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Background: Improving the reproductive health of females has be.come the focus of the developmental efforts of many nations., Objectives: To identify the reproductive health style of married females, and to determine the prevalence and predictors of circumcision among girls aged less than or equal 18 years in Hali semi-urban region., Design: A cross-sectional household survey SETTING: Houses in Hali, Al-Qunfudhah governorate, western Saudi Arabia during 2017., Subjects and Methods: A multistage systematic cluster random sampling method was used to select participants. A validated questionnaire was used in interviewing the head of the selected houses., Main Outcome Measures: Reproductive health profile of women, and circumcision of girls., Sample Size: 365 households., Results: Reproductive life starts early in the Hali region as 41.4% of women are married at or before 18 years of age. Consanguinity was recorded in 57.0% of houses. The prevalence of grand multiparity (GMP) was 54.7%; it was significantly associated with current maternal age, age at marriage, low educational levels of both parents and husbands with non-professional jobs. Current use of birth control methods was reported by 28.9% of families, and oral contraceptives (OCs) were the commonest method. Contraceptive use was significantly associated with higher educational levels of both parents and with women having professional work. The prevalence of circumcision was 80.3%. Circumcision was most frequent (59.4%) at age 7 years or less, and almost always done by doctors (91.4%). Hemorrhage (2.9%) and fever (2.3%) were the minimal recorded complications. Girls with higher parental education, enough income, no parental consanguinity, and whose mothers married at an older age had slightly lower rates of circumcision, but the difference was without statistical significance., Conclusion: The pattern of early female marriage, high consanguinity, GMP, low contraceptive use, and a high frequency of circumcision in girls was apparent in Hali. Public health education and legislative policies are needed., Limitations: Recall bias may affect the reported frequency of circumcision, and related complications., Conflicts of Interest: None.

Background: Asthma and chronic obstructive pulmonary disease (COPD) are chronic conditions with an increasing prevalence in developing countries. The evaluation of endobronchial biopsies has emerged as a tool to differentiate between both conditions via the measurement of the reticular basement membrane (RBM) thickness with various conclusions drawn from different studies., Objectives: Compare the thickness of the RBM between asthma and COPD and evaluate other histomorphological features in both groups., Design: Prospective, descriptive and analytical., Setting: University teaching hospital., Patients and Methods: The study included patients with COPD and irreversible and reversible asthma with diagnosis based on clinical assessment, pulmonary function tests and high-resolution computed tomography scans. Endobronchial biopsies were obtained from all patients and, using a light microscope and a computerized image analyzer, the thickness of the reticular basement membrane was calculated in all patients. We also made a qualitative assessment of other histo-morphological features., Main Outcome Measures: Mean RBM thickness., Sample Size: Thirty male patients., Results: The mean RBM thickness in asthmatic patients was 8.9 (2.4) micro m. The mean RBM thickness in COPD patients was 5.3 (1.1) micro m. However, there was no thickening of the RBM in patients with reversible asthma. The RBM was significantly thicker in patients with irreversible asthma than in patients with COPD or reversible asthma. There were no significant differences in epithelial desquamation or metaplasia, mucosal or submucosal inflammation, the presence of eosinophils, submucosal glandular hyperplasia or submucosal smooth muscle hyperplasia between groups., Conclusions: The thickness of the RBM is the only reproducible histopathological feature to differentiate COPD from irreversible asthma., Limitations: The study included a limited number of patients. A qualitative approach was used to compare epithelial cell injury, inflammation, submucosal glandular and muscular hyperplasia., Conflict of Interest: None.

Background: Failed corneal graft management is a challenge. Descemet stripping automated endothe.lial keratoplasty (DSAEK) and repeat penetrating keratoplasty (PKP) are two options. Only two studies have compared outcomes of DSAEK and PKP in the management of a failed graft., Objective: To compare the visual outcomes, changes in intraocular pressure (IOP) and complications in eyes with failed corneal grafts that were subsequently managed with DSAEK and PKP., Design: Retrospective cohort study., Settings: Tertiary eye hospital of central Saudi Arabia., Patients and Methods: A retrospective chart review was performed for cases managed between 2007 and 2012. Data were collected on the best-corrected visual acuity (BCVA) before and at day 1, 1 week, 4 weeks, 12 weeks, and 24 weeks after intervention. BCVA was compared in patients managed with DSAEK or PKP. Intra- and postoperative complications were compared in both groups., Main Outcome Measures: Clear graft, vision at last follow up, complications., Results: There were 15 eyes in the DSAEK group and 30 in the PKP group. The causes of previously failed PKP differed between groups. BCVA at 6 months after repeat surgeries was 20/20 to 20/40 in 4 (27%) eyes in the DSAEK group and in 8 (27%) eyes in the PKP group. The IOP at 6 months was statistically significantly higher in the DSAEK group than the PKP group (P=.006). In DSAEK group, one graft rejection occurred in one eye and graft dislocation in another eye. Seven eyes in PKP group had signs of graft rejection that regressed in 5 eyes following medical management., Conclusions: DSAEK and PKP for previously failed corneal graft resulted in similar BCVA 6 months after repeat surgery. However, the visual outcomes were less promising with both types of surgeries. The lower complication rate and surgical ease may favor DSAEK over PKP in managing failed grafts., Limitations: Small sample, retrospective study.

