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Taghrid S Alomar,1 Najla AlMasoud,1 Manal A Awad,2 Reem S AlOmar,3 Nada M Merghani,4 Mohamed El-Zaidy,5 Ajaya Bhattarai6 1Department of Chemistry, College of Science, Princess Nourah Bint Abdulrahman University, Riyadh, 11671, Saudi Arabia; 2King Abdullah Institute for Nanotechnology, King Saud University, Riyadh, 11451, Saudi Arabia; 3Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, 32210, Saudi Arabia; 4Central Research Laboratory, Vice Rectorate for Studies and Scientific Research, King Saud University, Riyadh, 11451, Saudi Arabia; 5Department of Botany and Microbiology, Faculty of Science, King Saud University, Riyadh, 11459, Saudi Arabia; 6Department of Chemistry, Mahendra Morang Adarsh Multiple Campus, Tribhuvan University, Biratnagar, 56613, NepalCorrespondence: Ajaya Bhattarai; Manal A Awad, Email ajaya.bhattarai@mmamc.tu.edu.np; mawad@ksu.edu.saIntroduction: Researchers are increasingly favouring the use of biological resources in the synthesis of metallic nanoparticles. This synthesis process is quick and affordable. The current study examined the antibacterial and anticancer effects of silver nanoparticles (AgNPs) derived from the Neurada procumbens plant. Biomolecules derived from natural sources can be used to coat AgNPs to make them biocompatible.Methods: UV-Vis spectroscopy was used to verify the synthesis of AgNPs from Neurada procumbens plant extract, while transmission electron microscopy (TEM), photoluminescence (PL) spectroscopy, dynamic light scattering (DLS), and Fourier transform infrared spectroscopy (FTIR) were used to characterize their morphology, crystalline structure, stability, and coating.Results: UV-visible spectrum of AgNPs shows an absorption peak at 422 nm, indicating the isotropic nature of these nanoparticles. As a result of the emergence of a transmission peak at 804.53 and 615.95 cm− 1 in the spectrum of the infrared light emitted by atoms in a sample, FTIR spectroscopy demonstrated that the Ag stretching vibration mode is metal-oxygen (M-O). Electron dispersive X-ray (EDX) spectral analysis shows that elementary silver has a peak at 3 keV. Irradiating the silver surface with electrons, photons, or laser beams triggers the illumination. The emission peak locations have been found between 300 and 550 nm. As a result of DLS analysis, suspended particles showed a bimodal size distribution, with their Z-average particle size being 93.38 nm.Conclusion: The findings showed that the antibacterial action of AgNPs was substantially (p≤ 0.05) more evident against Gramme-positive strains (S. aureus and B. cereus) than E. coli. The biosynthesis of AgNPs is an environmentally friendly method for making nanostructures that have antimicrobial and anticancer properties.Keywords: Silver nanoparticles, UV-Vis spectroscopy, transmission peak, dynamic light scattering

Nawfal A Aljerian,1,2 Abdullah A Alharbi,3 Hani A Alghamdi,4 Meshary S Binhotan,5,6 Reem S AlOmar,7 Ali K Alsultan,1 Mohammed S Arafat,1 Abdulrahman Aldhabib,1 Mohammed K Alabdulaali1 1Medical Referrals Centre, Ministry of Health, Riyadh, Kingdom of Saudi Arabia; 2Emergency Medicine Department, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia; 3Family and Community Medicine Department, Jazan University, Jazan, Kingdom of Saudi Arabia; 4Department of Family and Community Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia; 5Emergency Medical Services Department, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia; 6King Abdullah International Medical Research Centre, Riyadh, Kingdom of Saudi Arabia; 7Department of Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi ArabiaCorrespondence: Hani A Alghamdi, Department of Family and Community Medicine, College of Medicine, King Saud University, P.O Box 12372, Riyadh, 7065, Kingdom of Saudi Arabia, Tel +966507022266, Email Halhajalah@ksu.edu.saBackground: E-referral systems, streamlining patient access to specialists, have gained global recognition yet lacked a comparative study between internal and external referrals in Saudi Arabia (KSA).Methods: This retrospective study utilized secondary data from the Saudi Medical Appointments and Referrals Centre system. The data covers 2020 and 2021, including socio-demographic data, referral characteristics, and specialties. Logistic regression analysis was used to assess factors associated with external referrals.Results: Out of 645,425 e-referrals from more than 300 hospitals, 19.87% were external. The northern region led with 48.65%. Males were 55%, and those aged 25– 64 were 56.68% of referrals. Outpatient clinic referrals comprised 47%, while 61% of referrals were due to a lack of specialty services. Several significant determinants are associated with higher rates of external referral with (p-value < 0.001) and a 95% Confidence interval. Younger individuals under 25 exhibit higher referral rates than those aged 25– 64. Geographically, compared to the central region, in descending order, there were increasing trends of external referral in the northern, western, and southern regions, respectively (OR = 19.26, OR = 4.48, OR 3.63). External referrals for outpatient departments (OPD) and dialysis services were higher than for routine admissions (OR = 1.38, OR = 1.26). The rate of external referrals due to the lack of available equipment was more predominant than other causes. Furthermore, in descending order, external referrals for organ transplantation and oncology are more frequent than for medical specialties, respectively (OR = 9.39, OR = 4.50).Conclusion: The study reveals trends in e-referrals within the KSA, noting regional differences, demographic factors, and types of specialties regarding external referrals, benefiting the New Model of Care for the 2030 Vision. Findings suggest expanding virtual consultations to reduce external referrals. Strengthening primary care and preventive medicine could also decrease future referrals. Future studies should assess resource distribution, including infrastructure and workforce, to further inform healthcare strategy.Keywords: e-referrals, health policy, epidemiology, public health

Nouf A AlShamlan,1 Reem S AlOmar,1 Assim M AlAbdulKader,1 Marwa Mahmoud Shafey,1 Faisal A AlGhamdi,2 Abdullah A Aldakheel,2 Saud A AlShehri,2 Lyana A Felemban,3 Shahad A AlShamlan,2 Malak A Al Shammari1 1Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; 2College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; 3College of Medicine, Fakeeh College of Medical Sciences, Jeddah, Saudi ArabiaCorrespondence: Nouf A AlShamlan, Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia, Tel +966504901406, Email nashamlan@iau.edu.saBackground: Epidemiological evidence has shown that human papillomavirus (HPV) is the most frequent cause of sexually transmitted infection, and vaccination is an essential measure to prevent associated diseases and complications. This study aimed to assess the HPV vaccine uptake and its associated factors as well as HPV vaccine hesitancy by female healthcare workers (HCWs) in Saudi Arabia.Methods: This online, questionnaire-based, cross-sectional study involved female HCWs in Saudi Arabia between July and October 2022. The study tool included questions about sociodemographic, occupational, and reproductive characteristics, uptake of HPV vaccination, and reasons of hesitancy. Chi-squared and t-tests were used for bivariate analyses, and multivariable logistic regression was used to adjust for confounders.Results: The total number of participants was 1857. Around 20% of HCWs received at least one dose of the HPV vaccine, and around 45% were willing to take it this year. Lower odds of vaccine uptake were reported among older participants and those with a higher level of education. However, nurses, HCWs with a previous HPV infection, those with a family history of cervical cancer, or those with a previous cervical cancer screening test had higher odds of receiving the vaccine. On the other hand, older participants and diploma degree holders were less willing to take the HPV vaccine. Higher odds of willingness were reported in married HCWs, those with a previous HPV infection, those who received a previous HPV vaccine dose, or those who were screened for cervical cancer. Lack of knowledge and some misconceptions were the most reported reasons for hesitancy.Conclusion: Certain factors that affect HCWs personal decisions to take the vaccine were identified. By targeting these issues, epidemiologists, public health officials and women’s health care providers can work to increase HPV vaccine uptake and reduce the burden of HPV-related diseases in this population.Keywords: HPV vaccine, epidemiology, public health, women’s health, healthcare worker, uptake

