Histopathological features of breast cancer in Al-Madinah region of Saudi Arabia

Objectives:

To observe the frequency of breast cancer among Saudi patients and to highlight the age variations and features of advanced cancer.

Methods:

A retrospective study of breast cancer biopsies from all Saudi patients performed between January 2006 and December 2013 in King Fahad Hospital, Al-Madinah, Kingdom of Saudi Arabia. All the available demographic and tumor related data was analyzed.

Results:

Of 1005 breast tissues reviewed, 982 specimens were from female, and 23 from male patients. In females, 398 specimens (40.5%) were diagnosed as malignant. Invasive ductal carcinoma (IDC) (85.2%) was most common, followed by ductal carcinoma in situ (8%), and invasive lobular carcinoma (2.7%). The mean age of Saudi females with IDC was 46.9 years. Approximately 48.7% IDC were Grade III tumors. A tumor size >2.5 cm was found in 61.1% patients, whereas axillary nodal metastasis was present in 57.1% and lymphovascular invasion in 64.1% who underwent axillary nodal dissection. In males, 4 specimens (17.4%) were malignant (all IDC).

Conclusion:

Our finding are consistent with previous reports of breast cancer being diagnosed in younger age group, in advanced stages, and with features of aggressive behavior; which signals the urgency for implementation of breast screening programs.Breast cancer (BC) is the second most common cancer in the world, and most frequent cancer among women with an estimated 1.67 million new cancer cases diagnosed in 2012 (25% of all cancers).1 As reported by GLOBOCAN,1 in both, the less developed (883,000 cases) and the more developed regions (794,000 cases), it is the most common cancer in women. The American Cancer Society estimated 232,340 new cases of invasive BC in women, and approximately 2,240 new cases among men in the US during 2013.2 In the United Kingdom (UK), BC mortality is however, the second to lung cancer, accounting for 11,684 deaths in 2011.3 In the Kingdom of Saudi Arabia (KSA), BC is most prevalent cancer in Saudi females as reported in Saudi Tumour Registry Report 2012.4 In 2008, previous study3 from Jeddah, KSA compared the cancer statistics for the KSA and USA; with the aim to study the future cancer burden in Saudi Arabia. They concluded that the cancer rates demonstrate a considerable increase and enormous demands on healthcare resources, in the future.5 Al Diab et al,6 reported 80 articles on BC from KSA. They concluded that it is most common in the Central region of KSA, and least common in the Northern region, with Eastern, Western, and Southern regions falling in the middle.6 In our present, hospital based, retrospective study, we cited and compared similar recent studies from around the world; such as from India,7,8 Nigeria,9 Pakistan,10 and Yemen.11 The KSA medical literature also has a number of similar relevant hospital based studies available for comparison.12-15 There is however, only one article in the local literature for hospital-based cancer data for Al-Madinah, which was carried out almost 20 years back.16 Although there has been some very recent hospital-based research publications from Al-Madinah; these articles have reported general disease patterns and cancers in many different organs such as large bowel,17,18 prostate,19 lymph nodes,20 and thyroid,21 but no data is available for this common and important disease, namely BC. We will be investigating this important problem of BC in the rapidly growing and advancing region of Al-Madinah; based on the histopathology diagnosis of biopsies and mastectomies/axillary dissections performed in the local population; and compare our data with previous international and national studies.     

Adherence to the American Diabetes Association standards of care among patients with type 2 diabetes in primary care in Saudi Arabia

Objectives:

To assess adherence to 11 American Diabetes Association (ADA) standards of diabetic care.

Methods:

We conducted this one-year historical prospective study between October 2010 and September 2011 on 450 adult type 2 diabetes patients in a primary care center in Saudi Arabia. We used the definitions of the 2010 ADA standards of diabetic care processes and targets.

Results:

Four-hundred and fifty medical files were valid. The adherence to ADA process standards of measurement of glycated hemoglobin (HbA1c) was 68.7%, 92.9% for blood pressure, and 80.2% for serum lipids. Screening was lowest for nephropathy (35.6%), and highest for diabetic foot (72%). Adherence to medications ranged between 82.2% for antiplatelets, and 92.4% for dyslipidemia. For outcome standards, 24.2% of the patients had an HbA1c <7%, and 32.2% had controlled blood pressure (<130/80 mm Hg); and 58.5% achieved targeted low-density lipoproteins (LDL). Only 7.2% had glycemic control in addition to controlled blood pressure and targeted LDL level. An increasing trend of patients achieving glycemic control (<7%) was shown throughout follow-up (p=0.003).

Conclusions:

We found suboptimal adherence with many ADA standards of diabetic care among patients with type 2 diabetes treated at a primary care center in Saudi Arabia. The achievement of outcome standards, either singly or combined, is lower than the adherence rates. However, the figures show improvement in adherence during the follow-up period.Diabetes mellitus is a chronic disease that can cause devastating secondary complications, reducing the quality and length of life as well as increasing medical costs for the patient and society.1-3 Saudi Arabia has one of the highest diabetes prevalence rates worldwide. The International Diabetes Federation estimates that 8.3% of the world’s adult population (20-79 years) have diabetes, with Saudi Arabia one of the top countries affected (20%).4 Additionally, a national study estimated the overall prevalence of diabetes in Saudis aged 30-70 years at 23.7% (26.7% in women, and 21.5% in men).5Diabetes care is a complex process requiring ongoing patient self-management, education, and support to prevent acute complications, and to reduce the risk of long-term complications.6 Compelling evidence from clinical trials shows that intensive glycemic control effectively delays the onset and slows the progression of diabetic complications, such as nephropathy, retinopathy, and neuropathy.7-9 Likewise, substantial evidence shows that control of associated risk factors such as hypertension and dyslipidemia is protective against undesirable outcomes in patients with diabetes.10-14 The American Diabetes Association (ADA) put together a set of diabetic care standards that are annually revised.15 However, despite the availability of convincing evidence and clear guidelines, many studies throughout the world reported suboptimal adherence to diabetic care standards.16-19 Only a few studies have examined the quality of diabetic care among Saudi patients in a primary care setting,20 outpatient clinics of internal medicine,21,22 and specialized diabetic care centers.23 These studies covered one or more of the screening, diagnostic, and therapeutic components of the ADA standards of diabetic care. However, the extent to which these standards are met at primary care settings was not comprehensively studied. Moreover, the degree to which multiple ADA processes and outcomes are simultaneously achieved was also not studied. Therefore, we aimed to assess the adherence of primary care patients to 11 ADA standards of diabetic care including glycemic control, blood pressure control, and lipid management, singly and combined.     

Prevalence of intimate partner violence and its associated risk factors among Saudi female patients attending the primary healthcare centers in Western Saudi Arabia

Objectives:

To estimate the prevalence of intimate partner violence (IPV) among female patients, age 18-60 years, attending primary health care centers (PHCCs) and to measure its determinants, and reporting behavior.

Methods:

A cross-sectional study design using validated, translated, and self-administered questionnaire among 497 Saudi female patients attending PHCCs in Taif, Kingdom of Saudi Arabia (KSA) from January to February 2015 was employed. A 2-stage probability sampling was adopted for selection of PHCCs in the first stage, and then participants in the second stage.

Results:

The estimated prevalence of IPV during the last year was 11.9%. Predictors of IPV related to abused women included divorced status and divorced parents; while those related to abusers (husbands) included widowed parents, exposure to violence in childhood, and alcohol or drugs addiction. Most of the abused wives (56%) talked regarding their IPV to their families, their husbands’ families (15.2%), or their friends (11.8%); while only a minority (3.3%) complained to the police or to a judge, and no one reported this to a family physician, or to women protection agency.

