Prevalence of mental disorders among patients attending primary health care centers in the capital of Saudi Arabia

Objectives:To assess the prevalence of common mental disorders at primary health care (PHC) centers in Saudi Arabia using the Self-Reporting Questionnaire.Methods:This was a cross-sectional study carried out at a single PHC center in Riyadh city, Kingdom of Saudi Arabia. A self-medication questionnaire was utilized to collect the data. The prevalence of mental disorders has assessed by the Self-Reporting Questionnaire that consists of 20 items with binary answers (Yes/No).Results:This study reports that the prevalence of mental disorders among patients attended primary health care center was 28.5%. Moreover, prevalence did not significant differ by sociodemographic (p>0.05)Conclusion:The prevalence of mental disorders was slight high. The rates of untreated mental disorders necessitate the healthcare makers in Kingdom of Saudi Arabia to implement efficient strategies to halt the progression of untreated mental disorders.

There is growing concern about the mental disorders among people around the world.1 Due to its prevalence, depression and anxiety are considered major public health issues and is ranked as the fourth leading cause of the global diseases burden.2 However, the World Health Organization (WHO) has estimated that the impact of mental disorders will become the second leading cause of disability among individuals.3-5 Previous studies have shown that mental disorders are very common in almost every part of the world, with a significant difference in their frequency.1,6 Mental disorders refer to health conditions that are characterized by alterations in thinking, mood, or behavior. Diagnoses of mental disorders, also known as neuropsychiatric disorders, are made when people become mentally ill with the presence of somatic symptoms, such as irritation, headache, fatigue, forgetfulness, decreased concentration, anxiety, and mental retardation.7,8 It has been documented that in the USA, mental disorders are the third-most common cause of hospitalization of both young people and adults aged between 18 and 44 years. These include major depression, dysthymic disorders, and bipolar disorders.9 Approximately 1 in 5 adults in the USA, which can be expressed as 43.8 million or 18.5% of the individuals, suffer from mental disorders that cost about 193.2 billion dollars.10 Previously published studies have reported that 450 million people in the world suffer from some form of mental disorders.11 In the UK and the USA, about one-fourth and almost half of the populations, respectively, have a mental illness at some point during their life.12 In contrast to any other chronic illness, mental disorders are the highest reported illness.11 In Saudi Arabia, the prevalence rate of psychiatric disorders at primary health care (PHC) institutions is estimated to be 30-46%13 with the prevalence of depression of 20%.14 Chronic illness such as diabetes and hypertension increase the rate of the occurrence of mental disorders.15,16 Depression and anxiety are considered serious disorders that have a negative effect on the quality of life, medical comorbidity, and mortality.11,17-19 Despite the availability of some studies, most of these studies used specific screening tool for a particular disorder as the Beck Depression Inventory-Short Form (BDI-SF) for depression or the Rahim Anxiety-Depression Scale for anxiety/depression. The evaluation of common mental and psychiatric disorders at PHC centers using more generalized tools or techniques needs further research. In addition, the integration of mental health practices at PHC centers is one of the challenges faced by them, and investigating various psychiatric disorders using generalized assessment tools such as the Self-Reporting Questionnaire would help provide the real picture of mental disorder burden at PHC centers in Saudi Arabia. The objective of this study was to assess the prevalence of common mental disorders at PHC centers in Saudi Arabia using the Self-Reporting Questionnaire.     

Epidemiological study of epilepsy from a tertiary care hospital in kingdom of Saudi Arabia

Objectives:To identify the types of seizures and describe the clinical features, EEG and radiological findings among patients with epilepsy.Methods:In this retrospective epidemiological study, we analyzed the medical records of the patients with the diagnosis of epilepsy during the study period (January 1st 2016- December 2016)Results:The study included 184 patients, 91 (49.5%) were males and 93 (50.5%) females. Age ranged between 12 and 85 years (mean 35.4±19.5 SD years). Most of the patients 150 (82%) had Generalized tonic clonic seizures followed by focal onset in 27 (14%) of the patients. Main EEG abnormality was focal to bilateral was recorded in 53 (41%), idiopathic/ cryptogenic epilepsy was diagnosed in 61% of the patients. The most common abnormalities on brain imaging were temporal/hippocampal atrophy/stroke. The most common cause of symptomatic epilepsy was stroke found in 20(11%) followed by post infectious epilepsy and head trauma.Conclusion:Seizure types, EEG characteristics and etiologies of symptomatic epilepsy in our cohort of patients are in accordance with the current literature. Slight discrepancy observed in gender distribution and etiologies for symptomatic epilepsy compared with other studies from Saudi Arabia need to be studied further by prospective and population base studies.

Epilepsy is one of the most common neurological diseases and is a serious neurological disorder that is associated with social stigma.1 Epilepsy can be defined as a brain disorder that is characterized by episodes of vigorous shaking and disturbed brain activity (seizures) that can affect the patient’s attention and behavior.2 According to World Health Organization 2010 Global burden of Disease Study, it is the second most neurological disorder around the world in terms of disability adjusted life years.3 According to one of the prevalence study available from the kingdom of Saudi Arabia in 2001, the prevalence of epilepsy was found to be 6.54 per 10004 and in other Arab countries (Sudan, Libya and Tunisia) was about 2.3/1000.5 The incidence of epilepsy has been found to be substantially greater in developing countries compared with developed countries.6 Epidemiological studies about epilepsy from Arab countries especially Saudi Arabia are lacking. We were able to find only few studies about the prevalence of seizure disorder in an Arab population5,7 and even sparser from Saudi Arabia.4,8 we were unable to find any study regarding epidemiology of Epilepsy from our hospital. This study therefore was aimed to review and present the data of patients with epilepsy from our hospital, King Fahd Hospital of the University (KFHU), Alkhobar, Kingdom of Saudi Arabia.     