Background: Dental caries and obesity are multifactorial diseases with diet being a common contributory factor., Objective: The main purpose of the present study was to investigate the association between dental caries and obesity among special care female school children in Makkah City, Saudi Arabia., Design: Analytical cross-sectional study., Setting: Special schools in Makkah City., Study Population and Methods: Schools were chosen by lottery and female children were ran.domly selected. Dental caries detection was performed according to the World Health Organization criteria. The medical evaluation assessed the body mass index (BMI)., Main Outcome Measures: With appropriate sample weighting, relationships between dmft/DMFT (decayed, missing, filled teeth for deciduous and permanent dentition) and obesity were assessed using multilevel logistic regression., Results: In 275 special care children, the prevalence of dental caries was 56.7 percent. The mean dmft and DMFT scores for the entire study population were 3.9 (4.8) and 3.2 (4.1), respectively. Forty percent of children were mentally retarded, 22.2% presented with deafness, blindness or both, 18.9% presented with Down syndrome and 14.9% were autistic. From the total sample, the mean BMI was 20.2 (2.8). When adjusted for covariates, the logistic regression model showed strong association between caries and obesity (adjusted odds ratio=2.9; 95% CI=1.2-4.9)., Conclusion: This study demonstrated a significant association between caries frequency and overweight/obesity in special care school children., Limitations: Since the data was cross-sectional, causal relationships cannot be established and the observed association could be due to other unexplored factors. Because of cultural and ethical consideration, including segregation of gender in Saudi Arabia, only female children were included in the present study, which limited the findings.

Individuals with a factitious ocular disorder feign or exaggerate having an eye injury or intentionally produce an eye injury so as to assume the role of a sick person. We report two cases of self-inflicted ocular injury using needle-like foreign bodies and razor that represent possible diagnoses of Munchausen syndrome. Both patients presented with different clinical pictures that misguided the clinical diagnosis and delayed proper management. Although self-inflicted ocular injuries are rare, ophthalmologists should be aware of the possibility of their existence, particularly when caring for patients with psychiatric conditions., Similar Cases Published: 13.

Background: Diabetic patients with hypertension and dyslipidemia are at a high risk of cardiovascular complications., Objectives: To determine the effect of Nigella sativa supplementation on the lipid profile, mean arterial pressure, and heart rate in persons with type 2 diabetes on oral hypoglycemic agents (OHA)., Design: Single-blind, nonrandomized., Setting: Diabetes clinic of a university hospital in Saudi Arabia., Patients and Methods: Type-2 diabetic patients were recruited by purposive sampling and assigned to treatment or control at the discretion of the investigator with the patient blinded to treatment. Before the in.tervention and every 3 months thereafter until the end of the treatment period, the following parameters were measured: triglycerides (TG), total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR), and body mass index (BMI). Results at the baseline and each subsequent visit were compared between the two groups., Main Outcome Measure(s): Lipid and cardiovascular parameters, and BMI., Results: Fifty-seven patients were assigned to receive N sativa 2 g daily for one year and 57 were assigned to receive an identical regimen of placebo, along with OHA. A significant decrease in HDL-C and increase in the TC/HDL-C and LDL-C/HDL-C ratios were seen in the control group. The N sativa group had a signifi.cant decline in TC, LDL-C, TC/HDL-C and LDL-C/HDL-C ratios, compared with the respective baseline data and the control group. HDL-C was significantly elevated in the N sativa group. The control group showed a significant elevation in MAP. The N sativa group had a significant reduction in SBP, DBP, MAP and HR and a significant decrease in DBP, MAP and HR as compared with the control group., Conclusion: N sativa supplementation improves total cholesterol, mean arterial pressure and heart rate in type 2 diabetes patients on oral hypoglycemic agents., Limitations: There were 9 subjects in each group lost to follow up; thus the sample size could not be maintained as per the sample size calculation. The study was nonrandomized and thus there was a possibility of allocation bias. (Clinical trial registration number: CTRI/2013/06/003781, Clinical Trial Registry of India).