Conclusion:

One out of 10 women is a victim of IPV in Taif, KSA. Intimate partner violence is significantly associated with a number of victim and abuser-related psychosocial factors, the detection of which might help screening for individuals at risk.Intimate partner violence (IPV) is defined as any behavior within an intimate relationship that causes physical, sexual, or psychological harm. The present study examines IPV within the context of marriage,1 and focuses only on physical and psychological violence. Sexual violence, which is an important type of IPV was not assessed due to the sensitivity of the issue, and the expectation that there would be few instances to be reported. Intimate partner violence has major short- and long-term social, mental, and physical wellness effects.2 Nationwide surveys in Canada and the United Kingdom found that approximately 25% of women experienced IPV.3 In some Arab countries, IPV is still not properly investigated despite its relatively high prevalence.4 It is difficult to calculate the financial burden of IPV on the health system,5 but some studies estimate the cost to be from 1.7 - 10 billion US$ per year in the US,6 and approximately 400 million Swiss Francs in Switzerland.7 Many risk factors are associated with IPV, such as young age, low socioeconomic status, marital conflicts, a past history of violence in childhood, alcohol and drug addictions,1,6 disempowerment of women, stress, and jealousy.1 Intimate partner violence is a significant public health issue that is associated with serious health outcomes, including depression, suicide attempts, and death.1 Eldoseri8 conducted a cross-sectional study in Jeddah, Kingdom of Saudi Arabia (KSA) and interviewed women attending the primary health care centers (PHCCs), found that the prevalence of physical IPV was 45.5% that was significantly associated with husbands having alcohol or drug addictions, exposure to violence during childhood, and unemployment status. Al-Faris et al9 conducted a study in Riyadh, KSA on 222 women at a teaching hospital and found that 12.2% of them experienced lifetime physical abuse, which was significantly associated with unemployment, past exposure to violence, and living in rented houses. In Iraq, Al-Atrushi et al10 conducted a cross-sectional study at 2 community hospitals and found 58% of visiting women experienced lifetime IPV with physical violence accounting for 38.9%, and sexual violence accounting for 21.1% of the IPV. Due to the discrepancy in the prevalence rate of IPV across the country, a common simple measure is needed to assess and compare IPV in future studies. Therefore, the current study was conducted to measure IPV and its associated risk factors among female patients attending PHCCs in Taif, KSA, and to assess wives’ reporting behavior.     

High prevalence of iron deficiency anemia in infants attending a well-baby clinic in northwestern Saudi Arabia

Objectives:

To determine the prevalence of iron deficiency anemia (IDA) in infants aged 6-24 months attending the well-baby clinic in primary health care centers (PHCCs).

Methods:

This cross-sectional epidemiological study was conducted in the Northwestern region of Saudi Arabia from April 2013 to January 2014 in 5 randomly selected PHCCs. The sample size comprised 500 infants, with 100 infants screened from each PHC. Blood samples were obtained for estimation of hemoglobin and serum ferritin levels.

Results:

Out of 500 infants, 246 (49%) cases had IDA with a mean age of 15.4 ± 6.5 months, with 130 (53%) males, and 116 (47%) females (p=0367). Out of 274 Saudi infants, 126 (51%) cases were diagnosed as IDA.

Conclusion:

Iron deficiency anemia is very common in Saudi infants aged 6-24 months. A national program directed for primary prevention and early discovery of IDA in Saudi infants is recommended at PHCCs system. Iron supplementation is to be given at early infancy with universal screening of hemoglobin and ferritin estimation to all infants at 12 months of age.Iron deficiency anemia (IDA) is one of the most serious public health issues in developing countries, with 25% of the world population are affected by IDA.1 The population group at risk are infants from 4-24 months, school aged children, female adolescents, pregnant women, and nursing mothers.1 It is the common national problem throughout the world.2 This national problem continues to be a worldwide concern as iron deficiency (ID) without anemia leads to long term neurodevelopment and behavior disorders that may be irreversible.2-4 Iron is essential for intact development of the baby, especially for the development of central nervous system in the first 2 years of life. Iron deficiency anemia adversely affects the central nervous functions resulting in delay in cognitive development.5 Studies have shown large variations in the prevalence of IDA among developed countries (1-8%).6-8 A high prevalence of IDA (30-51%) has been reported in developing countries.9,10 The reported incidence in some Arab countries was 72% among infants.11 Al Hifzi et al12 reported that 52% of infants in the Kingdom of Saudi Arabia (KSA) attending well-baby clinics had IDA. For this global health problems, the American Academy of Pediatrics recommends universal screening with hemoglobin determination for IDA at one year of age.13 As the previous study in KSA showed a very high prevalence of IDA,12 and as KSA currently has undergone progressive development in many areas, the objective of this study was to determine the current prevalence of IDA, and to indicate whether this prevalence has decreased of these development, despite the lack of a national preventive program, which would recommend routine iron supplementation in all Saudi infants. Our aim is also to raise awareness of the Ministry of Health in KSA of this common problem, which requires national preventive measures to control help control the serious impact of this health issue.     

A cross-sectional study of anxiety and marital quality among women with breast cancer at a university clinic in western Saudi Arabia

Objectives:

To examine relationship between the quality of marital relationship and anxiety among women with breast cancer (BC) in the Kingdom of Saudi Arabia (KSA).

Methods:

This cross-sectional study recruited a consecutive series of 49 married women with BC seen in the Al-Amoudi Breast Cancer Center of Excellence at King Abdulaziz University, Jeddah, KSA in early 2013. Participants completed the Hospital Anxiety and Depression Scale, Spouse Perception Scale, and Quality of Marriage Index forms, and answered questions on demographic and cancer characteristics.

Results:

Anxiety symptoms indicating “possible” anxiety disorder were present in 10.4% and “probable” anxiety disorder in 14.6% (25% total). No significant relationship was found between the quality of marital relationship and anxiety symptoms (B=-0.04, standard error=0.05, t=-0.81, p=0.42). Anxiety was primarily driven by low education, poor socioeconomic status, and young age.

Conclusion:

Anxiety symptoms are prevalent among married women with BC seen in a university-based clinic in the KSA. Further research is needed to determine whether a diagnosis of BC adversely affects marital relationship, and whether this is the cause for anxiety in these women.Breast cancer (BC) is the most common cause of cancer death in women worldwide,1 and the Kingdom of Saudi Arabia (KSA) is no exception.2 Breast cancer has become a particular problem in Arab countries due to its late stage at presentation and its increased occurrence among young women.3 Both during and after treatment, even if the cancer goes into remission, concerns regarding recurrence, effect on the marital relationship, and frequent medical visits for monitoring, often result in high levels of anxiety (including post-traumatic stress-like symptoms).4-8 Anxiety and other mood symptoms are not benign in women with BC, as they are associated with increased mortality and cancer recurrence.9,10Studies in Western countries (United States, Canada, England, Australia, and Germany) indicate a prevalence of significant anxiety ranging from 4-45% in BC patients, depending on anxiety measure, cutoff score, geographical region, and time since diagnosis11-14 (compared with 15-37% of cancer patients in general with anxiety during the first year after diagnosis).15 The most commonly used measure of anxiety symptoms in BC patients is the Hospital Anxiety and Depression Scale (HADS), which assesses for “possible” and “probable” anxiety disorder (with a sensitivity and specificity of approximately 80%).12,16,17 Using this measure, the prevalence of “probable” anxiety disorder in BC patients ranges from 2-23% and “possible” anxiety disorder is present in an additional 19-22% (21-45% combined).11,13,18 Although factors that increase risk of anxiety in women with BC are poorly understood, a few studies largely from Western countries report more symptoms in younger persons and Caucasians, immigrants, those with lower education, later disease stage, and lower social support.8,11,13,19 In one of the few studies from an Eastern country,20 anxiety levels among BC patients from Bangkok, Thailand, were significantly higher among those with poor problem solving skills, more pain and fatigue, and poorer family functioning. Although research is limited almost entirely to the US and other Western countries, studies indicate that support from a spouse (especially emotional support) improves the adjustment of women to BC,21-25 and may even impact survival.26 Not all studies, however, report that having a marital partner buffers against the stress of BC.27,28 The demands of caregiving, the effects of BC and its treatments on sexual relationship, and coping with psychological changes in a BC patient can all lead to lower well-being in a spouse, and decrease his ability to provide support.24 Our exhaustive review of the literature uncovered several studies that have examined the prevalence of emotional reactions to BC in the Middle East, finding that 19-73% of women had significant anxiety symptoms.22,29-34 In those studies, anxiety was associated with poorer physical functioning, the presence of metastatic disease, higher education, lower social support, duration of marriage, and spouse’s level of anxiety. With regard to KSA, there has been a significant increase in the incidence of BC, which occurs at a younger age than in Western countries.35 A recent review of research on coping with BC, however, revealed not a single study from KSA.36 Our review identified only 2 studies37,38 that examined the prevalence or correlates of anxiety in Saudi cancer patients (none specifically in BC), and only one study39 that examined attitudes of Saudi males toward BC. The first study examined anxiety in 30 hospitalized patients with cancer (9 with BC) at the King Khalid National Guard Hospital in Jeddah, KSA.37 Researchers found that anxiety symptoms assessed by the Hamilton Anxiety Scale were significantly higher in cancer patients compared with 39 patients with a range of chronic illnesses; 3 patients with cancer (10%) had a clinical diagnosis of generalized anxiety disorder based on Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria. The second study examined non-pain symptoms in 124 cancer patients (27% with BC) at King Faisal Specialist Hospital in Riyadh, KSA.38 The most frequently reported non-pain symptoms were fatigue (80%), loss of appetite (72%), dry mouth (69%), and anxiety (61%). Finally, researchers examined attitudes toward BC among males accompanying female patients to outpatient clinics at King Abdulaziz Hospital in Jeddah, KSA. When men were asked what they would do if their wives were diagnosed with BC, 9.4% said they would leave their wives.39Given the current knowledge gap on this subject in KSA, we decided to: 1) determine the prevalence of anxiety symptoms in married women seen in an urban-based university outpatient clinic in Jeddah; 2) identify the correlates of anxiety symptoms (especially marital quality [MQ]); and 3) determine whether the relationship between MQ and anxiety differed between Saudi nationals and immigrants. We hypothesized that anxiety symptoms would be prevalent, that higher MQ would be strongly and inversely related to anxiety symptoms, and that this relationship would be particularly strong in women who were Saudi nationals (where cultural factors might have the most influence).     

The preparedness of private dental offices and polyclinics for medical emergencies: A survey in Western Saudi Arabia

Objectives:

To assess preparedness for medical emergencies in private dental offices in Jeddah, Kingdom of Saudi Arabia (KSA).

Methods:

In this cross-sectional study, a survey was distributed to 70 dental offices and polyclinics in Jeddah, Saudi Arabia between October 2013 and January 2014. The questionnaire gathered information on the prevention of medical emergencies, the preparedness of the office personnel, and availability of emergency drugs and equipment.

Results:

For prevention, 92% (n=65) of the offices reported that they obtain a thorough medical history prior to treatment; however, only 11% (n=8) obtain vital signs for each visit. Using a preparedness percent score (0 to 100), the mean level of preparedness of the office personnel in all surveyed dental offices was 55.2±20. The availability of emergency drugs was 35±35, and equipment was 19±22.

Conclusion:

We found a deficiency in personnel training, availability of drugs, and emergency equipment in the surveyed dental clinics. More stringent rules and regulations for emergency preparedness must be reinforced to avoid disasters in these clinics.Although uncommon, medical emergencies can occur at anytime in the dental office, possibly posing a direct threat to the patient’s life, and hindering the delivery of dental care.1,2 The prevalence, and severity of medical emergencies has been reported in various dental settings (academic or private) in many countries.3-5 In one 10-year survey study in Great Britain, an emergency event was reported, on average occurring with an average frequency of between one in 3.6-4.5 practice years.6 In a study published in 2009, Wilson et al7 found that the most prevalent medical emergency reported by dentists over a 12 month period was syncope (1.9 cases per year), followed by angina and hypoglycemia (0.17 per year), and epileptic fit (0.13 cases per year).7 Preparedness for acute medical emergencies in the dental office begins with a team approach by the dentist and staff members who have up-to date certification in basic life support (BLS) for health care providers. It also includes dentist and personnel training through mock drills and continuing education courses, a medical emergency protocol, availability of an emergency drug kit, and proper emergency equipment.8,9 The preparedness of dental offices was addressed through questionnaires for studies from different countries where a general consensus was reached for the need for continuous training and more stringent guidelines for medical emergencies.7,10 In the Kingdom of Saudi Arabia (KSA), there is a reported high prevalence of diabetes, obesity, and hypertension,11-13 all of which may contribute to a higher occurrence of medical emergencies in the dental office. A current literature search using the Medline and PubMed databases (from 1990-2014), revealed that there is a scarcity of published data on the prevalence, types, or severity of medical emergency events in government dental clinics, dental schools, or private dental practice. Additionally, no data could be found assessing the preparedness of private dental offices for medical emergencies in KSA. The Ministry of Health (MOH) in KSA oversees the licensing and operation of private dental clinics and polyclinics. It does not mandate that private dental offices have a specific emergency protocol, emergency drugs, or equipment. The objective of our study was to assess the preparedness and training of the office personnel, and availability of emergency drugs, and emergency equipment in a sample of private dental practices and polyclinics in Jeddah, KSA.     

Stress,shift duty,and eating behavior among nurses in Central Saudi Arabia

Objectives:

To investigate the association between stress, shift work, and eating behavior among non-Saudi female nurses working in Central Saudi Arabia.

Methods:

A sample of 395 non-Saudi female nurses from 2 major hospitals in Riyadh, Kingdom of Saudi Arabia participated in this cross-sectional study. The nurses completed a questionnaire from November 2013 to January 2014 that included items relating to stress and eating behavior using the Dutch Eating Behavior Questionnaire (DEBQ). The questionnaire also contained items pertaining to socio-demographic data, body mass index, shift work, and hours worked per week.

Results:

For all eating styles, stress, and shift duty influenced the amount of food nurses consumed, but was more significant under a restrained eating style. Under this eating style, a significantly higher percentage of nurses reported eating more fast food, snacks, and binging, while fruits and vegetables were the least likely to be eaten under stress. High stressed nurses were more likely to present with abnormal restrained eating (odds ratio [OR]=1.52, p=0.004), emotional (OR=1.24; p=0.001), and external (OR=1.21; p=0.001) DEBQ scores. Working nighttime shift duty was positively associated with restrained eating (OR=1.53; p=0.029) and emotional eating (OR=1.24; p=0.001), but negatively associated with external eating (OR=0.45; p=0.001).