Primary headache characters and coping strategies among medical students of Umm Al-Qura University in the Western Region of Saudi Arabia

Objectives:To assess the headache patterns among medical students of Umm Al-Qura College of Medicine, Makkah, Kingdom of Saudi Arabia. Medical students represent a vulnerable group for primary headache disorders, as they are exposed to various physical and psychological stressors.Methods:We carried an observational, cross-sectional study, and collected data during February, 2017 using electronic questionnaires. The international classification of headache disorders, third edition (ICHD-3) beta edition was used to classify headache into 10 types.Results:A total of 623 responses (82.2%) were received out of 758 participants. The one-year headache prevalence was 558 (89.6%). The most common diagnosis among both genders was frequent tension-type headache (TTH) (n=173, 31.0%), followed by probable infrequent TTH (n=114, 20.4%) and probable frequent TTH (n=63, 11.3%).The greatest proportions of students who reported an impact of their academic level were found among the chronic TTH, migraine without and with aura (n=2, 40.0%; n=14, 34.4%; n=11, 33.3%). Migraine without aura was more prevalent among females (n=29, 10.5%) than males (n=10, 3.5%). Self-medication was common (62.5%-100.0%). Simple analgesics (67.4%-80.0%), sleeping (54.3%-80.0%) and caffeine intake (28.3%-60.0%) were the top 3 therapies that were practiced.Conclusion:The prevalence of headache among Umm Al-Qura university (UQU), Makkah, Kingdom of Saudi Arabia’s medical students appears higher than the prevalence among the general population. This may have a significant impact on academic performance and necessitates special attention. We recommend further studies on interventions to reduce the prevalence and impact of this prevalent problem.

Headache disorders are among the most frequent complaints in neurology clinics.1-3 They constitute 13% of total neurology outpatient complaints and represent 1/1000 of hospital consultations according to a Saudi study.4 Headache disorders are underestimated, under-recognized and under-treated, and represent the third highest leading cause of disability worldwide.3,5 Headache disorders constitute a major socioeconomic burden on both the individual and society.3 In a population study of 2,421 people in the Kingdom of Saudi Arabia, 4% of all working days are lost due to absenteeism from headache disorders.6 Moreover, psychiatric morbidities were significantly higher among migraineurs than in healthy population, which reflects a more inferior quality of life in this population.7Headache disorders are classified according to their cause into primary headache disorders, which are not related to an underlying disease, and secondary headache disorders, wherein existent morbidity is a culprit (namely, head trauma and meningitis).8 Primary headache disorders, by far, are the most common type of headache disorders worldwide. In Kingdom of Saudi Arabia, a country-wide cross-sectional survey in one-year duration revealed a high prevalence of migraine (32%), followed by tension-type headache (27%), and medication overuse headache (2.7%).6Medical students represent a vulnerable group for primary headache disorders, as they are exposed to various physical and psychological stressors. Previous studies on primary headache disorders among medical students suggest an association with low academic performance, which calls for action.9 This study aims to determine the prevalence of primary headache disorders among medical students of Umm Al-Qura College of Medicine, Makkah, Kingdom of Saudi Arabia and the coping strategies they use to mitigate the effects of headaches on their academic performance.     

Gender-specific differences in depression and anxiety symptoms and help-seeking behavior among gastroenterology patients in Riyadh,Saudi Arabia

Objectives:

To evaluate the gender-specific difference in the prevalence of depression and anxiety and the help-seeking behavior among gastroenterology outpatients.

Methods:

A cross-sectional study was carried out in gastroenterology clinics in 4 hospitals in Riyadh, Saudi Arabia between February and September 2013. A self-administrated questionnaire was developed and administered to patients. The Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7) questionnaires were used to identify depression and anxiety.

Results:

A total of 438 patients completed the study questionnaire; 135 (31%) females, and 303 (69%) males. Compared with males, females had more depression symptoms (44% versus 32%, p=0.012), anxiety symptoms (34% versus 24%, p=0.036), anxiety-associated difficulty (65% versus 52%, p=0.012), but similar suicidal thoughts (14% versus 11%, p=0.347). Females had similar gastrointestinal complaints but longer duration of symptoms. In both females and males, the most common first interventions were using medications (63% versus 69%), and undergoing endoscopy (19% versus 15%), while very few patients initially used herbs or Islamic incantation “Roquia” (7% versus 8%). Compared with males, females were more likely to subsequently seek help at private clinics (23% versus 14%, p=0.014), or with a Quran therapist (11% versus 5%, p=0.012).

Conclusion:

There are clear gender-specific differences in depression and anxiety symptoms and associated perceived difficulty, but modest differences in help-seeking behavior. Female patients at the gastroenterology clinic may deserve more psychological attention to diagnose depression and anxiety and to alleviate their impact.Psychiatric disorders including depression and anxiety have been reported more frequently among females than male patients.1,2 Additionally, depression and anxiety in woman may be associated with increased symptom severity, chronic course, and functional impairment compared with men.3,4 Gender-specific differences in psychological, neurochemical, anatomic, hormonal, genetic, and personality factors have been suggested to explain the gender-specific difference in lifetime prevalence of depression and anxiety.2,4 After developing a disease, the patient behavior can be as active as rapidly seeking help from available healthcare services or as passive as dismissing the symptoms.5 Help-seeking behavior can be defined as the behavior of individual patients in response to developing a disease with the aim to relieve or improve the disease experience.5 Several socio-demographic and psychosocial factors have been reported to influence timing, frequency, and type of the help-seeking behavior among patients with different health problems.6,7 It was suggested that women are more likely than men to seek medical help for their medical and mental problems, but less likely to seek medical help for alcohol problems.8,9 A limited number of studies examined the help-seeking behavior among patients with gastrointestinal symptoms, and did not show a gender-specific difference.10,11 In Saudi Arabia, females apparently have a high burden of depression and anxiety.12,13 Local data on help-seeking behavior are limited and old.14 Additionally, there is a lack of data on any the gender-specific differences in help-seeking behavior, and in depression or anxiety, or help-seeking behavior in gastroenterology patients. The objective of the current study was to evaluate the gender-specific difference in the prevalence of depression and anxiety symptoms, and the help-seeking behavior among gastroenterology outpatients in Saudi Arabia.     