Background and Objectives: Dentists suffer a high prevalence of musculoskeletal disorders (MSDs) but studies are quite limited. The present study was carried out to investigate the prevalence of MSDs among dentists in the Ha'il Region, Saudi Arabia., Design and Settings: A cross-sectional, questionnaire study was conducted among 80 licensed dentists af.filiated with the Ministry of Health (MoH), Ha'il Region, Saudi Arabia from January 2014-January 2015., Patients and Methods: A self-administered questionnaire, based on the Nordic Musculoskeletal Questionnaire (NMQ) was sent to participants after translation to Arabic. The questionnaire was delivered by mail with a prepaid return envelope., Results: Sixty-eight questionnaires (85%) were returned. The prevalence of MSDs among respondents was 77.9% (n=53) with the most commonly affected areas the lower back (73.5%) (39/53) followed by the neck (66%) (35/53) and the shoulders (43.3%) (23/53). Twenty-four (45.2%) of 53 respondents had experienced MSDs in the neck and lower back at the same time throughout the past twelve months. Nearly 85% (45/53) of respondents were found to have MSDs affecting two or more sites., Conclusion: Prevalence of MSDs was high among dentists in the Ha'il region. Lower back, neck and shoul.ders were the most commonly affected body sites.

Tilletiopsis minor, a blastoconidia-forming yeast, was isolated from a 4-year-old boy suffering from severe pneumonia. Chest x-rays revealed the progression of widespread and multiple nodular lesions, nonsymmetrical interstitial and airspace infiltrates, and consolidations. Creamy yellow, irregular, wrinkled yeast-like organisms were isolated from the pleural fluid specimens when cultured on Sabouraud dextrose agar for 5 days and incubated at 30°C. Microscopically, the organisms showed broad, irregular filaments with blastoconidia but no budding cells. Manual bench tests and automated phenotypic analyses failed to recognize the organism. This unique and rare organism (AB7-11; DSM 29469) was identified using the sequence analysis of the internal transcribed spacer region of the nuclear ribosomal DNA. It showed a precise alignment with the type strains of T minor. Subsequent to this diagnosis, and the earlier nonre.sponse to vancomycin and meropenem, the patient was put on liposomal amphotericin. However, the condition continued to deteriorate, and then, intravenous voriconazole was added to control the infection. Finally, the patient's condition improved, and he was discharged in good condition after 1 month of stay in the hospital.

Background and Objectives: The lupus anticoagulant (LA) test is an advanced test that is time consuming and requires a highly trained lab specialist. A high proportion of clinicians do not adhere to international guidelines and request the test inappropriately., Design and Settings: This descriptive study covered the period from January 2012 and January 2013 at the Hematology Laboratory at King Khalid University Hospital, Riyadh., Patients and Methods: The 274 lupus anticoagulant requests were categorized as proper or improper based on the guidelines of the International Society of Thrombosis and Haemostasis (ISTH). Data on numbers of requests and cost are summarized., Results: Of the 274 requests, 222 (81%) were classified as proper while 52 (19%) requests did not satisfy ISTH guidelines. The most frequently encountered incorrect indications were warfarin therapy (46%), heparin therapy (27%), a normal aPTT with no clinical indication (25%) and low serum fibrinogen levels (2%). The total cost of all improper requests was about 41080 SAR (10954 USD)., Conclusion: A majority of improper requests were related to anticoagulant therapy, which highlights the importance of implementing a comprehensive diagnostic algorithm for patients on warfarin and heparin therapy.

Background and Objectives: There are limited data on changes in the prevalence of overweight among the Saudi school children and on associated risk factors. We compared recent prevalence data (2012) with early data (1994-98) and assessed risk factors., Design and Setting: Data from a cross-sectional study of children in primary schools in two cities in Al-Qassim province., Patients and Methods: Parental questionnaires were used to collect sociodemographic data and informa.tion on the child's diet/exercise behavior. Children's weight and height were measured. Current and previous data on overweight prevalence were compared and risk factors were assessed in a multiple logistic regression model., Results: The sample consisted of 874 randomly chosen school children, aged 6-10 years; analysis was based on 601 with complete data. Current overweight prevalence was 16.9% and was higher in girls than in boys (29.7% vs. 11.7%, P value < .0001). Prevalence has risen in the last 15 years (overall: 16.9% vs. 10.1%; boys: 11.7% vs. 8.5%; girls: 29.7% vs. 11.5%; all P values < .05). Those who ate restaurant food >=2 times/week were 2.4 times more likely (95% CI=1.26, 4.64) to be overweight and those who engaged in sports >=2 hours/day were 0.5 times less likely to be overweight (95% CI=0.25, 1.20)., Conclusion: The overweight prevalence in primary school children in Saudi Arabia has risen significantly. The focus should be on developing obesity prevention programs for this population.