Conclusion:

Our findings suggest that stress and shift duty were associated with eating habits.Kingdom of Saudi Arabia (KSA) has committed enormous resources to improving health care, with the ultimate goal of providing free and accessible health care services. The Kingdom currently faces a chronic shortage of local nurses. In 2013, Saudi nurses comprised 25% of the total nurse workforce.1 This shortage, as well as the expansion in public and private health care sectors, has contributed to an increased demand for expatriate nurses from different countries. For example, nurses come from over 40 different countries, including the Philippines, Sudan, United Kingdom, Ireland, India, and USA.2,3 Stress and shift work are both factors that influence nurses’ eating behavior. The mechanism through which stress influences food choices involves hormonal interactions and metabolic processes, as well as individual differences in psychological and neurochemical response to stress and eating.4,5 Stress is associated with reduced levels of insulin and leptin, which interact to bring about changes in appetite. Stress elicits a more passive response driven by the hypothalamic pituitary adrenal, with an increase in cortisol that may entice people to consume hedonic, energy-dense foods and potentially lead to unwanted weight gain and obesity.5-7 Research has indicated that work-related stress induces consumption of foods that are high in sugar, fat, and salt, and a decrease in the consumption of fruits, vegetables, and fiber.8-11 Emotional eating under stress was associated with a higher intake of sweets and negatively associated with fruit and vegetable intake, and it was found to occur in people with poor coping skills, poor interceptive awareness, and high alexithymia.12-15 Restrained eaters ate more than usual or binged under stress and increased their intake of fatty and sugary foods. External eating under stress was found to have gender differences in subjects’ reports of food choices. In women, sweet foods emerged as important when compared with men. In laboratory and survey studies,16-18 restrained eaters consistently showed hyperphagia; sweets and chocolate, cake and biscuits, and savory snacks were reported to be eaten more under stress. Food choices leaned toward more high energy-dense, snack-type foods. Recent studies19,20 have identified shift work as a major source of stress. Several studies9,21,22 have shown that this affects the circadian distribution of food, regularity of meals, and the number of meals eaten during the different shifts. These studies9,19,22 have demonstrated a higher total energy intake among night nurses than day nurses and reduced consumption of dietary fibers, primarily due to a reduction in the consumption of green vegetables and in increase in sucrose resulting from higher intake of soft drinks, snacks, or limited food choices. This study examined the associations among stress, shift work, and eating behavior among non-Saudi female nurses in Riyadh, KSA.     

Frequency and associated risk factors of recurrent diabetic ketoacidosis among Saudi adolescents with type 1 diabetes mellitus

Objectives:

To explore the frequency and associated risk factors of recurrent diabetic ketoacidosis (RDKA) among Saudi adolescents with type 1 diabetes mellitus (T1DM).

Methods:

A cross-sectional study was conducted among 103 T1DM adolescents (aged 13-18 years, 57 males) who were hospitalized for diabetic ketoacidosis (DKA) between January 2013 and May 2014 at Prince Sultan Military Medical City (PSMMC), Riyadh, Kingdom of Saudi Arabia. The respondents were purposively, conveniently selected, and interviewed using a structured Arabic questionnaire including clinical information and demographics.

Results:

Fifty-six participants had experienced one episode of DKA, 41 had 2 episodes, and 6 had ≥3 episodes. Compared with adolescents who had hemoglobin A1c (HbA1c) ≤9, mean difference in RDKA was found among adolescents with >9 HbA1c. Similarly, adolescents who stopped insulin and those with lipodystrophy at the injection site had a higher frequency of RDKA. Discontinuing insulin (67%) was the major reason for RDKA followed by infection (31%). Among adolescents who discontinued insulin treatment, 31 (46.3%) gave no reason for stopping, 25 (37.3%) reported feeling sick, 7 (10.4%) gave a combination of reasons, and 4 (6%) reported a lack of supplies or other reasons. Regression analysis revealed that a higher HbA1c level and the presence of lipodystrophy were independent risk factors for RDKA.

Conclusion:

The frequency of RDKA was significantly greater in the T1DM adolescents with a higher HbA1c level, lipodystrophy, and those who had discontinued insulin treatment. Comprehensive multidisciplinary diabetes education should be offered to control modifiable risk factors in these patients.According to the latest report by the International Diabetes Federation, Saudi Arabia is listed as third among the top 10 countries with the highest prevalence rates of diabetes (3.6 million cases of diabetes).1 While type 2 diabetes dominates in great numbers, type 1 diabetes mellitus (T1DM) remains an imperative issue. Over the last 3 decades, the incidence rate of T1DM is growing in Saudi Arabia,2 and the prevalence of T1DM in Saudi Arabian children and adolescents is 109.5 per 100,000.3 It is well established that adolescents diagnosed with T1DM, face several lifestyle changes and the risk of facing debilitating and life-threatening complications, such as diabetic ketoacidosis (DKA).4,5 Diabetic ketoacidosis is a recurrent problem with acute complications and is the most common cause of death in adolescents with T1DM.5,6Diabetic ketoacidosis is an acute metabolic complication of diabetes characterized by the triad of hyperglycemia, acidosis, and ketosis that take place in the presence of very low levels of effective insulin action.7 In some cases, DKA may be the first indication of previously undiagnosed diabetes, but it may often occur in those who already have diabetes as a result of a variety of causes, such as poor compliance with insulin therapy.8,9 Further, studies stated that infection is the important precipitating cause for DKA worldwide, occurring in 30-50% of cases. Vomiting, dehydration, confusion, deep gasping breathing, and occasionally coma are typical symptoms of DKA. Many studies reported that DKA is the leading cause of mortality in children with T1DM, and is associated with increased morbidity and health care expenditure.10,11 Longitudinal studies also indicate that 20% of pediatric patients account for 80% of all admissions for DKA, and the incidence of DKA peaks during the adolescent period.12Research shows that recurrent diabetic ketoacidosis (RDKA) rates are dependent on medical services and socioeconomic circumstances of the adolescents.13 Effective treatment of DKA requires frequent monitoring of patients, replacement of electrolyte losses, modification of hypovolemia and hyperglycemia, and careful search for the precipitating cause. As most DKA cases occur in patients with a known history of diabetes, this acute metabolic complication can be preventable by the education of patients, healthcare professionals, and the general public and frequent self measured blood glucose.14,15Compared with the developed countries, the dearth of research currently available on the frequency, associated risk factors of RDKA, as well as the socio-demographic properties of RDKA certainly warrants concern, particularly the lack of appropriate studies in this specified area in Saudi Arabia. Hence, we conducted this study to investigate the frequency and associated risk factors of RDKA among Saudi adolescents with T1DM.     

Sentinel lymph node biopsy in breast cancer

Objectives:

To report our experience in sentinel lymph node biopsy (SLNB) in early breast cancer.

Methods:

This is a retrospective study conducted at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia between January 2005 and December 2014. There were 120 patients who underwent SLNB with frozen section examination. Data collected included the characteristics of patients, index tumor, and sentinel node (SN), SLNB results, axillary recurrence rate and SLNB morbidity.

Results:

There were 120 patients who had 123 cancers. Sentinel node was identified in 117 patients having 120 tumors (97.6% success rate). No SN was found intraoperatively in 3 patients. Frozen section results showed that 95 patients were SN negative, those patients had no immediate axillary lymph node dissection (ALND), whereas 25 patients were SN positive and subsequently had immediate ALND. Upon further examination of the 95 negative SN’s by hematoxylin & eosin (H&E) and immunohistochemical staining for doubtful H&E cases, 10 turned out to have micrometastases (6 had delayed ALND and 4 had no further axillary surgery). Median follow up of patients was 35.5 months and the mean was 38.8 months. There was one axillary recurrence observed in the SN negative group. The morbidity of SLNB was minimal.