Reem S AlOmar,1 Nouf A AlShamlan,1 Marwa Mahmoud Shafey,1 Assim M AlAbdulKader,1 Khalid S AlHarkan,1 Wejdan M Al-Johani,1 Sameerah Motabgani,1 Nourah K Alkaltham,1 Abdullah A Alharbi2 1Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; 2Family and Community Medicine Department, Faculty of Medicine, Jazan University, Jazan City, Jazan, Saudi ArabiaCorrespondence: Reem S AlOmar, Email rsomar@iau.edu.saIntroduction: COVID-19 remains a public health concern. Vaccinations, testing and tracing have been proven to provide strong protection against severe illness and death. Older adults are amongst the groups with an increased risk of severe illness. This study aimed to explore the willingness and hesitancy of the elderly population in the Kingdom of Saudi Arabia to test and vaccinate against COVID-19.Methods: This cross-sectional study targeted participants aged 65 years and above. The questionnaire included both sociodemographic variables, and variables related to willingness and hesitancy to vaccinate and test for COVID-19 that were mainly based on existing literature. Bivariate analyses were performed to test for associations. Significance was set at the 0.05 level.Results: The total sample of respondents was 502. The results show that 52.4% were not aware of a previous infection. Participants aged above 70 years and females were found to be more aware of a previous infection (51.6% and 53.1% respectively) (P < 0.05). Also, 54.7% felt it necessary to test against COVID-19, and among those, 70.8% believed that testing would contain and control the spread. The results also show that 3.2% were not vaccinated to date, compared to 95.41% who had the complete dose as well as the recommended booster dose for elderlies. Age, sex and level of education were significantly associated with vaccine uptake, where participants aged between 65 and 70 years, males and high levels of education were associated with a complete vaccine uptake.Discussion: The current findings add to the epidemiological evidence and show that the social network theory within the context of health may have played a role in self-awareness of previous infections. Also, social factors should be incorporated in public health interventions and public health campaigns targeting the elderly are still needed especially with the continued discovery of variants of interests.Keywords: COVID-19, public health, health promotion, prevention, elderly

Reem S AlOmar,1 Nouf A AlShamlan,1 Wejdan M Al-Johani,1 Ali H Almayyad,1 Hadeel K Alotaibi,1 Sarah I Alsamin,1 Naif Y Alfrayyan,2 Leila A Boubshait,1 Layla M Alghamdi,1 Malak A Al-Shammari1 1Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia; 2Internal Medicine Department, Psychiatry Division, Security Forces Hospital, Riyadh, Kingdom of Saudi ArabiaCorrespondence: Reem S AlOmar, Email rsomar@iau.edu.saBackground: Attention deficit hyperactivity disorder (ADHD) among the youth and university students differs internationally. This study aims to assess the prevalence of ADHD positivity from a validated screening test among medical students across the Kingdom of Saudi Arabia (KSA) and its associated sociodemographic and family-related factors and the impact of ADHD on students’ academic performance. Also, to highlight the implications of the current findings on epidemiologists and family physicians in the region.Methods: This cross-sectional study utilised the Adult ADHD Self-Report Scale (ASRS) symptom checklist along with several questions on sociodemographic, siblings and personal academic achievement. Multivariable logistic regression models were performed to obtain the Odds Ratios (ORs) of risk of ADHD screening positivity and their 95% confidence intervals (CIs) against potential predictors.Results: The overall prevalence of positively screened medical students was 38.86%. After adjustment, a statistically significant increased risk of ADHD positivity was observed for students who had one sibling (OR = 1.70, 95% CI = 1.09– 2.64). Also, upon examination of birth order, a significant increased risk was observed for students who were firstborn (OR = 1.22, 95% CI = 1.02– 1.47). With regard to academic achievement, both before and after adjustment, students who screened positive had a 14% increased risk of obtaining an F GPA (OR = 1.14, 95% CI = 0.99– 1.30).Conclusion: A considerable number of medical students are potentially positive for ADHD. Albeit not diagnostically confirmed – this indicates that a substantial number of people have displayed symptoms akin to ADHD, but were not clinically diagnosed. Research into ADHD in the region is still in its infancy, and epidemiologists would benefit from high-quality databases to address this condition. Also, primary care physicians should develop skills in detecting and managing ADHD in children at an earlier age to improve symptoms in adulthood.Keywords: attention deficit hyperactivity disorder, epidemiology, family physicians, cross-sectional study, Kingdom of Saudi Arabia

Nouf A AlShamlan,1 Reem S AlOmar,1 Assim M AlAbdulKader,1 Faisal A AlGhamdi,2 Abdullah A Aldakheel,2 Saud A Al Shehri,2 Lyana Atif Felemban,3 Marwa Mahmoud Shafey,1 Malak A Al Shammari1 1Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; 2College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; 3College of Medicine, Fakeeh College of Medical Sciences, Jeddah, Saudi ArabiaCorrespondence: Nouf A AlShamlan, Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia, Tel +966 504901406, Email nashamlan@iau.edu.saPurpose: Epidemiologically, cervical cancer is the fourth most commonly diagnosed cancer among females globally and the third most commonly diagnosed gynecological cancer in Saudi Arabia. Screening is an important measure to prevent it. The current study aimed to assess, epidemiologically, female healthcare workers’ (HCWs) utilization of cervical cancer screening services and its association with their beliefs about cervical cancer and the screening test, as well as their personal characteristics.Methods: This cross-sectional study included female HCWs in Saudi Arabia. A predesigned, self-administered survey was used to collect data, and it included questions about sociodemographic and reproductive characteristics, self-utilization of cervical cancer screening services, and the Health Belief Model (HBM) scale. Regression analyses were conducted to identify predictors of cervical cancer screening service utilization.Results: A total of 1857 females participated. The cervical cancer screening test uptake was 24.6% of ever-married females. However, 45% of the participants were willing to have the test. The odds of utilizing a screening were significantly higher among older participants, those with a higher level of education, and those with a higher number of pregnancies. Furthermore, HCWs with a history of HPV infection, cervical cancer in the family, hormonal contraception, or immunocompromised diseases were more likely to have the screening. An increase in the mean scores of the perceived benefits and motives subscales of HBM was associated with an increase in the uptake of screening. However, an increase in perceived barrier scores was significantly associated with a lower likelihood of cervical cancer screening uptake.Conclusion: Low cervical screening uptake and slightly higher intentions to have the test exist among HCWs. Certain personal factors and health beliefs significantly affect the utilization of the screening test. Approaches that target perceived benefits, health motivation, and perceived barriers to improve the screening rates of cervical cancer among HCWs are recommended.Keywords: cervical cancer screening, health belief model, Pap smear, healthcare worker, utilizations, Saudi Arabia

Wejdan M Al-Johani,1 Nouf A AlShamlan,1 Manar F AlGhamdi,2 Assim M AlAbdulkader,1 Waleed M Aljohani,3 Rehab F AlGhamdi,2 Munir Alrefae,4 Muna Alshehabi,5 Reem S AlOmar,1 Moataza M Abdel Wahab1 1Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, 34224, Saudi Arabia; 2College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; 3Supply Chain Department, Security Forces Hospital, Dammam, Saudi Arabia; 4Department of Internal medicine, King Fahad Hospital of University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; 5Palliative Medicine Department, King Fahad Specialist Hospital, Dammam, Saudi ArabiaCorrespondence: Wejdan M Al-Johani, Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, P.O. Box 1982, Dammam, 34224, Saudi Arabia, Tel +966599721175, Email wmaljohani@iau.edu.saPurpose: A cancer diagnosis is an overwhelming process for both patients and doctors. Many studies have addressed doctors’ opinions and knowledge regarding breaking bad news (BBN). However, scarce knowledge exists regarding patients’ perspectives for communicating bad news. Therefore, the current study aims to assess cancer patient preferences and satisfaction about BBN.Patients and Methods: This is a mixed methods study consisting of two phases; an in-depth interview and cross-sectional quantitative analysis. Thematic analysis was used for the qualitative data to explore patients’ satisfaction and preferences about BBN. For quantitative analyses, the overall satisfaction was calculated as satisfaction percent. Bivariate analyses were performed, and statistical significance was set as p < 0.05. Quality function deployment was used to effectively define patient requirements of highest priority.Results: Thematic analysis revealed two main themes. Theme 1; patients’ requirements for BBN and theme 2; patients’ reaction at the time of diagnosis with their categories. For the quantitative part, a total of 222 patients responded to the survey, females made up 70% of the sample. Satisfaction score percent ranged from 25.5 to 100%, with a mean of 82.7± 11.9%. The most preferred items were mainly concerned with the doctor being honest and encouraging, good listener and interacting giving simple smooth explanations without using medical terms, and empathetic (average score 4.8/5). Also, providing the diagnosis in a calm and private environment (4.7/5). Analysis also found that the requirements for improvement included providing a written summary after receiving the diagnosis and patient perception assessed by the doctor before telling the diagnosis.Conclusion: Communicating bad news effectively is crucial in the management of cancer patients. The process of BBN should be patient-centered, focusing on patients’ needs. Thus, the current study has demonstrated the patients’ preferences and the requirements, which should be incorporated into BBN protocols.Keywords: breaking bad news, cancer, patients’ preferences, patients’ satisfaction