Neurophobia among medical students

Objective:

To assess the attitude of medical students and junior physicians toward neurology.

Methods:

A self-administered, previously validated, questionnaire was distributed among 422 students and junior physicians at King Abdulaziz University, Jeddah, Saudi Arabia from September to December 2012. In this cross-sectional study, the questionnaire included demographic data and 12 statements to examine attitudes toward neurology using a Likert scale.

Results:

The response rate among participants was 70.3%. The mean age was 22.35 (SD+/-1.28) years. Males comprised 46.2%. While 31.3% of students had not decided regarding their future career, 11.8% selected neurology as their first possible choice. Whereas 29.6% of students were not satisfied with their neurology teaching experience, 84.4% found neurology difficult, and 42.7% of the whole group thought that their neuroscience knowledge was insufficient. Advanced clinical year students (namely, interns) were less likely to consider neurology as a career choice (p=0.001).

Conclusion:

Most of the students had an unfavorable attitude toward neurology on the Likert scale. New strategies are needed to change students’ attitude toward this demanding specialty.Neurological disorders comprise 6.4% of the global health burden, and contribute to 12% of global mortality.1 A large proportion of these disorders are chronic, outpatient based, and typically cared for in the community by general medical staff.2-6 Hence, it is important that medical students, and eventually medical doctors of different specialties, become more familiar and comfortable with dealing with these common diseases. Neurophobia, or the fear of neuroscience and clinical neurology, is well known among medical students and junior physicians.2 Neurology is considered, throughout the world, as the most difficult and the least understood medical specialty.2-5 Students, residents, and general practitioners display less confidence when dealing with neurological cases compared with other medical conditions.5,7 This has been attributed to limited patient exposure, difficult neuroanatomy, complex clinical examination, insufficient teaching, and diagnostic complexity.3,5,6,8 In Saudi Arabia, the attitude of medical students toward neurology and the extent of neurophobia is not well explored. Our study aimed to examine this issue and its extent among Saudi medical students.     

Role of environmental factors in autism spectrum disorders in Saudi children aged 3-10 years in the Northern and Eastern regions of Saudi Arabia

Objectives:To study the environmental factors which can contribute to the development of autism spectrum disorders in Saudi children aged 3-10 years in Northern region (Arar) and Eastern region (Dammam) in the Kingdom of Saudi Arabia.Methods:A case control study was conducted and the data was collected from September 2017 to December 2017 by interviewing the parents of 100 Saudi autistic children and 100 normal children aged 3-10 years from Arar and Dammam. A specially designed questionnaire was used to collect the data which includes socio-demographic characteristics of the parents and ante-natal history of the mother and developmental history, social history and dietary habits of the child. To find out the association between environmental factors and development of autism in children, logistic regression with odds ratio used.Results:There was a significant association between consanguineous marriages and autism. A significant association was also found between medications taken by the mother during pregnancy and autism. Significantly lowered ORs for Autism were observed for children in families of perceived adequate income and children consuming a Vitamin-D rich diet. Increased maternal age was observed in autistic children when compared to normal children.Conclusion:The environmental factors which could contribute to the development of autism are consanguineous marriage, inadequate family income, medications taken by the mother during pregnancy, vitamin D deficient diet of the child and maternal age during pregnancy.

Autism spectrum syndrome (ASD) consists of a group of developmental disorders that are difficult to detect without trained personnel. It is characterized by qualitative impairments in social interaction, qualitative impairments in communication, and restricted repetitive, stereotyped patterns of behavior, interests, and activities.1 The number of children diagnosed with autism spectrum disorder is rising.2,3 It is not clear whether it is due to better detection and reporting or a real increase in the number of cases.4,5 Many factors can contribute to increase in prevalence estimates including changes in diagnostic criteria and specialized diagnostic tools.The causes of autism remain unclear even though genetic and environmental factors may play a role in increasing the risk of autism. Researchers claim that toxic food contaminants like mercury can affect metabolism and alter neuronal plasticity and cause autism in children.6 Studies have shown that supplementation with Vitamin D and Tryptophan is an affordable solution to prevent autism.7 According to one study, high iron intake decreases autism.8 Other risk factors that increase the chance of having a child with autism are consanguinity, advanced parental age, and maternal lifestyle.9-11 Vaccinations are sometimes cited as a cause of autism, but there is no definite evidence to prove it.12According to World health organization (WHO) fact sheet published in April 2017, one in 160 children have autism spectrum disorder. Despite its increasing rate, currently autism remains untreatable.13 Most of the research in the field of autism has been conducted in Western countries. In the Arab world, the research conducted in the field of autism is relatively less. Autism was not the subject of interest in the region until the late 1990s. Lack of awareness and culture as well as lack of resources contribute to the unmet needs of autism patients in the region.14 The males diagnosed with autism are 4 times more when compared to females.Although various studies have been conducted in ASD’s etiology across the world, only few scientific researches have been conducted in Middle East especially in Kingdom of Saudi Arabia (KSA).15 Also, dietary habits should be looked into as they could help in identifying high risk foods that could affect their children.16 The present study was therefore undertaken to explore the various environmental factors including dietary factors which can contribute to the development of autism.     