Conclusion:

The obtainable results from our local experience in SLNB in breast cancer, concur with that seen in published similar literature in particular the axillary failure rate. Sentinel lymph node biopsy resulted in minimal morbidity.Breast cancer (BC) is the top cancer in women both in the developed and developing world.1 In the USA, nearly 230,000 BCs are diagnosed annually.2 The population of Kingdom of Saudi Arabia (KSA) is approximately 30 million, 65% of them are below the age of 30.3 In KSA, the total number of patients diagnosed to have BC in the year 2010 was 1,473 patients, which constituted 27.4% of all newly diagnosed female cancers in the year 2010. The Age Standardized Rate was 24.9/100,000 for female population. The median age at diagnosis was 49 years. More than half of BC patients in KSA presented with locoregional or distant disease.4 In KSA, there is no national screening program for BC and the Saudi Cancer Registry does not include ductal carcinoma in situ (DCIS) cases in their capture form, which may explain the low number of DCIS cases reported from local centers. It is clear that, KSA is among countries with low disease burden, but it is expected that this burden will increase in the years to come.5 Axillary lymph node status is considered the most important prognostic factor for patients with BC, and it participates largely in the decision regarding subsequent adjuvant systemic treatment.6,7 Axillary lymph node dissection (ALND) for patients with BC was introduced more than 200 years ago for staging and local control.8,9 It is associated with an increase risk of adverse outcomes, including lymphedema in 14% of cases, limited shoulder motion in 28% of the cases and neuropathic pain in 31% of the cases.10 The therapeutic advantage of removing negative nodes with respect to axillary control and survival remains questionable.11-14 At the present time, most BC patients receive some sort of adjuvant systemic therapy irrespective of their lymph node status.15 Based on that, minimally invasive procedures for staging the axilla have been introduced. Sentinel lymph node biopsy (SLNB) in BC, a minimally invasive procedure, was first described in 1994.16 Since then, it has been widely practiced with a wide literature to support its reliability for ascertaining the status of the axillary lymph nodes. Currently, SLNB is accepted as the standard of care for axillary staging in early BC.17-19 In this paper, we are documenting the beginning, development, results and follow up of patients who underwent SLNB for BC at King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia.     

Knowledge of Saudi female university students regarding cervical cancer and acceptance of the human papilloma virus vaccine

Objectives:

To assess the level of knowledge regarding cervical cancer and the acceptance of the human papilloma virus (HPV) vaccine among Saudi female students in health colleges.

Methods:

This cross-sectional study of a convenient sample encompassed 1400 students in Health Colleges at Princess Nora Bint Abdul Rahman University, Riyadh, Saudi Arabia was conducted between December 2013 and February 2014. A self-administrated questionnaire was distributed to all participants. Data collected included socio-demographic data, knowledge of cervical cancer risk factors and clinical presentation, Pap smear, and HPV vaccine acceptance. The questionnaire reliability as tested by Cronbach’s alpha was 0.82.

Results:

The response rate was 89.9%, and data analysis revealed that 95.7% of students had poor knowledge level. The Pap smear was poorly recognized as a screening tool, with 46.7% of students having heard of the test. Senior and medical students had a significantly higher knowledge score. Father’s health profession, high monthly income, and presence of cervical cancer among family members or friends increased the level of knowledge. Vaccine acceptance is influenced by its price, approximately 80% of students thought that an affordable vaccine price should not exceed 300 Saudi Riyals. Perceived barriers to the vaccine were fear of injections and vaccine side effects.

Conclusion:

There is a lack of knowledge and misinformation regarding cervical cancer, Pap smear, and HPV as a major risk factor for cancer of the cervix. These data can be used as a benchmark to formulate effective awareness programs.Cancer of the cervix uteri is a frequent cancer affecting women, and is a leading cause of mortality worldwide.1 The highest incidence rates have been reported from sub-Saharan Africa, Central and South America, Southeast Asia, and Brazil. In contrast, the incidence rates were the lowest in the Middle East, particularly among Muslims and Jews, as compared to other religious groups.2,3 In the Kingdom of Saudi Arabia, carcinoma of the cervix uteri accounts for 2.6% of female cancers, and is ranked ninth among all carcinomas affecting Saudi females.4 The pathogenesis of cervical cancer in Muslim countries might be different from that of Western societies because of differences in cultural and religious factors that influence human behavior, and reduce the risk of exposure to cervical cancer.4-7 Among all known risk factors, persistent infection with high-risk human papillomavirus (HPV) plays a considerable role in the pathogenesis of cervical cancer.8-11 The worldwide HPV prevalence in cervical cancer was estimated to be between 85-99%.10,12 The HPVs are grouped according to their association with cervical cancer and their genomic sequence into oncogenic high, probable high, and non-oncogenic low-risk.11-14 The strong association of oncogenic HPV infection and the development of cervical cancer provides an opportunity for primary prevention through prophylactic vaccination. Human papillomavirus vaccines (bivalent and quadrivalent) have been shown to be immunogenic, safe, and highly effective in preventing chronic infection and precancerous lesions in women.15,16 The vaccine is available in the KSA market, but national campaigns to vaccinate females are not launched yet.Cytological screening based on Pap smear plays a major role in reducing both the incidence and mortality of invasive cervical cancer. In the USA and Canada, the reduction in the incidence of cervical cancer and the subsequent reduction of female mortality rate was attributed to the widespread introduction of the Pap smear screening program as a secondary preventive measure for early detection of cases.17-19 However, in Saudi Arabia, most cases present at advanced stages that require extensive chemoradiation therapy. This might be due to lack of proper screening programs,20,21 and inadequate knowledge among the target population. Noteworthy, most female cancer awareness campaigns in KSA are mainly focused on breast cancer. Appropriate level of knowledge, attitude, and beliefs are key elements for adopting a healthy lifestyle, influencing human behaviors, and accepting newly introduced preventive measures. Concerning cervical cancer, the gap of knowledge of clinical presentation, risk factors, primary and secondary prevention has been documented in several studies both in developed and developing countries.22-24 However, few studies have been reported from Saudi Arabia. The present study was designed to assess the level of knowledge and beliefs regarding cervical cancer, and the acceptance of the HPV vaccine among Saudi university students enrolled in health colleges because of their important role as health care providers to raise community awareness and to modify population behavior.     

Road safety and road traffic accidents in Saudi Arabia: A systematic review of existing evidence

Objectives:

To identify the changing trends and crucial preventive approaches to road traffic accidents (RTAs) adopted in the Kingdom of Saudi Arabia (KSA) over the last 2.5 decades, and to analyze aspects previously overlooked.

Methods:

This systematic review was based on evidence of RTAs in KSA. All articles published during the last 25 years on road traffic accident in KSA were analyzed. This study was carried out from December 2013 to May 2014 in the Department of Family and Community Medicine, Taibah University, Al-Madinah Al-Munawwarah, KSA.

Results:

Road traffic accidents accounted for 83.4% of all trauma admissions in 1984-1989, and no such overall trend was studied thereafter. The most frequently injured body regions as reported in the latest studies were head and neck, followed by upper and lower extremities, which was found to be opposite to that of the studies reported earlier. Hospital data showed an 8% non-significant increase in road accident mortalities in contrast to police records of a 27% significant reduction during the years 2005-2010. Excessive speeding was the most common cause reported in all recent and past studies.