Background and Objectives: Job satisfaction refers to the extent to which people like or dislike their job. Job satisfaction varies across professions. Few studies have explored this issue among physicians in Saudi Arabia. The objective of this study is to determine the level and factors associated with job satisfaction among Saudi and non-Saudi physicians., Methods: In this cross-sectional study conducted in a major tertiary hospital in Riyadh, a 5-point Likert scale structured questionnaire was used to collect data on a wide range of socio-demographic, practice environment characteristics and level and consequences of job satisfaction from practicing physicians (consultants or residents) across different medical specialties. Logistic regression models were fitted to determine factors associated with job satisfaction., Results: Of 344 participants, 300 (87.2%) were Saudis, 252 (73%) males, 255 (74%) married, 188 (54.7%) consultants and age [median (IQR)] was 32 (27-42.7) years. Overall, 104 (30%) respondents were dissatisfied with their jobs. Intensive care physicians were the most dissatisfied physicians (50%). In a multiple logistic regression model, income satisfaction (odds ratio [OR]=0.448 95% CI 0.278-0.723, P < .001) was the only factor independently associated with dissatisfaction., Conclusion: Factors adversely associated with physicians job satisfaction identified in this study should be addressed in governmental strategic planning aimed at improving the healthcare system and patient care.

Background and Objectives: Diffuse alveolar hemorrhage (DAH) is a life threatening condition with very limited, often unsuccessful, therapeutic options. This study aimed at exploring the feasibility and efficacy of nebulized tranexamic acid TXA (n-TXA) and nebulized recombinant factor VIIa (n-rFVIIa) when used in a two-step therapy protocol in children with intractable DAH in a pediatric intensive care unit., Methods: In a prospective trial, n-TXA (250 mg/dose for children < 25 kg and 500 mg/dose for children > 25 kg) was administered to 18 children (median age [interquartile range]; 24.0 months [11.3, 58.5]) with intractable DAH. N-rFVIIa (35 micro g/kg/dose for children < 25 kg, and 50 micro g/kg/dose for children > 25 kg) was added if no or minimal response was seen after 3 to 4 doses (18 to 24 hours) of n-TXA., Results: DAH was stopped in 10 (55.6%) children with n-TXA alone within 24 hours of therapy. Documented concomitant respiratory infection showed a significant negative association with response to n-TXA in a step.wise regression analysis (OR=0.06; 95% CI=0.01-0.74). In the other 8 (44.4%) children, n-rFVIIa was added due to n-TXA failure. Six (75.0%) showed complete cessation of DAH, while two children failed to respond with the addition of n-rFVIIa (25.0%). None of the children who responded to therapy showed recurrence of DAH after therapy termination. No complications related to therapy were recorded., Conclusions: n-TXA and n-rFVIIa were effective and safe when used in a two-step-therapy protocol to control intractable DAH in pediatric patients in intensive care settings. This therapy modality warrants further exploration through larger multicenter clinical trials.

Background and Objectives: The doctor-patient relationship has been influenced by the appearance of physicians, and there is an association between a physician's physical appearance and the patients' initial perceptions of physician competence. This study aims to explore patients' preferences toward the attire of a male physician, and to examine if a physician's choice of uniform influences the degree of trust, confidence, and follow-up care among respondents., Design and Settings: A cross-sectional survey conducted among patients of the Alwazarat family medicine center in Riyadh, Saudi Arabia., Patients and Methods: A self-administered questionnaire was completed by 300 patients (50% were male and 83.6% had received a secondary education; the mean age was 33.4 [10.1] years) in the Alwazarat family medicine center in Riyadh. The questionnaire was also customized for the local setting with the inclusion of photos of a male doctor in Saudi Arabian national costume, and 3 other dress styles (Western dress with white coat, scrubs with white coat, and scrubs only)., Results: Overall, across all questions regarding physician dress style preferences, participants significantly preferred Western dress (39.9%, P < .001), followed by Saudi national dress (26.3%), a scrub suit with a white coat (22.3%), and scrubs only (11.5%). Respondents reported that they were more likely to follow medical advice and would return for follow-up care if a physician wore Western dress. They were significantly more willing to share their social, sexual, and psychological problems with a physician wearing Saudi national dress (P < .001). The importance of a physician's appearance was ranked significantly higher by older patients (P=.002)., Conclusion: Respondents were more likely to favor a physician wearing Western attire with a white coat. However, Saudi national dress, followed by Western dress, is the preferred attire when physicians are dealing with social, sexual, and psychological problems.

Gastrointestinal basidiobolomycosis (GIB) is an unusual fungal infection that manifests in the skin and rarely involves other systems. All of the few cases of GIB reported so far were diagnosed with difficulty, necessitating laparotomy and resection of the inflamed part of the bowel. We report a child with GIB who was successfully diagnosed endoscopically without surgical intervention.