Treatment of shoulder pain in spastic hemiplegia by reducing spasticity of the subscapular muscle: a randomised, double blind, placebo controlled study of botulinum toxin A

Objective

This randomised, double blind, placebo controlled, two parallel group study was conducted to assess the beneficial effect of injection of botulinum toxin A (Dysport) into the subscapularis muscle on shoulder pain in stroke patients with spastic hemiplegia.

Methods

A single dose of botulinum toxin A (500 Speywood units) or placebo was injected into the subcapularis muscle. Pain was assessed using a 10 point verbal scale. Subscapularis spasticity was assessed by the change in passive shoulder lateral rotation and abduction. Upper limb spasticity was assessed using the Modified Ashworth Scale for shoulder medial rotators, and elbow, wrist and finger flexors. Assessments were carried out at baseline and at weeks 1, 2 and 4.

Results

Twenty patients (10 patients per group), 11 with ischaemic stroke and 9 with haemorrhagic stroke, completed the study. Pain improvement with botulinum toxin A was observed from week 1; score difference from baseline at week 4 was 4 points versus 1 point with placebo (p = 0.025). Lateral rotation was also improved, with a statistically significant difference compared with placebo at week 2 (p = 0.05) and week 4 (p = 0.018). A general improvement in upper limb spasticity was observed; it was significant for finger flexors at week 4 (p = 0.025).

Conclusions

Subscapularis injection of botulinum toxin A appears to be of value in the management of shoulder pain in spastic hemiplegic patients. The results confirm the role of spasticity in post‐stroke shoulder pain.Pain and spastic shoulder are frequent in hemiplegia following a stroke. Shoulder pain is a major problem for these patients, interfering with physiotherapy, sleep and daily activities. It is usually due to local causes: algoneurodystrophy (shoulder–hand syndrome), capsulitis, gleno‐humeral subluxation and also spasticity because of the prolonged muscular contracture and possible tendinopathies.^1,2,3,4 These causes can be associated, especially spasticity and algoneurodystrophy in severe hemiplegia, and patients exhibit the typical arm posture: adduction and medial rotation of the shoulder, and flexion of the elbow, wrist and finger.Different approaches are used for treatment of pain in such patients, depending on the mechanism involved. Oral medications for pain, as those for spasticity, are usually ineffective or insufficient. Treatment of algoneurodystrophy and capsulitis mainly consists of corticosteroids, systemic treatment being more effective than local administration.^3,5 To treat spasticity or its consequences, transection of the subscapularis tendon^6,7 or subcapularis nerve block^8,9 has been reported, but these treatments are not in common use. Botulinum toxin A has been shown to be effective in reducing spasticity and increasing the passive range of motion of the spastic upper limb in hemiplegic patients^{10,11,12,13,14} with a real functional benefit.¹⁵ The effect of botulinum toxin A on shoulder pain after a stroke has not been systematically studied. However, improvement of pain by the toxin has been reported in a placebo controlled study, although pain was not the main objective of the study.¹⁵ A beneficial effect has also been observed in an open study.¹⁶ Other controlled studies in which upper limb pain was assessed failed to show a significant reduction in pain.^10,11,12No specific treatment of the spastic shoulder muscles has been studied. Suprasupinator and infrasupinator muscles are not involved in painful contracted shoulder,¹⁷ and among the muscles implicated in medial rotation, the subscapularis and pectoralis muscles undoubtedly play a major role,¹⁸ with apparent pre‐eminence of the subscapularis muscle.¹⁹ In a recent study of three cases, injection of botulinum toxin A into the subscapularis muscle was shown to reduce pain and improve the passive range of motion.¹⁸Based on these observations, we formed the hypothesis that shoulder pain occurring in patients with spastic hemiplegia, even with limited range of motion compatible with capsulitis, can be relieved by reducing the spasticity of the main medial rotator muscle (ie, the subscapularis muscle). Therefore, we conducted the present study to further assess the beneficial effect of injection of botulinum toxin A (Dysport) into the subscapularis muscle on shoulder pain. An improvement in the passive range of motion was expected as a parameter of the efficacy of botulinum toxin on spasticity and as a possible secondary benefit.     

Public awareness of central nervous system tumors in the Kingdom of Saudi Arabia

Objectives:To investigate individuals’ knowledge about central nervous system tumors (CNST) signs and symptoms and risk factors, as well as their readiness to seek medical advice. The signs and symptoms associated with CNSTs are often vague, and failure to recognize them could lead to delays in seeking help and possibly fatal results.Methods:This was a cross-sectional survey that utilized 2 delivery methods. A total of 1,500 personally delivered and 1,500 online self-administered questionnaires were completed in parallel between June 2015 and June 2016 for the occupants of the Kingdom of Saudi Arabia.Results:Significant differences were observed for the sociodemographic characteristics of participants recruited via the 2 methods. The most recognized symptom was “Headaches” (45.2%), and the most recognized risk factor was “Radioactive location/occupation” (84.1%). Overall knowledge scores were low, significantly predicted by employment and cancer contact (p<0.05), while the scores significantly higher for participants who were willing to see their doctors within a week (p<0.005). The most recognized barrier to seeking help was “Worry about what the doctor might find” (74.0%).Conclusion:The level of awareness of CNSTs was low. Using a questionnaire delivered in 2 different ways enabled the recruitment of sample pools with different sociodemographic characteristics.