Nouf A AlShamlan,1 Reem S AlOmar,1 Roba Aldossary,2 Maha Alahmari,2 Asma Alghamdi,2 Mawaddah AlGhamdi,2 Najla Alkanaan,2 Abdullah H AlReedy,1 Amani S AlOtaibi,3 Nada S Alghamdi4 1Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; 2College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; 3Department of Obstetrics and Gynaecology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; 4Department of Microbiology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi ArabiaCorrespondence: Nouf A AlShamlan, College of Medicine, Imam Abdulrahman Bin Faisal University, P.O. Box 1982, Dammam, 34224, Saudi Arabia, Tel +966504901406, Email nashamlan@iau.edu.saPurpose: Asymptomatic bacteriuria (ASB) is the presence of significant amounts of bacteria within the urinary tract in the absence of urinary tract infection (UTI) symptoms, resulting in negative neonatal and pregnancy consequences. This study determined the prevalence, bacteriology patterns, and associated factors with ASB among pregnant women in both primary and hospital levels of care in the Eastern Province of Saudi Arabia.Methods: This retrospective chart review study included pregnant women between 18 and 50 years who performed the screening urine culture test during their first antenatal visit between 2017 and 2021, without UTI symptoms. The collected data involved the demographic, medical, and obstetric characteristics, and urine culture results. T-tests and chi-squared tests were used for bivariate associations followed by binary logistic regression models.Results: ASB was positive among 03.42% of the 6471 pregnant women included in the study. Logistic regression revealed that the risk of positive ASB increased in pregnant women in the first and second trimesters (OR = 2.04, 95% CI = 1.41– 2.93 and OR= 1.50, 95% CI = 1.03– 2.19, respectively), as well as pregnant women with a history of previous UTI (OR = 2.98, 95% CI = 2.14– 4.15). The predominant organism isolates were E. coli, followed by GBS, Klebsiella pneumoniae, and Enterococcus faecalis.Conclusion: With limited data on ASB among pregnant women in Saudi Arabia, findings from the current study could help decision-makers in the country assess the epidemiological characteristics of the condition. Further study is recommended to investigate the susceptibility patterns of commonly prescribed antibiotics with different uropathogens to guide the clinicians who deal with these cases. Additionally, a large national study across the other regions in the kingdom is suggested to calculate the prevalence of ASB in Saudi Arabia.Keywords: asymptomatic bacteriuria, pregnant, prevalence, E. coli, epidemiology, Saudi Arabia

Nouf A AlShamlan, Malak A Al Shammari, Reem S AlOmar, Danya Gari, Assim M AlAbdulKader, Sameerah Motabgani, Abdulaziz Farea, Magdy A Darwish Department of Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi ArabiaCorrespondence: Nouf A AlShamlanDepartment of Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi ArabiaTel +966504901406Email nashamlan@iau.edu.saBackground: Understanding the distribution of blood groups and blood donation willingness in a population is crucial in managing blood banks and transfusion services. Moreover, awareness of one’s own blood group is essential especially in emergencies that mandate blood donation. This study aimed to determine the distribution of ABO and Rhesus (Rh) blood groups among health students, the students’ knowledge about their blood group, and their willingness to donate blood.Methods: This cross-sectional study included all newly accepted health students in a large university in the Eastern Province of Saudi Arabia (N=1145) during August 2020. The data included a self-administered questionnaire and the serology results of ABO and Rh factors. Chi-squared and Fisher’s exact tests were performed followed by a multivariable binary logistic regression analysis which identified the predictors of willingness of blood donation.Results: Blood group O was the most frequent type among students (51.1%), followed by group A (24.5%) and B (20.4%). The majority (93.3%) of students had Rh-positive factor. When we compared students’ answers with their sample results, most students (75.5%) correctly reported their ABO and Rh blood groups. Male students and those with a previous history of blood donation correctly reported their blood group more than others. Of the total sample, 47.3% were willing to donate blood within the next year. Positive predictors of the willingness of student to donate blood included being male, and those with a history of blood donation. Interestingly, students with a family member in the healthcare field were significantly less likely to donate blood.Conclusion: Blood group O and Rh positive were the most frequent blood groups. Most students had a good knowledge about their blood groups, and about half of students were willing to donate blood. Efforts to encourage the young population to participate in blood donation are crucial.Keywords: ABO blood group, Rh factor, blood donation, Saudi, students

Nouf A AlShamlan,1 Reem S AlOmar,1 Omar Y Almukhadhib,2 Saad A Algarni,2 Askar K Alshaibani,2 Sara A Elmaki,3 Malak A Al Shammari,1 Abdulaziz M Sebiany1 1Department of Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; 2College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; 3Department of Radiology at Family and Community Medicine Center, Imam Abdulrahman Bin Faisal University, Dammam, Saudi ArabiaCorrespondence: Nouf A AlShamlanDepartment of Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi ArabiaTel +966504901406Email nashamlan@iau.edu.saBackground: Breast masses are common among females presenting to primary health care (PHC) facilities. The family physician’s role is crucial in detecting breast disease. Utilization of breast ultrasonography has been increasing recently as a diagnostic tool.Objective: This study aims to determine the characteristics of masses detected on breast ultrasound, their associations with characteristics of females attending the PHC setting and explore the management of these cases by family physicians.Methods: This registered based, cross-sectional study included 321 females who were referred for diagnostic breast ultrasound in the PHC center of the University hospital, Eastern province, Saudi Arabia (2017– 2019). t-test, Chi-squared and Fisher’s Exact tests were performed to assess associations between the presence of breast masses in the ultrasound and patients’ characteristics. Moreover, to compare the breast masses in two groups of patients (< 40 years and ≥ 40 years) regarding their characteristics, ultrasound findings, and further management performed. P < 0.05 was considered statistically significant.Results: Approximately 24% patients had a breast mass and 70.92% of cases were detected among females ≥ 40 years old. The odds of having a breast mass were highest among overweight, females complaining from a breast lump, and who had early menarche. Grand multiparous had lower odds of a breast mass. Females < 40 years old had higher rates of breastfeeding, increasing parity, and obesity than older females. Sonographic examined masses were larger in young females, and posterior enhancement of the mass was more reported in older. BI-RADs of the masses were not associated with the patient’s age.Conclusion: Breast masses were prevalent among females who underwent breast ultrasound. The results support referral for investigation when a female complains of a breast lump. Family physicians have a vital role in encouraging protective behaviors from developing breast masses such as maintaining normal weight and breastfeeding.Keywords: breast, mass, ultrasound, primary care, family physician