Conclusion:

Disparity was common in the type of reporting of RTAs, outcome measures, and possible causes over a period of 2.5 decade. All research exclusively looked into the drivers’ faults. A sentinel surveillance of road crashes should be kept in place in the secondary and tertiary care hospitals for all regions of KSA.The burden of road traffic accidents (RTA) is a leading cause of all trauma admissions in hospitals worldwide.1 According to the World Health Report (WHR) in 2010,2 road traffic injuries (RTI) have been identified as the ninth most common cause of disability adjusted life years (DALYs) lost for all age and gender categories. The World Health Organization (WHO) reported that 1.24 million people were killed on the road, and up to 50 million people were injured worldwide, and the number of road traffic deaths is expected to increase further by 2020.3,4 Nearly three-quarters of overall road deaths occur in developing countries, although road deaths are common in developed countries. Road traffic fatality in the Kingdom of Saudi Arabia (KSA) accounts for 4.7% of all mortalities, while road traffic fatalities do not exceed 1.7% in Australia, United Kingdom (UK), or United States of America (USA).5 Similarly, road fatalities in KSA have increased over the last decade from 17.4-24 per 100,000 population compared with 10 in USA, and 5 in UK, where road safety has been taken seriously, and all primary and secondary preventive measures are implemented appropriately.6 Saudi Arabia was found to have higher number of deaths from RTAs among high income states (accident to death ratio is 32:1 versus 283:1 in USA), and is considered to be the country’s main cause of death for 16-30-year-old males.7 Road injuries are reported to be the most serious in this country with an accident to injury ratio of 8:6, compared with the international ratio of 8:1.8 The rate of RTA caused by 4-wheeled vehicles is the highest of all worldwide accidents.9Saudi Arabia is a vast country of 2,149,690 km², and is the largest Arab state in Western Asia. The Kingdom has been categorized as a high-income nation, and is part of the “Group of Twenty” (G-20) of major economies. It has a total population of approximately 27 million, one-fourth of whom are expatriates, with the highest population density (per km²) of 101 in Jizan, and 38 in Makkah, and the lowest of 2.8 in Najran, and 3.6 in Al Jawf.10 In KSA, motor vehicles are the main means of transportation within, and in-between cities. According to a recent estimate, more than 6 million cars are found on the roads of KSA.11 According to the morbidity and mortality records in the Ministry of Health (MOH) hospitals, 20% of beds are occupied by RTA victims, and 81% of deaths in the hospitals are due to RTIs.8 Over the past 2 decades, KSA has recorded 86,000 deaths, and 611,000 injuries in RTAs with 7% resulting in permanent disabilities.12 The economic implications of RTAs estimated in terms of potential productive years life lost (PPYLL) were examined in a study that reported a 31.6% increase in deaths due to RTA among males in 1997-2002 compared with a 1.3% increase in deaths due to RTA among females.13,14 Road traffic accidents are a major health hazard with 19 killed daily, and 4 injured every hour in KSA. The young and economically productive age groups are the most affected.9 In industrialized countries, the gross loss due to accidents is 1 ± 2% of the national income, while for KSA, this loss has been estimated to be between 2.2 and 9%.8,15 The accident or injury reporting system in KSA has been much improved over the last couple of decades. Legislation on seat belt use has been put into practice, along with fully operational speed camera systems in large cities under the control of police departments, and police department record keeping of road mortalities and collisions.16 This improved reporting system shows a paradoxical rise in the magnitude of the problem over the years. The WHO has identified 5 Road Safety Pillars, namely: road safety management or policy; road infrastructure; safe vehicles; road users’ safe behavior; and post-crash care.17 Driver errors has been mostly reported in different regions of KSA as a cause of RTAs, in addition to some deplorable vehicles, and road conditions. However, post-crash care is largely ignored in all possible direct, or indirect evidence on the subject. There is scarcity of local standardized information on RTAs; therefore, measures for injury related mortality and disability are mostly available, either in popular press articles, police records, or WHO projected estimates. The aim of this study was to identify the changing trends and crucial preventive approaches to RTAs adopted in KSA over the last 2.5 decades, and to analyze aspects previously overlooked. This systematic review was planned to propose a standardized surveillance system for RTAs in KSA. This analysis aims to provide helpful information in limiting the overall incidence of RTAs, and the severity of the resultant injuries in KSA.     

Asthma control among adults in Saudi Arabia: Study of determinants

Objectives:

To explore the determinants of uncontrolled asthma in Saudi Arabia.

Methods:

A consecutive series of adult asthma patients attending 3 pulmonary primary care clinics in Riyadh, Saudi Arabia for a scheduled appointment were interviewed. A multiple logistic regression analysis was used.

Results:

The proportion of patients with uncontrolled asthma was 68.1% (177/260). Daily tobacco smoking or monthly household income less than 15,000 Saudi Arabian Riyals were associated with a 4.6 (95% confidence interval [CI]=1.3-16.4) and 3.4 (95% CI=1.8-6.6) times increase in the odds of having uncontrolled asthma. Patients with less than a graduate degree (odds ratio [OR]=3.1; 95% CI=1.0-9.5) or patients who were unemployed, disabled, or too ill to work (OR=3.1; 95% CI=1.4-6.9) had poorer asthma control. Having heartburn during the past 4 weeks decreased the odds of asthma control by 2.5 (95% CI=1.3-4.9), and having chronic sinusitis during the past 4 weeks decreased the odds of asthma control by 2.0 (95% CI=1.0-4.0) times. Being female (OR=2.0; 95% CI=1.0-4.0) or ≥35 years of age (OR=2.0; 95% CI=1.0-3.9) was also associated with having uncontrolled asthma.

Conclusion:

Our findings suggest that most respondents had uncontrolled asthma. Less modifiable socio-demographic factors (for example, income, education, occupation, gender, and age) significantly increased the odds of having uncontrolled asthma. However, modifiable risk factors such as tobacco smoking and clinical factors such as heartburn and chronic sinusitis could also be targeted for intervention.Asthma is a chronic disease that is caused by airway inflammation and obstruction. The prevalence of asthma is approximately 300 million worldwide and continues to increase. Common asthma symptoms include coughing, wheezing, chest tightness, and shortness of breath. These symptoms range from mild to severe and can lead to a fatal outcome. Symptoms of uncontrolled asthma can appear several times a day and can considerably decrease the quality of life of asthma patients and their family members. The economic burden of asthma is substantial and includes medical and non-medical costs.1-4 Currently, the main goal of asthma treatment is to control the disease and minimize the number of episodes of exacerbation. Asthma can be effectively controlled in most patients by avoiding common triggers and by adhering to prescribed treatment regimens.5 However, even in developed countries, 40-70% of patients have inadequately controlled asthma.6,7 The proportion of patients with uncontrolled asthma is also high in Kingdom of Saudi Arabia (KSA), with reports as high as 64% in adults,8 and 59.3% in children.9 Factors affecting asthma control include socio-demographic characteristics, psychosocial factors, asthma severity, adherence to treatment, an appropriate inhaler technique, and exposure to infectious agents (especially viruses), and to indoor and outdoor allergens or pollutants.1,10-14 The presence of comorbidities (for example, hypertension, chronic sinusitis, and gastroesophageal reflux disease) also contribute to an increased risk of poor asthma control.11,15-17 Uncontrolled asthma is an important public health problem in KSA, but only a very limited number of studies have been conducted to explore this issue. The objectives of the current study were to determine the proportion and determinants of uncontrolled asthma in adults who presented at 3 pulmonary primary care clinics Riyadh, KSA.     

Prevalence and predictors of habitual snoring in a sample of Saudi middle-aged adults

Objectives:

To determine the prevalence of habitual snoring among a sample of middle-aged Saudi adults, and its potential predictors.

Methods:

A cross-sectional study was conducted from March 2013 until June 2013 in randomly selected Saudi Schools in Jeddah, Kingdom of Saudi Arabia. The enrolled subjects were 2682 school employees (aged 30-60 years, 52.1% females) who were randomly selected and interviewed. The questionnaire used for the interview included: the Wisconsin Sleep Questionnaire to assess for snoring, medical history, and socio-demographic data. Anthropometric measurements and blood pressure readings were recorded using standard methods.

Results:

Forty percent of the 2682 enrolled subjects were snorers: 23.5% were habitual snorers, 16.6% were moderate snorers, and 59.9%, were non-snorers. A multivariate analysis revealed that independent predictors of snoring were ageing, male gender, daytime sleepiness, hypertension, family history of both snoring and obstructive sleep apnea, water-pipe smoking, and consanguinity.