For many health-related issues, awareness is considered an important factor associated with behavior.1 Several studies have linked high knowledge to the ability to address modifiable associated causes, for instance, improving diet and increasing exercise to prevent cancer, as well as taking appropriate actions in response to detecting associated symptoms.2 Assessing the level of public awareness of health-related issues is important for identifying deficient areas and increasing awareness in areas where needed.3 The occurrence of a central nervous system tumor (CNST) in any individual, with its associated consequences, is a devastating event.4 In 2012, the World Health Organization (WHO) Global Cancer report (GLOBOCAN) stated that more than 250,000 individuals worldwide were diagnosed with a CNST, and approximately 190,000 died, ranking CNSTs in the top 10 mortalities caused by cancer.5,6,7 More than 120 CNST entities have been classified by the World Health Organization (WHO) based on their clinicopathological characteristics and histological patterns.8 The signs and symptoms for CNSTs depend on the tumor location, and they are not exclusively indicative of the presence of these tumors.3,9,10 Causes associated with the development of CNSTs vary, and many are still under investigation.11-20 Many studies that assess health public awareness rely on random sampling through telephone directories, a system that is not necessarily available in many developing countries. Questionnaires provided online have frequently been used, including in marketing research and psychological studies. Due to their attractive ability to access larger cohorts and improve validation checks, and thus data quality, these Web-based questionnaires represent an important tool for many epidemiological studies on public health.21,22 Awareness of the symptoms and risk factors for CNSTs is especially critical, since the disease signs tend to be vague and easily overlooked, resulting in a delayed response to take appropriate action. Unfortunately, there is a lack of CNST awareness studies that assess the level of public understanding in many regions of the world. In this study, we aimed to investigate the knowledge concerning CNST signs and symptoms and risk factors, as well as readiness to seek medical advice, among citizens of the Kingdom of Saudi Arabia (KSA) using 2 questionnaire delivery methods.     

Pain as the only symptom of cervical artery dissection

Background

Headache or neck pain is a frequent symptom of spontaneous cervical artery dissection (sCAD).

Patients and methods

Patients were drawn from an ongoing hospital‐based registry of consecutive cases diagnosed with sCAD. Only patients with isolated pain were included in this series. Pain topography, dynamics, severity and quality, imaging findings and outcome were analysed.

Results

20 of 245 (8%) patients with sCAD presented with pain as the only symptom (mean (SD) age 39 (8) years; 14 (70%) women). Of them, 12 had vertebral artery dissection, 3 had internal carotid dissection and 5 had multiple dissections. The median delay from symptom onset to diagnosis was 7 days (range 4 h to 29 days). 6 patients presented with headache, 2 with neck pain and 12 with both. Onset of headache was progressive in 6, acute in 8 and thunderclap‐type in 4 patients; neck pain was progressive in 7 and acute in 7. Headache was throbbing in 13 and constrictive in 5 patients; neck pain was throbbing in 4 and constrictive in 10. Pain was unilateral in 11 and bilateral in 9. Pain was different from earlier episodes in all but one case. All patients were pain free at 3 months.

Conclusion

Pain may be the only symptom in sCAD, even when multiple arteries are dissected. Pain topography, dynamics, quality and intensity were heterogeneous. Data from this study lend support to recommendations favouring imaging studies of the cervical arteries in patients with new‐onset unexplained headache or neck pain.Spontaneous cervical artery dissection (sCAD) is a well‐recognised cause of stroke, particularly in the young, with a wide spectrum of clinical presentations.^1,2 Patients may present with local manifestations, ischaemic signs or both. The typical clinical manifestations of spontaneous vertebral artery dissections (sVADs) are thought to be occipital headache, posterior neck pain or both, as well as posterior circulation ischaemia or subarachnoid haemorrhage (SAH).^3,4,5 Patients with spontaneous internal carotid artery dissection (sICAD) mainly present with ipsilateral anterior headache or neck pain, Horner''s syndrome, cranial nerve palsies and retinal or cerebral ischaemia.^2,6Pain is the most frequent local symptom and often the initial manifestation of sCAD. However, it has rarely been reported as the only symptom of sCAD.^{7,8,9,10,11,12} Therefore, to determine patterns of pain that could raise suspicion about sCAD, we analysed patients with sCAD, who presented with only headache or neck pain.     

Quantitative assessment of vertebral artery anatomy in relation to cervical pedicles: surgical considerations based on regional differences

Objectives:To quantify the anatomic relationship between the Cervical pedicle screw (CPS), vertebral artery (VA), and related anatomic structures in the Saudi population.Methods:This retrospective single center study included 50 consecutive patients (35 males) with normal neck findings on computed tomography angiography performed for trauma or vascular evaluation between 2012 and 2014. Radiologic parameters were assessed and correlated with age, weight, height, and body mass index (BMI).Results:Mean age, weight, height, and BMI were 45.74±18.93 years, 79.72±21.80 kg, 164.74±11.53 cm, and 29.38±6.13 kg/m², respectively. Mean cervical pedicle diameter (PD) increased from the cranial to caudal vertebrae (p=0.0001). Mean free zone (FZ) value, defined as the distance between the lateral CP border and medial VA border, was 1 mm (range 0.95–1.16 mm). The VA entry into the transverse foramina was at C6 level on both the right 92% and left side in most patients 94%. However, the right and left side level of VA entry differed in 14% of individuals.Conclusion:The PD and FZ are smaller in Saudi Arabians than in western populations. Assessment of VA entry at each level should be performed on an individual basis as the level of VA entry can differ in the same patient. Anatomic variations between different geographic areas should be studied to provide better surgical guidance.