Naheel A AlAmer,1 Reem S AlOmar,1 Shikha M AlKaltham,2 Rawan S AlYami,2 Fatimah N AlRashidi,2 Mai M AlJrri,2 Moataza M Abdel Wahab1 1Department of Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; 2College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi ArabiaCorrespondence: Naheel A AlAmerDepartment of Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi ArabiaEmail naalamer@iau.edu.saBackground: As the Saudi Food and Drug Authority (SFDA) has recently requested all food facilities to display the calorie count on their menus, this study aimed to identify the perceived changes in costumers’ eating behaviours in response to the calorie count display (CCD) policy in the Eastern Province.Methods: This was a mixed methods study. The first being quantitative, using a cross-sectional questionnaire which included 400 customers of both genders, aged 10 years and older, and was collected at food facilities from three cities in the Eastern Province. Customers completed a self-administered questionnaire and handed their registered receipts. Collected receipts were used to calculate the total calories ordered per customer. The second method is a qualitative in-depth interview with food facility managers.Results: Customers who reported checking the CCD were 30.5% of the total sample, and 58.2% of them changed their order accordingly. The mean calories ordered were 36 kcal less in customers checking the CCD than those who do not (P=0.674). Customers who exhibit healthy lifestyle habits calculate their daily consumed calories, knowledgeable of the recommended daily caloric intake (RDCI), dining in a dine-in restaurant, and have an educational level of above high school were more likely to check the CCD. This study found that customers who cared to check the CCD were more likely to change their eating behavior. It has been found that only a small percentage (12% to 18%) of customers were knowledgeable regarding the RDCI. After the implementation of the policy, restaurant managers reported a positive change in customers eating behavior, which was more profound in females and athletes.Conclusion: There is a significant association between checking the CCD and positive behavioral changes in customers’ eating behaviors. The results of this study suggest that further enforcement and awareness raising are crucial to increase the number of customers checking and using the CCD.Keywords: calories, energy intake, restaurants, Saudi Arabia, behavior, nutritional

Nouf A AlShamlan,1 Reem S AlOmar,1 Malak A Al Shammari,1 Reem A AlShamlan,2 Abeer A AlShamlan,2 Abdulaziz M Sebiany1 1Department of Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; 2College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi ArabiaCorrespondence: Nouf A AlShamlanDepartment of Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi ArabiaTel +00966504901406Email nashamlan@iau.edu.saBackground: Anxiety disorders are a significant global health concern with destructive morbidity and mortality. Medical school is a stressful environment worldwide. This study measures the prevalence of anxiety symptoms among clinical-year medical students in Saudi Arabia. As well as to explore its association with students’ sociodemographic factors, academic performance, issues experienced by them during the study of medicine, and their perceived readiness for their future specialties.Methods: The generalized anxiety disorder (GAD-7) tool along with a sociodemographic questionnaire was distributed to 523 clinical-year medical students (fourth, fifth and sixth years) from the Imam Abdulrahman Bin Faisal University, Saudi Arabia, in this cross-sectional study. Data analysis was performed with SPSS version 23 and it included the Chi-Square or Fisher’s exact tests for bivariate analysis, and the multivariable logistic regression to account for confounders.Results: The prevalence of anxiety symptoms as measured by the GAD-7 was found to be 31.7%. Of these, 14.3% had severe symptoms. Only 4.4% students went to a healthcare professional and were diagnosed with psychiatric problems. Logistic regression analysis revealed that the odds of anxiety was higher among females and students who had perceived psychological problems. However, students’ grade point average (GPA) and perceived readiness for their future specialty were not statistically significant with anxiety symptoms.Conclusion: Anxiety was highly prevalent among clinical-year medical students included in this study. This urges periodic mental health screening, proper diagnosis of high-risk individuals in medical schools, and early interventions through confidential access to mental health services.Keywords: prevalence, generalized anxiety disorder, medical students, Saudi

Background: In the Kingdom of Saudi Arabia (KSA), little is known about the adoption of virtual consultations (VCs), with most studies being survey-based leading to varying results. This study aims to utilise secondary collected data on the use of both kinds of VCs currently available, and to epidemiologically describe the adoption of these consultations., Methods: This retrospective study analysed data provided by the Ministry of Health between January 1st 2021 and June 30th 2022. For both the home-based and the hospital-based consultations, variables included the age and sex of patients, date of consultation, duration in minutes, closure status for the appointment and the governorate in which the patient is residing. A heat map was drawn to present patterns of utilisation across the country., Results: The total number of VCs for both types were 1,008,228. For both types, females were higher adopters (54.73%). Of the total number of consultations, 751,156 were hospital-based. Of these consultations, family medicine consultations were the most common (20.42%), followed by internal medicine. Maternity follow-up clinics were higher in home-based clinics. The proportion of patient no-shows was high overall (48.30%). Utilisation was high in urban governorates, and low in rural ones., Conclusion: Findings have several implications on health policy. It provides further evidence of the importance of family medicine, where it was the most common speciality even in hospital-based settings. The high variability in the adoption of consultations across rural and urban areas as well as the extremely high number of patient-no-shows warrants further investigation., (© 2024. The Author(s).)

Objective: Inferior turbinate (IT) hypertrophy-induced chronic nasal obstruction is one of the most common problems in rhinology. However, the histopathological analysis of the hypertrophic IT is unclear. Therefore, this study aimed to identify the histological changes and the most functional areas of the IT to assist otolaryngologists with improving and modifying surgical techniques and minimizing potential complications., Methods: This prospective, cross-sectional study was conducted to evaluate the contribution of hypertrophic IT to nasal obstruction. For the analysis, a total of 38 adult patients (IT hypertrophy group and non-IT hypertrophy [control] group) were enrolled, and 131 specimens were obtained during the surgical procedures (IT hypertrophy group, endoscopic submucosal turbinoplasty and septoplasty; non-IT hypertrophy group, septoplasty). Intraoperative samples were collected from four sites of the IT to determine the dimensions, composition, and possible pathological changes in each individual site. The samples were analyzed using light microscopy., Results: A comparison of the four sites of the IT in the IT hypertrophy group showed that the posterior end had the highest normal epithelium percentage, and cilia count. This suggests that preserving the functional part of the IT during surgery is crucial. Furthermore, a comparison of both groups in terms of basement membrane thickness and vessel wall thickness (p = 0.005 and p = 0.03, respectively) showed significant differences., Conclusion: Our findings can assist otolaryngologists select the most appropriate surgical procedures for IT hypertrophy. In addition, they advocate the importance of preserving the functional part of the IT during surgical intervention to achieve an efficiently working IT and avoid undesirable complications while improving the nasal airway passage., Level of Evidence: Level 3., (Copyright © 2024 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier España S.L.U. All rights reserved.)

Introduction: An effective referral system is necessary to ensure quality and an optimum continuum of care. In the Kingdom of Saudi Arabia, an e-referral system known as the Saudi Medical Appointments and Referrals Centre (SMARC), has been fully functioning since 2019. This study aims to explore the rate of medical e-referral request acceptance in the KSA, and to study the factors associated with acceptance., Methods: This period cross-sectional study utilised secondary collected data from the SMARC e-referral system. The data spans both 2020 and 2021 and covers the entirety of the KSA. Bivariate analyses and binary logistic regression analyses were performed to compute adjusted Odds Ratios (aORs) and 95% confidence intervals., Results: Of the total 632,763 referral requests across the 2 years, 469,073 requests (74.13%) were accepted. Absence of available machinery was a significant predictor for referral acceptance compared to other reasons. Acceptance was highest for children under 14 with 28,956 (75.48%) and 63,979 (75.48%) accepted referrals, respectively. Patients requiring critical care from all age groups also had the highest acceptance including 6,237 referrals for paediatric intensive care unit (83.54%) and 34,126 referrals for intensive care unit (79.65%). All lifesaving referrals, 42,087 referrals, were accepted (100.00%). Psychiatric patients were observed to have the highest proportion for accepted referrals with 8,170 requests (82.50%) followed by organ transplantations with 1,005 requests (80.92%). Sex was seen to be a significant predictor for referrals, where the odds of acceptances for females increased by 2% compared to their male counterparts (95% CI = 1.01-1.04). Also, proportion of acceptance was highest for the Eastern business unit compared to all other units. External referrals were 32% less likely to be accepted than internal referrals (95% CI = 0.67-0.69)., Conclusion: The current findings indicate that the e-referral system is mostly able to cater to the health services of the most vulnerable of patients. However, there remains areas for health policy improvement, especially in terms of resource allocation., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Alharbi, Aljerian, Binhotan, Alghamdi, AlOmar, Alsultan, Arafat, Aldhabib, Aloqayli, Alwahbi and Alabdulaali.)