Conclusion:

This study shows that snoring is a common condition among the Saudi population. Previously reported risk factors were reemphasized but consanguinity was identified as a new independent predictive risk factor of snoring. Exploring snoring history should be part of the clinical evaluation.Snoring is defined as a harsh buzzing noise produced by vibration of the soft palate and pillars of the oropharyngeal inlet, primarily with inspiration during sleep. Habitual snoring (HS) is defined as the presence of loud snoring at least 3 nights per week, and is strongly associated with obstructive sleep apnea (OSA).1,2 Even in the absence of OSA, HS is associated with health and social consequences including sleep fragmentation, family discord, excessive daytime sleepiness, and more seriously, the development of systemic hypertension in individuals aged <50 years.3 However, many individuals regard HS as a benign and a common behavior; moreover, physicians often disregard snoring as a disorder in their clinical practice. Such denial may lead to delayed recognition and management of OSA.1 Loud snorers have a 40% greater chance of developing hypertension, 34% greater chance of developing heart attack, and 67% greater chance of developing stroke, compared to non-snorers after adjustments for age, gender, body mass index, diabetes, level of education, smoking, and alcohol consumption.4 More recently, heavy snoring has been independently associated with carotid atherosclerosis and treating it was suggested as an important goal in prevention of stroke.5 There have been many international epidemiological studies to establish the prevalence of habitual snoring. Habitual snoring was reported to affect 35.7% of American,2 37.2% of Polish,6 35% of Spanish,7 19.6% of Chinese,8,9 17.3% of Korean,10 and 25.6% of Indian populations.20 The main reported risk factors were aging, male gender, obesity, and smoking. However, very limited data is available on the prevalence and impact of HS in the Middle Eastern countries. A limited study on Saudi health care workers reported HS in only 5.4%.11 Another primary health care clinics based study found a snoring prevalence of 52.3% in Saudi males, and 40.8% in Saudi females.12,13 Therefore, we conducted the current study to assess the actual prevalence and risk factors predictive of HS in a cohort of subjects in Saudi Arabia. Our results will be used to assess the size of the problem and increase awareness of this health disorder among health care professions, so that sleep disordered breathing can be effectively diagnosed and treated.     

Decline in menarcheal age among Saudi girls

Objectives:

To estimate age at menarche and to assess trends in menarcheal age among Saudi women.

Methods:

A prospective longitudinal study was conducted among healthy prepubertal female school children and adolescents from September 2006 to July 2012 in Riyadh, Kingdom of Saudi Arabia. Study participants were invited from diverse socioeconomic backgrounds. Tanner stage, height, weight, body mass index, and socioeconomic parameters including parent’s level of education were collected. Age at menarche was compared with maternal age at menarche.

Results:

The study included 265 girls and mothers. Mean±standard deviation (SD) age at menarche for girls was 13.08 ± 1.1 years, and their distribution category across the ≤10 years was 4 (1.5%), 11-14 years was 239 (90.2%), and ≥15 years was 22 (8.3%) girls. Anthropometric measurements, mother’s level of education, and family income were not statistically significant determining factors associated with age at menarche. Mean ± SD age at menarche for mothers was 13.67 ± 1.4 years, and their distribution category across the ≤10 years was 7 (2.6%), 11-14 years was 172 (64.9%), and ≥15 years was 86 (32.5%). Girls attained menarche at younger age compared with their mothers (p<0.0001). A downward secular trend in age of menarche was observed (Cuzick test for trend = 0.049).

Conclusion:

Saudi girls attain menarcheal age earlier than their mothers, reflecting a downward secular trend in menarcheal age.Menarche is a unique life event for each female; as it marks transition from childhood into adulthood with all known biological and psychological consequences.1 More recently, the timing of puberty gained much attention owing to the increased recognition of the association between menarche and breast cancer and cardiovascular diseases in adulthood.2,3 Onset of menarche is affected by many genetic and environmental factors including ethnicity, geographic location, and body mass index.4-7 Age at menarche is also affected by many prenatal and postnatal factors including birth size,7 rapid postnatal weight gain,7,8 and stressful childhood experiences.9,10 Since the middle of the last century, age at menarche was declining at an estimated rate of 3 to 4 months per decade.1 This trend might have slowed, or even stopped in some European countries, although it is still ongoing in Asia and the United States.1 The status of this trend among Saudi girls is not known. In 1995, mean age at menarche was found to be 15.1 years for girls at the western part of the Kingdom of Saudi Arabia (KSA).11 No data exists on age at menarche among Saudi girls since then. In this study, we aim to estimate the age at menarche for Saudi girls in the central part of KSA. Factors affecting onset of menarche was determined together with evaluation for a possible secular trend by comparing age at menarche in these girls with the age at menarche of their mothers.     

Effects of 12-month, 2000IU/day vitamin D supplementation on treatment na?ve and vitamin D deficient Saudi type 2 diabetic patients

Objectives:

To determine whether 12-month, 2000IU/day vitamin D supplementation cardiometabolically improves treatment naïve type 2 diabetes mellitus (T2DM) Saudi patients with vitamin D deficiency.

Methods:

This 12-month interventional study was conducted at primary health centers in 5 different residential areas in Riyadh, Saudi Arabia between January 2013 and January 2014. Forty-five Saudi T2DM patients were enrolled. Baseline anthropometrics, glycemic, and lipid profiles were measured and repeated after 6 and 12 months. All subjects were provided with 2000IU vitamin D supplements for one year.

Results:

Vitamin D deficiency at baseline was 46.7%, 31.8% after 6 months, and 35.6% after 12 months, indicating an overall improvement in the vitamin D status in the entire cohort. Insulin and homeostatic model assessment-insulin resistance (HOMA-IR) after 12 months were significantly lower than a 6 months (p<0.05), but comparable to baseline values. Mean levels of triglycerides increased overtime from baseline (1.9±0.01 mmol/l) to 12 months (2.1±0.2 mmol). This modest increase in serum triglycerides was parallel to the insignificant decrease in circulating high-density lipoprotein -cholesterol levels.

Conclusion:

Twelve-month vitamin D supplementation of 2000IU per day in a cohort of treatment naïve Saudi patients with T2DM resulted in improvement of several cardiometabolic parameters including systolic blood pressure, insulin, and HOMA-IR. Further studies that include a placebo group are suggested to reinforce findings.Diabetes mellitus (DM) is a major public health problem worldwide. The population of people with DM is on the rise secondary to an aging and urbanized population as well as an increasing prevalence of risk factors such as obesity and physical inactivity.1 In the Kingdom of Saudi Arabia (KSA) alone, the most-recent age-adjusted prevalence of type 2 diabetes mellitus (T2DM) was reported to be 31.6% in adults, considered among the highest in the Gulf region.2 Type 2 diabetes mellitus among Saudis results from the interaction between a genetic predisposition, behavioral, and environmental risk factors, which can manifest as early as pre-teens.3 This is alarming since the long-term cost of diabetes can be crippling to any health care system as there are many associated health problems, including: increased risk of coronary heart disease, eye problems, nerve damage, foot, and kidney problems.4 Vitamin D insufficiency, defined as serum 25-hydroxyvitamin D levels <50 nmol/l (25-OH-D), is also common in patients with T2DM.5 Using this arbitrary definition, it has been estimated that one billion people worldwide have either vitamin D deficiency or insufficiency.6 In KSA, there is an abundance of local literature pointing to an increased prevalence of vitamin D deficiency.7,8 Taken together, current evidence suggests a link between vitamin D deficiency and progression of T2DM, but results are not consistent and therefore the beneficial effects of vitamin D correction among T2DM patients with vitamin D deficiency remains controversial.9,10 Given that patients with T2DM are at higher risk for cardiometabolic complications, this study aims to determine whether vitamin D status improvement through dietary means improves the cardiometabolic profile of treatment naïve T2DM Saudi patients with vitamin D deficiency.     