Cervical spine instrumented fusion is a common treatment for a variety of pathologic conditions.1 Several approaches for cervical spine stabilization have been developed, including anterior or posterior approaches.2-4 Currently, posterior fixation of the subaxial cervical spine is performed using lateral mass screws (LMS) or cervical pedicle screws (CPS).4 The CPS has the advantage of a stronger pullout strength than LMS.5,6 However, CPS is more technically demanding and is associated with a potentially higher risk of injury to the neurovascular structures.6-11 Precise anatomic knowledge is paramount for preventing a potentially life threatening vertebral artery (VA) injury during CPS insertion.12-15 The close proximity of the VA to the bony structures increases the risk of VA injury. Previously, anatomic studies identified a distance of 1–2 mm between the VA and the lateral wall of the cervical pedicle (CP).16 Additionally, the VA occupies one- to two-thirds of the axial diameter of the transverse foramen (TF), narrowing the space around the VA for potential screw misplacement.16,17 Additionally, variability in vertebral artery anatomy or osseous anatomy exists and should be assessed on an individual basis.16 Good knowledge of anatomic details combined with modern intra-operative imaging technology with navigation could reduce the risk of VA injury during CPS insertion.18,19 The purpose of this study was to quantify the relationship between anatomic structures of the subaxial spine and the VA and the CP in the Saudi population and to compare the results with published data from other geographic areas. These findings are relevant to the instrumentation of the spine, showing regional variations in the spinal anatomical structures measurement. Moreover, the data is critical for surgical planning, decision-making, and safety of cervical spine instrumentation.     

Outcomes of patients with multiple sclerosis at a neurorehabilitation unit in Saudi Arabia

Objectives:To assess the impact of inpatient multidisciplinary rehabilitation on a Saudi Arabian population of patients with multiple sclerosis (MS).Methods:We retrospectively analyzed the data of patients with MS who underwent inpatient rehabilitation between 2009 and 2015 at King Fahad Medical City (KFMC). Differences in Functional Independence Measure (FIM) scores (used in rehabilitation settings to assess the functional independence of patients) and length of stay (LOS) were measured between patients of different ages, sexes, and types of MS and analyzed using the independent t-test. The Pearson correlation coefficient was used to investigate the correlation between FIM, LOS, and other variables.Results:In total, 24 patients were identified, with an average age of 36 years. The average age at disease onset was 31 years. Disease duration ranged from 1-20 years, with a mean of 7 years. The most common type of MS was relapsing-remitting (45.8%). The mean FIM score at admission was 77.5 and at discharge 97.25. Functional independence measure gain ranged from 2-51, with a mean of 18.58. Functional independence measure efficiency (FIM gain divided by LOS) ranged between 0.09-0.95. The length of stay ranged between 21-95 days, with a mean of 37.79 days. There was a significant association between age and FIM efficiency (p=0.043).Conclusions:Inpatient rehabilitation is an important intervention that improves the functional independence of patients with chronic MS.

Multiple sclerosis (MS) is a chronic inflammatory demyelinating autoimmune disease with a female preponderance and an estimated prevalence of 30-190 cases per 100,000 people in Europe.1 Because of its early onset, progressive course, and long survival time, MS can lead to long-term disability with a significant negative impact on personal and social life.2,3 Among neurologic diseases, it is the third most common cause of disability, with 50% of patients requiring a walking aid and 10% requiring a wheelchair within 15 years of onset; within 25 years of onset, more than 90% of patients experience significant functional impairments.4,5 Life expectancy in patients with MS is reduced by about 5-10 years compared with age-matched individuals without MS.6 Around 2 million people worldwide are affected by MS.7 In young adults, this disabling neurodegenerative disease of the central nervous system is considered the leading cause of non-traumatic disability.8 In the Middle East, the risk of MS has recently been reported to be moderate to high.9 The Kurtzke classification places the Middle East in a low-risk zone for MS; however, a moderate-to-high prevalence in areas within the region (31-55 cases per 100,000 individuals), especially among women, has recently been reported.10,11 Thus, MS represents a considerable burden to Middle Eastern countries. In the Kingdom of Saudi Arabia, the prevalence of MS is poorly documented. Reviews of epidemiologic studies have suggested that it is underdiagnosed and that its prevalence is increasing.10,11 A few studies have reported an increase in the prevalence of MS in the Kingdom of Saudi Arabia to 40/100,000 in 2008 from 25/100,000 in 1998.9,12 Likewise, there are no data on the effects of inpatient rehabilitation in the Arabian Peninsula. In the literature, common treatment strategies are based on a combination of pharmacotherapy and rehabilitation. In daily practice, multidisciplinary rehabilitation (MDR) is often recommended to patients with MS. However, the evidence regarding the outcomes of MDR is contradictory. Some trials have reported improvements in impairment and in the mental component of a health-related quality of life measure, but others have shown that MDR improves the experience of people with MS in terms of activity and participation without changing the level of impairment.13,14-16 The overall evidence on the efficacy of MDR is limited by variation in the clinical presentation of MS and problems associated with study methodology.13 In this study, we assessed the impact of short-term inpatient MDR in a Saudi-Arabian population of patients with MS to identify the clinical predictors of effective rehabilitation treatment. At KFMC, both inpatient and outpatient services are included in the neurorehabilitation program. King Fahad Medical City treats patients from all regions of the country, including those internally transferred from the National Neuroscience Institute within KFMC. The integrated neurorehabilitation program was deemed to meet the standards of the Commission on Accreditation of Rehabilitation Facilities.17     

Systematic review of the epidemiology of attention deficit hyperactivity disorder in Arab countries

Objective:

To assess the epidemiology of attention deficit hyperactivity disorder (ADHD) in Arab countries, and identify gaps for future research.

