus disease 2019 or COVID-19) was declared a global pandemic by the World Health Organization in March 2020. Older adults and individuals with comorbidities have been reported as being more vulnerable to COVID-19. Patients with chronic liver disease (CLD) have compromised immune function due to cirrhosis and are more susceptible to infection. However, it is unclear if patients with CLD are more vulnerable to COVID-19 and its complications than other populations. The high number of severe cases of COVID-19 has placed an unusual burden on health systems, compromising their capacity to provide the regular care that patients with CLD require. Hence, it is incredibly crucial at this juncture to provide a set of interim recommendations on the management of patients with CLD during the current COVID-19 outbreak.