Introduction: Referrals are an integral part of any healthcare system. In the Kingdom of Saudi Arabia (KSA) an electronic referral (e-referral) system known as the Saudi Medical Appointments and Referrals Centre (SMARC) began formally functioning in 2019. This study aims to showcase the Saudi experience of the e-referral system and explore the epidemiology of referrals nationally., Methods: This retrospective descriptive study utilised secondary collected data between 2020 and 2021 from the SMARC system. Cross tabulations with significance testing and colour-coded maps were used to highlight the patterns across all regions., Results: The study analysed over 600,000 referral requests. The mean age of patients was 40.70 ± 24.66 years. Males had a higher number of referrals (55.43%). Referrals in 2021 were higher than those in 2020 (56.21%). Both the Autumn and Winter seasons had the highest number of referrals (27.09% and 27.43%, respectively). The Surgical specialty followed by Medicine had the highest referrals (26.07% and 22.27%, respectively). Life-saving referrals in the Central region were more than double those in other regions (14.56%). Emergency referrals were also highest in the Southern regions (44.06%). The Central and Eastern regions had higher referrals due to unavailable sub-speciality (68.86% and 67.93%, respectively). The Southern regions had higher referrals due to both unavailable machine and unavailable beds (18.44% and 6.24%, respectively)., Conclusion: This study shows a unique system in which referrals are between secondary, tertiary, and specialised care. It also highlights areas of improvement for equitable resource allocation and specialised care in slightly problematic areas as well as the use of population density in future planning., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Aljerian, Alharbi, AlOmar, Binhotan, Alghamdi, Arafat, Aldhabib and Alabdulaali.)

Introduction: Lower back pain is common worldwide and affects over 600,000 people annually, including teachers. The study aimed to investigate the prevalence of low back pain and disability among secondary school teachers in the Eastern Province of the Kingdom of Saudi Arabia., Materials and Methods: This cross-sectional study included secondary school teachers in the eastern province of Saudi Arabia. 34 schools were selected using a multistage stratified sampling approach. Teachers were allotted randomly and proportionally to each school. Data was collected by anonymous questionnaire having three elements: sociodemographic and health-related questions, the Standardized Nordic Questionnaire, and the Oswestry Low Back Pain Disability Questionnaire. The anthropometric data was also included. Both unadjusted and adjusted logistic regression analyses were performed., Results: A total of 601 teachers participated in the study with 62.56% reported low back pain. The overall mean age was 40.31 ± 8.13 years. The male-to-female ratio was similar. Back pain was significantly higher among females than males (73.36 and 51.52%, respectively). Additionally, back pain will significantly increase when stress levels and the number of classes increases. A positive correlation was found between age with low back pain ( p  = 0.001).There was minimal disability in 64.63% of the 376 teachers who reported low back pain, moderate disability in 29.79%, and severe disability in 4.79%, and only three (0.8%) were considered crippled. Females were more frequently seen in moderate and crippled categories, and perceived stress levels generally increased mean disability scores. Age and female gender were revealed to be significant predictors of low back pain by logistic regression (adjusted odds ratio [OR] = 1.04, 95% confidence interval [CI] = 1.02-1.07) and (adjusted OR = 2.11, 95% CI = 1.45-3.05), respectively. The number of classes per week was also a significant predictor., Conclusion: This study adds to the epidemiological evidence that reveals a high prevalence of low back pain and disability among teachers. Identified risk factors in this study may also reinforce the importance of setting different interventions and preventive measures to reduce lower back pain risk., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Almansour, Almutairi, Alaskar, Kalkatawi, Aljubair, Alotaibi, AlHarkan, Alqahtani and AlOmar.)

Introduction: Older adults aged 65 years and above are among the most vulnerable to adverse outcomes and death following a COVID-19 infection. The weekly epidemiological updates by the World Health Organisation show that the continued emergence of concerning subtypes of the virus indicates that the pandemic remains a public health concern and the public should continue to comply with personal preventive measures (PPMs). This study applies the Theory of Planned Behaviour (TPB) which is rooted in the field of Public Health, Epidemiology, and Preventive Medicine to Saudi older adults to predict their health behaviour., Methods: This behavioural epidemiological study recruited older adult participants aged 65 years of age and above. A tool which consisted of sociodemographic and health-related questions, as well as questions regarding the components of the TPB, namely, Attitude, Subjective Norm, Perceived Behavioural Control was used. Bivariate analyses, followed by unadjusted and adjusted multivariable logistic regression analyses were performed to derive odds ratios and 95% confidence intervals., Results: The total number of participants was 502. The mean age was 70.34 years, with similar distributions between males and females. In total, 52.2% intended to practice PPMs, whereas only 48% had a good practice. Also, 56% had a favourable Attitude towards PPMs, 61.4% had a positive Subjective Norm and 39.8% had perceived they had a high control over their behaviour. Females, and high educational status were predictors for high intention to practice PPMs (OR = 1.59, 95% CI = 1.01-2.52 and OR = 2.72, 95% CI = 1.44-5.16 respectively). Further predictors included Attitudes, Subjective Norm and Perceived Behavioural Control. Results also show that intention to practice was significantly associated with a lower odd of practicing PPMs (OR = 0.06, 95% CI = 0.04-0.10)., Conclusion: Current findings highlight the need to continue with public health efforts targeting vulnerable older adults. Also, the fact that intention negatively predicted practice highlights the need for further behavioural epidemiological studies addressing the intention-behaviour gap., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer OA declared a shared affiliation with the authors to the handling editor at the time of review., (Copyright © 2023 AlOmar, AlHarbi, Abu Abdullah, Almuqbil, Albahrani, Aldar, Alzouri, Al-Shiban, AlShamlan, Shafey, AlAbdulKader and Alotaibi.)

Background: Emergency department length of stay is a vital performance indicator for quality and efficiency in healthcare. This research aimed to evaluate the length of stay patterns in emergency departments across Saudi Arabia and to identify predictors for extended stays. The study used secondary data from the Ministry of Health's Ada'a program., Methods: Using a retrospective approach, the study examined data from the Ada'a program on emergency department length of stay from September 2019 to December 2021. These data covered 1,572,296 emergency department visits from all regions of Saudi Arabia. Variables analyzed included quality indicators, year of visit, shift time, hospital type, and data entry method. The analysis was conducted using multiple linear regression., Results: The study found that the median length of stay was 61 min, with significant differences among related predictors. All associations were significant with a value of p of less than 0.001. Compared to 2019, the length of stay was notably shorter by 28.5% in 2020 and by 44.2% in 2021. Evening and night shifts had a shorter length of stay by 5.9 and 7.8%, respectively, compared to the morning shift. Length of stay was lower in winter, summer, and fall compared to spring. Patients in levels I and II of the Canadian Triage and Acuity Scales had longer stays than those in level III, with those in level I reaching an increase of 20.5% in length of stay. Clustered hospitals had a longer length of stay compared to the non-clustered ones. Pediatric hospitals had a 15.3% shorter stay compared to general hospitals. Hospitals with data entered automatically had a 14.0% longer length of stay than those entered manually. Patients admitted to the hospital had a considerably longer length of stay, which was 54.7% longer compared to non-admitted patients. Deceased patients had a 20.5% longer length of stay than patients discharged alive., Conclusion: Data at the national level identified several predictors of prolonged emergency department length of stay in Saudi Arabia, including shift time, season, severity level, and hospital type. These results underline the necessity of continuous monitoring and improvement efforts in emergency departments, in line with policy initiatives aiming to enhance patient outcomes in Saudi Arabia., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Alharbi, Muhayya, Alkhudairy, Alhussain, Muaddi, Alqassim, AlOmar and Alabdulaali.)