Methods:

We searched PubMed from July 1978 to July 2014 and reviewed local journals with cross-referencing. The keywords we used were ADHD, diagnosis, prevalence, incidence, factor, diagnosis, rate, risk, and each of the names of the 22 Arab countries (Jordan, Egypt, Lebanon, Saudi Arabia, and so on). Studies were eligible for inclusion if they investigated the epidemiology of ADHD in any Arab country, and were published in English. The search was conducted from 2nd to 5th August 2014 in King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.

Results:

A total of 22 articles were included in the review. Twenty studies were cross-sectional and found the prevalence of ADHD ranged between 1.3-16%, prevalence of hyperactive type ADHD between 1.4-7.8%, and the prevalence of inattention type between 2.1-2.7%. Only 2 case-control studies investigated potential risk factors. Evidence extracted from these studies shows a significant association between ADHD and male gender, previous psychiatric illness in the family, vitamin D deficiency, poor school performance, sleep problems, and nocturnal enuresis.

Conclusion:

The prevalence of ADHD in Arab countries is comparable to reports in North America, Africa, and other countries of the Middle East. Longitudinal studies are needed to investigate the prognosis and determinants of this condition in the Arab world.According to the Diagnostic and Manual of Mental Disorder (DSM-IV), attention deficit hyperactivity disorder (ADHD) is a neurobehavioral disorder characterized by pervasive and impairing symptoms of inattention, hyperactivity, and impulsivity.1 It is a condition that occurs primarily in childhood, and presents profound impairments impacting every aspect of life.2 The ADHD symptoms are caused by a neurological dysfunction within the brain. The physiological mechanism of ADHD is still under study.1,2 This disorder has been associated with a broad range of negative outcomes for affected subjects,3 and with a significant financial burden.4 The prevalence of ADHD varies from 0.2-28%.5 Reported differences in prevalence across countries might be related to differences in diagnostic criteria used, but also might be related to biological, cultural, and family factors.6 A comprehensive systemic review conducted in 2007 documented the worldwide-pooled prevalence at 5.3% (95% confidence interval [CI]=5.01-5.56).6 The National Survey of Children’s Health in 2011 reported 11% prevalence of ADHD in children aged between 4 and 17 years of age.7 Attention deficit hyperactivity disorder is more common in boys than girls (ratio 4:1 for the predominantly hyperactive type, and 2:1 for the predominantly inattentive type).8 Accordingly, the DSM-IV proposed 3 subtypes of ADHD that are the inattentive type, hyperactive/impulsive type, and combined type.9 During the past decade, evidence has accumulated indicating that symptoms of ADHD persist into adulthood for 30-70% of children diagnosed with the disorder.10 Many studies have demonstrated conclusively that genetic and environmental influences play a role in the etiology of ADHD, as is true for virtually all psychological traits and disorders.11 Attention deficit hyperactivity disorder is 6-8 times higher among first-degree relatives with ADHD, where 30-35% of full siblings meet the ADHD criteria.12 Prenatal or perinatal complications significantly predicted the later development of ADHD.13 Virus infections, meningitis, encephalitis, head injury, epilepsy, toxins, and drugs, were among the childhood illnesses associated with ADHD. Furthermore, diet-related sensitivities and mineral deficiencies have always been controversial factors.14 Worldwide, several systematic reviews have been conducted to summarize the epidemiological evidence with respect to the occurrence and determinants of ADHD. In the Arab region only one systematic review was completed in 2009.15 However, with increased interest in research on ADHD, several new studies have been conducted in the Arab world. This systematic review provides an update on the current state of knowledge with respect to ADHD literature in the Arab world.     

Telmisartan inhibits hyperalgesia and inflammatory progression in a diabetic neuropathic pain model of Wistar rats

Objective:

To evaluate the potential therapeutic value of telmisartan (TMT) against diabetic neuropathy (DN) and associated pain in Wistar rats.

Methods:

Peripheral DN was induced by a single intraperitoneal streptozotocin injection (55 mg/kg), and 3 weeks later TMT treatment was started (5 and 10 mg/kg/day), and continued for 4 weeks. Mechanical nociceptive threshold, motor coordination, and thermal nociceptive threshold tests were performed before and after TMT treatment. In serum, glucose, pro-inflammatory cytokines including tumor necrosis factor-α, interleukin-1β, and interleukin-6 were assessed. Nerve growth factor (NGF) levels and histopathological changes were estimated in the sciatic nerve. This study was conducted at the Experimental Animal Care Center, Department of Pharmacology, College of Pharmacy, King Saud University, Riyadh, Kingdom of Saudi Arabia between January 2013 and May 2014.

Results:

We observed a significant reduction in mechanical nociceptive threshold, motor coordination, and thermal nociceptive threshold in diabetic animals. The TMT treatment significantly enhanced the reduced mechanical nociceptive threshold. The untreated diabetic animals revealed a significant decrease in sciatic NGF, which was markedly attenuated by TMT. The elevated serum levels of cytokines in diabetic animals were inhibited by the TMT treatments. Histopathological evaluation showed obvious nerve degeneration in the diabetic group that was eliminated in the TMT treated diabetic groups.