Visual and neurologic sequelae of methanol poisoning in Saudi Arabia

Objectives:

To present the visual sequelae of methanol poisoning and to emphasize the characteristics of methanol exposure in the Kingdom of Saudi Arabia (KSA).

Methods:

A retrospective case series was carried out on 50 sequential patients with methanol poisoning seen at the King Khaled Eye Specialist Hospital and King Saud University Hospitals in Riyadh, KSA between 2008 and 2014. All patients were examined by a neuro-ophthalmologist at least one month after methanol intoxication.

Results:

All 50 patients were young or middle-aged males. All admitted to drinking unbranded alcohol within 2-3 days before profound or relatively profound, painless, bilateral visual loss. Mean visual acuity in this group was hand motions (logMAR 2.82; range 0.1 - 5.0) with some eye to eye variability within individuals. Worse visual acuity was correlated with advancing age (Pearson correlation: oculus dextrus [right eye] - 0.37, p=0.008; oculus sinister [left eye] - 0.36, p=0.011). All patients had optic atrophy bilaterally, and all tested patients had visual field defects. Tremors with or without rigidity were present in 12 patients, and 11 of 30 patients who had neuroimaging performed had evidence of putaminal necrosis.

Conclusion:

Methanol intoxication causes visual loss within 12-48 hours due to relatively severe, painless, bilateral optic nerve damage that may be somewhat variable between eyes, and is generally worse with advancing age. The coincidence of bilateral optic nerve damage and bilateral putaminal necrosis in a young or middle-aged male is very suspicious for methanol-induced damage.Methanol is a clear and colorless alcohol that tastes and smells the same as ethanol, but causes much less behavioral intoxication.1 It is commonly used in industry as a component of products such as antifreeze, windshield-wiper fluid, and model airplane fuel.2 In the Kingdom of Saudi Arabia (KSA), it can be found as a solvent in some brands of perfume and cologne. Ingestion of methanol may be accidental, or due to a suicide attempt. But the most common situation occurs as isolated episodes, or epidemics of methanol poisoning and its toxic optic neuropathy, which are seen due to the contamination of handmade liquor, smuggled alcohol, and so forth with methyl alcohol.2,3 Death from methanol toxicity has been reported to range between 8-36%,4-6 and permanent loss of vision has been observed in another 20-40% of patients who survive the acute injury.2,5,7 Vision loss is painless and often occurs in both eyes within one to 3 days; vision in some patients may either improve, or decline over subsequent weeks.8 The optic disk in acute intoxication has a hyperemic appearance with edema of the peripapillary retina;9 however, the optic nerve gradually becomes pale within 30-60 days after ingestion. Large, sluggishly reactive pupils have been reported to occur frequently in acute methanol poisoning, sometimes leaving both pupils permanently dilated.5,9 Neurological signs, such as confusion and coma are common in acutely hospitalized patients, and putaminal hemorrhage, and/or necrosis occur less frequently.1,2,10 This study evaluates ophthalmologic, neurologic, and neuroimaging signs in 50 consecutive patients seen at 2 major ophthalmologic centers in KSA due to visual loss after methanol poisoning.     

The clinical utility of eye exam simulator in enhancing the competency of family physician residents in screening for diabetic retinopathy

Objectives:

To evaluate the utility of eye exam simulators in the training and assessment of family medicine residents for screening diabetic retinopathy (DR) utilizing direct ophthalmoscopy (DO).

Methods:

This prospective, single arm, cross-sectional study was conducted at King AbdulAziz University Hospital, Jeddah, Kingdom of Saudi Arabia in April 2013, wherein the final year family medicine residents of the Saudi Board family medicine training program, underwent a practical session on DO using an eye exam simulator. The cognitive and motor skills of the participating family residents in performing DO, and their competency at diagnosing DR was assessed before, and after a practical session with the eye simulator.

Results:

A total of 14 out of total 20 final year residents consented to join the study. Of these, 57.1% were females. A total of 42.9% (6/14) showed initial motor skill competency, and 35.7% showed cognitive skill competency to diagnose DR. Before the session on the eye simulator, merely 7.1% of the residents expressed confidence in performing DO. After the practical session, 78.6% (11/14) showed motor, and 64.3% (9/13) showed cognitive skill competency, in diagnosing DR. A total of 50% were adequately confident in performing DO. A total of 71.4% (10/14) of the residents preferred learning DO via simulation practical sessions than clinical rotation in ophthalmology clinics.

Conclusion:

Eye exam simulators are good tools in learning and assessment of DO skills leading to significant improvement in the efficiency and confidence of family physicians in screening for DR.Diabetes mellitus (DM) is a widespread chronic disease with an estimated global prevalence of 2.2%, which is expected to double by the year 2030.1 Epidemiological studies have shown a constant rise in the prevalence of DM in the Saudi population within the last decade, escalating from 3.8% in the year 20002 to 27.3% in 2004,3 and finally to 30% as reported in 2011.4 Diabetic retinopathy (DR) is a known systemic complication of DM, and it is listed by the World Health Organization (WHO) as one of the top 5 leading causes of blindness in the world.5 It has been found to affect 30% of diabetic patients in Saudi Arabia,6,7 and the cause of blindness in 20.9% of patients, making it the third most common cause of visual impairment in the Saudi population with refractive errors and cataract8 being the leading causes. Hence, it is of utmost clinical importance to screen diabetic patients for the presence of DR as early as possible following a diagnosis of DM.9,10 Primary health care practitioners and family physicians represent the very first level of care, most diabetic patients receive. Patients can be accurately screened for DR in primary care clinics.11 However, ensuring that the primary health care and family physician can optimally and competently performing direct ophthalmoscopy (DO) is vital for timely referral of patients in need for urgent treatment. Clinical studies have shown that 23% of diabetics present with DR during their first visit to the ophthalmologist.12 A significant correlation has been reported between the rate of detection of DR and the delay in screening diabetic patients for DR.13 Although guidelines proposed by the major international ophthalmic societies,14 emphasize the need to acquire the basic skills, to perform DO by all undergraduate medical students and ophthalmologists, and other physicians believe that learning the skill of performing DO is an essential part of medical education this need has not been addressed by most medical schools, as studies in different countries demonstrated a lack of uniformity in the implementation of the ophthalmology curriculum,15 ophthalmology attachment is not compulsory in all the medical schools within the same country,16 and presence of gaps between teaching, knowledge, and clinical skills in several medical schools.17-19 This deficiency in the undergraduate ophthalmology education adversely affects the competency of family physicians resulting in lack of their ability to detect important ocular pathologies.20 Direct ophthalmoscopy is classically learnt on fellow students. However, the limitation of practicing DO on fellow students is that most often ocular pathologies cannot be encountered during this approach. This leads to the understanding that learning and practicing DO on patients with ocular pathologies is a more efficacious method of learning. Moreover, patients with ocular pathologies would be easily willing to participate in sessions, wherein their eyes would be examined via an ophthalmoscope.21 However, the flip side of this approach is the fact that learning DO on patients might be an intimidating experience for students. In addition, the absence of standardized setting is a challenge while choosing the best education method to be used for skill acquisition and assessment. Hence, the situation presents an unmet medical need: the need to adopt alternative methods, which are feasible for teaching DO like the use of eye exam simulators. This study was conducted to evaluate the efficacy of workshops using an eye exam simulator in improving competency and confidence level of the final year family medicine residents in performing DO.