Background: Physical inactivity is a major problem of adolescents worldwide. Fitness trackers are widely used technologies that assess physical activity and allow self-monitoring of daily activities. Thirty-five percent of the Saudi population is made up of adolescents, which makes them an important target population. Few studies have evaluated the association of fitness trackers with physical activity levels of adolescents. This study aimed to evaluate physical activity among adolescents and its relationship to their use of fitness trackers and overall health., Materials and Methods: A cross-sectional study was carried out among adolescents in middle and high schools in the Eastern Province. Data was collected using a structured questionnaire and physical activity was assessed using International Physical Activity Questionnaire for Adolescents. Chi-square test and ANOVA were performed to test for statistical significance. Unadjusted and adjusted odds ratios (ORs) were obtained through ordered logistic regression models. Model diagnostics were run as post hoc analyses., Results: Majority of participants (82.6%) had low physical activity levels, 12.2% had moderate and 5.2% had vigorous activity level. The model revealed that as participants' ages increased, the odds of having higher levels of physical activity decreased (OR = 0.92; 95% confidence interval [CI]: 0.85-0.99). Moreover, participants who did not go to a gym regularly or own a fitness tracker were less likely to have higher physical activity levels (OR = 0.43; 95% CI:0.30-0.61, and OR = 0.44; 95% CI: 0.33-0.59, respectively). Motivation for using fitness trackers was mostly "no specific reason" for females. However, "luxury and esthetics" were mostly reported by males., Conclusion: Physical activity tends to be higher in younger adolescents who use fitness trackers, or go to the gym regularly, with no significant difference between males and females. However, the motivation behind adolescents' use of fitness trackers varied by gender., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of Family and Community Medicine.)

Background: Falls are dangerous to the health of older adults and can impact their functional status leading to frailty. The use of potentially inappropriate medications (PIMs) among older adults may lead to adverse health outcomes and increase the risk of falls. Polypharmacy increases the incidence of falls. Beers criteria by the American Geriatric Society is one of the many criteria used to detect PIMs. It assesses the appropriateness of drug prescriptions (i.e., correct dose, duration, and indications) to ensure the safety of these drugs, reducing drug interactions and decreasing the hazards of side effects. This epidemiological study aims to explore the association between polypharmacy and Beers criteria with the risk of falls in the elderly., Method: A total of 387 outpatients aged 60 or older were interviewed in person. The patients were recruited from the University Hospital and the Family and Community Medicine Center in Khobar city, Saudi Arabia, between the period of November 2021 to March 2022. All patients were able to walk independently. The survey began by collecting patients' demographics, gathering medication history, and asking three key questions to detect the risk of falls which was developed by the Center of Disease Control (CDC). Polypharmacy (defined as concurrent use of five or more medications) and PIMs (defined as use of one or more medications in the Beers list) were examined against risk of falls in the elderly. Multiple logistic regression analyses were used to estimate adjusted Odds Ratios (ORs)., Result: A total of 387 patients participated in the study; 62% were male, and most participants belonged to the 60 < 65 years age category (47.80%). Among all patients, 55% had a high risk of falling, and 21% of patients had fell during the past year. Polypharmacy applied to 50.90% of all patients, while Beers criteria positive group applied to 51.42%. Risk of falls and prior falls were associated with polypharmacy both before and after adjustment., Conclusion: The results showed a significant association between risk of falls with polypharmacy and PIMs, and more than half of our study population had a high risk of falls. Of those at a higher risk, one out of five had indeed experienced a fall in the last 12 months. Higher rates of falls were associated with older aged patients, lower educational levels, female gender, and cardiovascular medications., (© 2023. The Author(s).)

Background: Decreasing the number of Emergency Department patient visits for treatment, especially in non-urgent cases, is an international healthcare goal. The same applies for pediatric emergency rooms where the utilization of ED is much more than adults., Objective: We aim to measure the length of stay for all pediatric patients and examine the factors influencing it., Methods: A retrospective chart review study was conducted at the pediatric ED of King Fahd Hospital in the Eastern Province of Saudi Arabia. The study included all patients presented to the pediatric ED, between January 1, 2018, and December 31, 2018, aged from 1 day to < 14 years old. Data included patient's age, sex, season in which the patient presented in, chief complaint, time of presentation, and whether admission to the hospital ward was collected., Results: The total number of patients was 37,613. The median LOS was 100, interquartile range (IQR) = 53 - 272 minutes. Male pediatric patients were (55.12%). Among all patients, (32.04%) were toddlers, followed by school aged children (25.05%). The ER received more patients during the winter months followed by summer (32.92% and 24.72%, respectively). Fever was the most common complaint for all patients combined. For prolonged LOS patients, the most common complaints were respiratory related (23.44%). Pre-school children and school aged children were found to have a 5.49% and a 7.93% increased LOS when compared to toddlers (95% CI = 2.52 - 8.53, and 95% CI = 5.01 - 10.93, respectively). Summer was associated with a statistically significant increased LOS (% change = 28.92, 95% CI = 25.53 - 32.40). Morning shift was found to have a 7.89% increased LOS when compared to the evening shift. The highest increase in LOS was attributed to haematology related complaints (% change = 108.32, 95% CI = 85.69 - 133.71)., Conclusion: Several pediatric LOS predicting factors have been identified; morning arrival, and presentation during summertime. Systemic factors such as staffing, and infrastructure can be modified and may affect the length of stay of patients. The implementation of these strategies and the evaluation of their impact on the length of stay in the pediatric emergency department require further investigation., Competing Interests: There are no conflicts of interest., (© 2023 Abdullah A. Yousef, Mohammed H. Al Qahtani, Abdullah K. Al-Mutairi, Faisal O. AlQurashi, Reem S. AlOmar, Nouf A. AlShamlan, Malak A. Al Shammari, Hannen A. Yousef.)

Objective: Wake-up stroke (WUS) comprises a significant proportion of ischemic strokes. However, due to unclear onset, these patients are often not considered for reperfusion therapy. The objective of this study was to investigate the clinical and imaging differences between WUS patients and those with clear-onset stroke, documenting any sex, age, or risk factor predilection for WUS., Methods: This prospective observational cohort study used an ongoing stroke registry to identify patients with acute ischemic stroke admitted to a hospital in Saudi Arabia within 5 days of symptom onset from April 2018 to March 2020. Patients were classified into 2 groups: WUS and clear-onset stroke., Results: Among 645 patients, 448 met the criteria for acute ischemic stroke and were included in the study. WUS was identified in 112 (25%) patients. There were no differences in sex or median age between the 2 groups. Diabetes mellitus, hypertension, and dyslipidemia were higher in the WUS group, while atrial fibrillation, history of stroke and epilepsy were higher in the clear-onset stroke group. Bihemispheric stroke was higher in the clear-onset stroke group than in the WUS group (6.0% vs 2.7%)., Conclusions: Only minor dissimilarities between clinical and radiologic features of WUS and clear-onset stroke were found. Circadian patterns of stroke onset were observed in both groups. Stroke was more likely to occur during waking than during sleep, and a diurnal pattern of common occurrence during the morning was documented. Recognition of the acceptable timeframe for acute reperfusion therapy in unwitnessed strokes is crucial so that thrombolytic treatment can be started for these patients., (© Copyright 2022 Physicians Postgraduate Press, Inc.)