Conclusion:

Telmisartan has a potential neuro-protective effect on peripheral DN; this is mediated through its anti-inflammatory effects and its dual properties as an angiotensin receptor blocker, and a partial peroxisome proliferator activator receptor-g ligand.Worldwide, diabetic neuropathy (DN) is a major complication of diabetes mellitus. It affects around 15-25% in type-1, and 30-40% in type-2 diabetic patients, causing disabilities, and a high mortality rate. Neuropathic pain defined as a form of chronic pain resulting from damage or abnormal function of the central or peripheral nervous system.1 Patients with neuropathic pain frequently report sensory abnormalities such as burning sensations, hyperalgesia, allodynia, and dysesthesia.2 Diabetic neuropathy can also alter the patient’s quality of life by interfering with emotional well-being, which represents a challenge for clinicians because of its severity, chronicity, and resistance to some classical analgesics.3 The behavioral responses of diabetic rodents to thermal and mechanical hyper- and hypoalgesia as well as tactile allodynia to external stimuli have led to the identification of several mechanisms of abnormal sensation and pain in diabetes. It is confirmed that DN is characterized by neuronal degeneration and marked alterations in neural growth factors such as nerve growth factor (NGF) and insulin-like growth factor (IGF).4 Despite the availability of therapies to alleviate the symptoms of DN, a limited number of medications are available to control its basic causes. Diabetic associated disability and premature mortality are also caused by vascular complications, and several observational reports suggest the potential benefits of intensive blood pressure lowering of diabetic patients.5 The use of angiotensin converting enzyme inhibitors (ACEI) or an angiotensin receptor blocker (ARB) is recommended by current hypertension guidelines for patients with diabetes to achieve a target blood pressure level of 130/80 mm Hg or lower.5 The correlation between the renin angiotensin system and diabetic complications has been observed. Besides being clinically effective in diabetic nephropathy, ACEI or ARBs can improve nerve conduction deficit during peripheral DN in both animal models and human clinical studies. Furthermore, it has been suggested that ARBs are beneficial for nerve regeneration deficits in peripheral DN.6,7 Peroxisome proliferator-activated receptor-γ (PPAR-γ) is a nuclear receptor that activates cellular metabolism leading to cellular growth and differentiation,8 and improved insulin sensitivity.9 The beneficial effects of PPAR-γ ligands were demonstrated in experimental DN by suppressing the angiotensin type receptor 1 (AT1R) expression.10 The PPAR-γ ligands also have anti-inflammatory and antioxidant properties, which are known to be beneficial for microvascular complications in diabetes.9 Telmisartan (TMT) (Micardis^®) is one of the most widely used antihypertensives for diabetic patients. It is an ARB with a nephro-protective11 and neuro-protective effect against retinal inflammation.12 Recently, we reported that TMT increases the levels of neurotrophic factors, endogenous antioxidants, and reduces the signs of apoptosis efficiently in diabetic retina.13 The present study was designed to investigate the potential neuro-protective effects of TMT (Micardis^®) in a Wistar rat model of peripheral DN of streptozotocin-induced diabetes.     

Pain and motor complications in Parkinson's disease

Aims

To study the association of pain with motor complications in 117 patients with Parkinson''s disease.

Methods

Patients were asked to refer any pain they experienced at the time of study and lasting since at least 2 months. Basic parkinsonian signs and motor complications (including motor fluctuations and dyskinesia) were assessed and Unified Parkinson''s Disease Rating Scale (UPDRS) motor score part III (during on) and part IV were calculated. Information on age, sex, duration of disease, use of dopamine agonists and levodopa, years of levodopa treatment and current levodopa dosage, medical conditions possibly associated with pain, and depression were collected. Single and multiple explanatory variable logistic regression models were used to check the association of pain with the investigated variables.

Results

Pain was described by 47 patients (40%) and could be classified into dystonic (n.19) and non dystonic pain (n.16); in 12 patients both types coexisted. Multiple explanatory variable logistic regression models indicated a significant association of pain with motor complications (adjusted OR, 5.7; 95% CI, 2 to 16.5; p = 0.001). No association was found between pain, dystonic or non dystonic, and the other investigated variables including medical conditions known to be associated to pain in the general population. There was a significant correlation (r = 0.31, p<0.05) between severity of pain (measured on a Visual Analogue Scale) and severity of motor complications (UPDRS part IV).

Conclusions

Pain may be a representative feature of Parkinson''s disease frequently associated with motor complications. The association is independent of a number of potentially relevant demographic and clinical variables.Several patients with Parkinson''s disease complain of painful sensations that can be described in different categories.^{1,2,3,4,5,6,7} These include dystonic spasm‐associated pain and non‐dystonic pain such as musculoskeletal or rheumatic pain, neuritic or radicular pain, primary or central pain, and akathitic discomfort.^8,9 The suggested involvement of basal ganglia in the modulation of somatosensory function is thought to account for pain in Parkinson''s disease.¹⁰ Nevertheless, the response of pain to levodopa is uncertain: whereas some studies reported that treatment for Parkinson''s disease was sometimes effective in relieving pain in patients with Parkinson''s disease,^4,5 other studies failed to find any correlation between motor symptoms, drugs against Parkinson''s disease and pain.^11,12 In some cases, dopaminergic drugs even aggravated pain.⁴Those designing strategies to prevent or cure pain in patients with Parkinson''s disease should consider the possible pathogenetic mechanisms and potential risk factors. The few studies considering these issues described a higher frequency of fluctuations in motor function and end or peak of dose dyskinesia among patients with Parkinson''s disease experiencing pain, and suggested a relationship between some pain categories and motor complications.^5,7In this study, we evaluated the association of pain with motor complications, taking into account possible confounding by demographic and clinical variables related to Parkinson''s disease and medical conditions associated with painful symptoms.