Purpose of the Study: This study aims at identifying the predominant learning approaches by Saudi medical students across Saudi Arabia and assess its possible associations with sociodemographic and educational characteristics., Study Design: A cross-sectional study design using the Approaches and Study Skills Inventory for Students questionnaire. The questionnaire gives rise to three possible learning approaches; deep, strategic and surface approaches. Bivariate analyses were performed through independent samples t-test and χ2 tests where appropriate. A multinominal regression analysis was performed to obtain risk estimates and 95% CIs., Results: A total of 3767 students participated and were included in the analysis. The predominant learning approach was the deep approach, followed by the strategic and surface approaches (40.59%, 37.81% and 21.60%, respectively). Males and students belonging to private medical schools were more likely to adopt a strategic rather than a deep one (relative risk ratio (RRR) 1.22, 95% CI 1.06 to 1.42 and RRR 1.32, 95% CI 1.05 to 1.65, respectively). Students with an A grade point average (GPA) were less likely to adopt a surface approach, whereas those with a C GPA were more likely to adopt it (RRR=0.67, 95% CI 0.54 to 0.83 and RRR=1.29, 95% CI 1.02 to 1.61, respectively)., Conclusion: The findings from this study show that medical students predominantly favour the deep learning approach. Results from this study encourage the continuous adaptation of clinical teaching in medical schools to optimise students' learning experiences., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Social Anxiety disorder (SAD) is common worldwide. However, data from Saudi Arabia is deficient. This study aims to determine the prevalence of SAD across Saudi medical students and its associations with sociodemographic factors and their academic performance., Methods: The main outcome was presence/absence of SAD and the secondary outcome was its level of severity. These were assessed from the Social Phobia Inventory. Associated factors included sociodemographic variables, as well as educational characteristics of students. Descriptive statistics were reported as counts and percentages, and unadjusted and adjusted odds ratios (OR) and their 95% confidence intervals (CIs) were computed through bivariate and multivariate logistic regression., Results: Of 5896 Saudi medical students who participated in the study, the prevalence of SAD was almost 51%. While 8.21% and 4.21% had reported severe and very severe SAD, respectively. Older age students were at lower risk of developing SAD (OR = 0.92, 95% CI = 0.89 - 0.96). In contrast, females (OR = 1.13, 95% CI = 1.01 - 1.26), students enrolled in private colleges and colleges implementing non-problem-based learning (OR = 1.29, 95% CI = 1.09 - 1.52 and OR = 1.29. 95% CI = 1.15 - 1.46 respectively) were at higher risk. A significant elevated risk of SAD was found among students who had previously failed, and had a low GPA., Conclusion: SAD is prevalent among the sampled population, and different associated factors were identified. Current results could raise the awareness of faculty members and healthcare providers towards early detection and management of these cases., (© 2022. The Author(s).)

Purpose of the Study: To assess the attitudes and acceptance of cosmetic surgeries and procedures among undergraduate university students in the Eastern Province, Saudi Arabia, as well as the barriers against having cosmetic surgeries and procedures., Study Design: A cross-sectional study of undergraduate university students in the Eastern Province, Saudi Arabia, during October 2020. The research instrument included the Attitudes towards Cosmetic Surgery Scale (ACSS), sociodemographic data and perceived barriers towards cosmetic surgeries and procedures. A bivariate analysis was performed followed by a linear regression to account for confounders., Results: A total of 1240 students participated in the study. The mean ACSS for cosmetic surgeries was 3.14 (±1.37 SD), and 3.25 (±1.49 SD) for cosmetic procedures. Older students, students with a history of previous cosmetic surgeries/procedures, and students with engineering specialties had more acceptance scores in both cosmetic surgeries and procedures. On the other hand, men, students belonging to a middle family income and students who perceived themselves to be aware of the risk associated with cosmetic surgeries/procedures had less acceptance scores. The most reported barrier to have cosmetic surgeries and procedures among students was feeling that they do not need it., Conclusion: The findings from the current study could help dermatologists, plastic surgeons and adolescent specialists wishing to recognise the rising interest in cosmetic surgeries and procedures in Arabic youth populations, the possible associated factors, as well as the barriers to have these surgeries and procedures. A further qualitative in-depth study to explore the acceptance is suggested., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

The COVID-19 pandemic has disrupted cancer care to a certain degree. There is objective evidence that COVID-19 outbreaks are causing substantial emotional distress among cancer patients regardless of their disease severity. This study aims to measure the levels of psychological distress, depression, and pandemic anxiety among cancer patients in Saudi Arabia during the outbreak of COVID-19 and their impact on patients' cancer treatment plans. Methods: This was a cross-sectional study conducted among oncology patients in Saudi Arabia in November of 2020. The levels of stress, depression, and anxiety symptoms during the COVID-19 outbreak were measured using the Questionnaire for Depression and Anxiety (PHQ-4), and patients were classified as depressed/distressed if the total score was 6 and above and classified as not depressed/distressed if they scored less than 6. Results: Among the sampled population, anxiety symptoms and depression were detected in 61.5% and 70.2%, respectively. Statistical analyses revealed that feeling more isolated was significant for anxiety symptoms ( p = 0.005), while patients who used institutions as a source of COVID-19 information had significant depression ( p = 0.010) compared to patients who accessed information from other sources. In the binary regression model, feeling more isolated than before was 3.208 times more likely to be associated with anxiety symptoms (OR = 3.208; 95% CI = 1.391-7.396; p = 0.006), while those patients who had a support institution as a source of COVID-19 information were 4.2 times more likely to be associated with depression (OR = 4.200; 95% CI = 1.328-13.280; p = 0.015). Conclusion: The COVID-19 pandemic has added to the burden on cancer patients. The increased risk of anxiety symptoms and depression was clearly demonstrated in this study. Feeling isolated had a greater impact on anxiety symptoms, while obtaining COVID-19 information from a patient support institution negatively affected depression.

Introduction/objectives: The prevalence of thyroid disorders is high in Saudi Arabia. Among the disorders, goiter and thyroiditis are the most common and have unique ultrasound (US) features, underscoring the need for US screening for thyroid pathologies. This study aimed to determine the prevalence of thyroiditis and thyroid nodules in patients attending the Family and Community Medicine Center of Imam Abdulrahman Bin Faisal University., Methods: This registry-based cross-sectional study analyzed laboratory and US data from 240 patients who attended the Family and Community Medicine Center of Imam Abdulrahman Bin Faisal University from January 2020 to December 2021. Abnormalities of the thyroid gland were categorized according to laboratory and US data. Associations between different types of thyroid pathology and clinical and laboratory findings were assessed using appropriate statistical methods., Results: The majority of participants were Saudi women. The prevalence of thyroiditis in the study population was 43%. Approximately 25% of these patients had more than 1 nodule, and fine-needle aspiration biopsy showed that most nodules were benign. Most nodules were found in clinically euthyroid patients. Thyroiditis might be associated with abnormal thyroid function., Conclusions: Thyroiditis and thyroid nodules were common in our cohort. Vitamin D deficiency, other autoimmune diseases, and a family history of thyroid disorders were associated with thyroiditis and thyroid nodules. US is useful for identifying the type of thyroid disease.

Background: Musculoskeletal disorders are common worldwide. Several factors are suggested in their aetiology, one of which is ergonomics alongside other individual factors. This study aims at investigating the prevalence of musculoskeletal disorders among administrative office workers at a large university in Saudi Arabia., Methods: This cross-sectional study recruited office workers at a Saudi university. A questionnaire was used that involved three sections, the first section consisted of sociodemographic questions, the second included the Rapid Office Strain Assessment (ROSA) checklist to assess ergonomic factors possibly involved, and the third included the Nordic Musculoskeletal Questionnaire to measure the outcome. Bi-variate analyses were performed by Chi-Squared tests and T-tests where appropriate, and a multivariable logistic regression was done to yield odds ratios (OR) and 95% confidence intervals (CIs)., Results: The prevalence of musculoskeletal symptoms in any region during the past 12 months preceding the study was 84.5%, and only 30% have sought medical advice. The most common area of complaint was the lower back (54.5%). After adjustment, age and years of experience were positively associated with musculoskeletal symptoms (OR = 1.04, 95% CI = 1.01-1.09 and OR = 1.10, 95% CI = 1.05-1.15). Normal weight was associated with a significant reduction in risk (OR = 0.10, 95% CI = 0.05-0.18). ROSA score was an independent risk factor (OR = 1.77, 95% CI = 1.05-2.96)., Conclusions: Musculoskeletal symptoms were highly prevalent in the current sample. Identified predictors may support the need for interventions to reduce risk., (© 2021. The Author(s).)

Background: Color vision deficiency (CVD) affects approximately one in 12 men and one in 200 women in the world. It is considered a problem in the medical field since the color is often used as a sign in the practice of medicine, in observational assessment, diagnosis, and follow-up. These conditions make the appreciation of color essential in doctors' lives, thus we aimed at finding the prevalence and predictors of CVD in medical students., Materials and Methods: This cross-sectional study included 1115 medical students. A pretested questionnaire consisting of personal data, history of vision problems, familial color vision defect, eye surgery, bad trauma on the head or eyes, drugs taken or chemicals exposed to, other health problems, and whether sufficient amount of Vitamin A is taken was used. This was followed by the screening of the participants for CVD using the Ishihara 15-plates test., Results: A total of 1115 students participated in the study; 52.2% were females and the mean age of the participants was 21.7 years (±1.4). The prevalence of definitive CVD was found to be 2.1%; all of which comprised males. Eighty-seven percent of the affected participants were not aware of their color vision problem. A highly statistically significant association was found between history of vision problems and CVD status (P < 0.008). No association were found for nationality, marital status, family history of CVD, history of eye surgery, and eye trauma., Conclusion: The percentage of CVD in the present study is lower than that reported by previous studies done in other countries. Many medical students with CVD remain unaware of their condition. Therefore, we recommend early screening of all school-age children, and proper counseling of medical students with definite CVD to take care of their own health and wellbeing., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Family and Community Medicine.)

Background: The Emergency Repartment (ER) is one of the most used areas in healthcare institutions. Problems with over utilisation and overcrowding have been reported worldwide. This study aims at examining the characteristics of paediatric ER visits, the rate of hospital admissions and its associated predictors at King Fahd Hospital of the University in the Eastern Province of Saudi Arabia., Methods: This is a retrospective, medical record-based study. Variables included gender, age group, nationality, complaints, Triage level, shifts and seasons. Descriptive statistics were reported as frequencies/percentages. P-values were obtained through a Chi-Squared test while unadjusted and adjusted odds ratios were estimated by binary logistic regression, where admission was considered as the outcome., Results: The total number of paediatric patients included was 46,374, and only 2.5% were admitted. Males comprised 55.4% while females comprised 44.6%. The most common age group were toddlers, and 92.4% of the total sample were Saudis. The most common complaint was fever (26.9%) followed by respiratory symptoms (24.9%). Only 7 patients (0.02%) were classified as triage I (Resuscitation), and most were triage IV (Less urgent) (71.0%). Most visits occurred during the winter months. Adjusted ORs showed that neonates had higher odds of admission (OR = 3.85, 95%CI = 2.57-5.76). Moreover, those presenting with haematological conditions showed an OR of 65.49 (95%CI = 47.85-89.64), followed by endocrine conditions showing an OR of 34.89 (95%CI = 23.65-51.47). Triage I had a very high odds of admission (OR = 19.02, 95%CI = 2.70-133.76), whereas triage V was associated with a very low odds of admission (OR = 0.30, 95%CI = 0.23-0.38)., Conclusions: A low rate of hospital admission was found in comparison with other rates worldwide. This was mostly attributed to an alarmingly high number of non-urgent ER visits. This further emphasises the problem with improper use of ER services, as these cases should be more appropriately directed towards primary healthcare centres. Further studies to examine the impact of prioritising patients in the ER based on the identified predictors of hospital admission, in addition to the standard triage system, are suggested.

Objectives: This study aimed to determine rubella virus infectivity and immune status in pregnant females who visited the family medicine and obstetrics clinics at a large hospital in Saudi Arabia, and to identify the possible predictors of rubella susceptibility., Methods: This registered-based, cross-sectional study included pregnant, aged between 18 and 50 years old, who presented for the first antenatal visit between 2017 and 2020. Data on sociodemographic, antenatal characteristics and serological results were collected. Chi-Squared or Fisher's Exact test and t tests were used for bivariate analysis followed by the multivariable logistic regression model., Results: A total of 4328 pregnant were included in the study. Seroprevalence of rubella immunity was 76.41%. Positive rubella IgM antibody was identified in 1.21% of those who performed the test (17/1409). Odds of susceptibility were decreased with an increase in age (OR = 0.96, 95% CI = 0.95-0.97) and in non-Saudis' (OR = 0.44, 95% CI = 0.36-0.54)., Conclusions: Approximately 24% of pregnant were susceptible to rubella virus infections in this study. Screening females of child-bearing age and reimmunisation of susceptible cases before pregnancy are suggested. Further studies to investigate the impact of applying this policy in premarital screening are recommended., (© 2021 John Wiley & Sons Ltd.)

Background: In recent times, mental health problems have been on the increase worldwide. Among these are eating disorders. The current study aim was to assess the prevalence of the symptoms of eating disorders in patrons of sport centers in the Eastern Province of Saudi Arabia, and its association with patrons' sociodemographic, and exercise characteristics, as well as social media use., Materials and Methods: This cross-sectional study was conducted among 560 sport center clients. The Eating Attitude Test (EAT-26), as well as questions on sociodemographic, exercise, and the use of the social media was collected through self-administered questionnaires. Descriptive statistics, Chi-squared test, and Fischer's exact tests were performed., Results: The prevalence of the symptoms of eating disorders was found to be 36.6% according to the results of the EAT-26. There were no significant differences in the rates of eating disorders between genders. Frequencies of eating disorder symptoms increased with an increase in the body mass index of the participants. In addition, more than half of the participants who were pressured by social media to be slim and perceived that social media influencers motivated them to go to the gym had eating disorders' symptoms., Conclusion: The prevalence of eating disorders symptoms was high among the sport center patrons examined. The findings from this study might help family physicians, mental health professionals, and sport medicine specialists wishing to understand this issue in Arab populations. Developing strategies regarding mental health in sport center patrons are suggested. In addition, a screening program is recommended for this population to identify those who need further evaluation and management., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Family and Community Medicine.)

Background: In-flight medical emergencies (IMEs) are common, and for a traveling physician, it is very likely to encounter such a condition. Data discussing this issue are limited. Thus, this study aimed to evaluate the willingness and confidence of physicians in the Kingdom of Saudi Arabia (KSA) in responding to IMEs. As well as, to assess the associated sociodemographic, occupational, and travel-related factors, and their previous experience with such events., Methods: This cross-sectional, online-based, study was conducted among all physicians in KSA during January 2021. The self-administered questionnaire included questions on sociodemographic, occupational, travel profiles, willingness and confidence towards IMEs. Chi-Squared or Fisher's Exact test were used for bivariate analysis followed by the multivariable binary logistic regression analysis., Results: A total of 4558 physicians participated in the study. About one-third of participants reported one or more IME incidents, and the vast majority of them provided assistance. Cardiovascular diseases were the most common IMEs. About half of the participating physicians are concerned about the medico-legal consequences of providing assistance with such a condition. Among all specialties, emergency physicians reported the highest willingness and confidence toward IMEs. Predictors for a physician's willingness to assist in IMEs were being male, having been involved in a previous IME situation, attended life support and IME courses, frequent traveling, and practicing medicine in the Central region of Saudi Arabia., Conclusion: Findings from the current study stressed the need for establishing standardized guidelines about the roles of healthcare workers and the legal consequences of providing medical assessment in IMEs. Moreover, training programs on IMEs to all physicians, especially those who deal with a variety of cases during their practice such as internal medicine and family medicine are also suggested.

Objectives: The objectives of this study were to assess the volunteering of undergraduate health students and interns in the Ministry of Health (MOH) services in the Kingdom of Saudi Arabia (KSA) during the COVID-19 pandemic, its motivational factors and barriers, as well as their risk perception of COVID-19., Design: A cross-sectional study., Participants: From 12 to 21 May 2020, an online survey was sent to all undergraduate health students and interns in the KSA. This included questions on demographics, volunteering status, risk perception of COVID-19, as well as motivations and barriers towards volunteering., Results: In a convenience sample of 6016 students and interns across KSA, 1824 (30.31%) have volunteered with the MOH services during the COVID-19 pandemic. Volunteering was more likely among older participants, from the College of Medicine, those with self-perceived at risk of COVID-19 infection and those with self-perceived healthy participants. Females, those who did not think that students had moral duties to volunteer, those who were at risk of seasonal influenza and those with self-perceived at risk of hospitalisation from COVID-19 were less likely to volunteer. Patriotism, gaining experience, assisting when able and religious rewards all were reported as major motivators to volunteer. Non-volunteering participants reported that lack of interest, protocol and knowledge, as well as issues related to their personal health and transportation were the main barriers to volunteering., Conclusions: About one-third of undergraduate health students and interns volunteered during the first 2 months of the COVID-19 pandemic in KSA. Moral values were the most important motivations among volunteers. Efforts to encourage heath students and interns to volunteer and providing those with appropriate educational programmes are recommended., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Musculoskeletal disorders (MSDs) are common worldwide. Recommendations to reduce discomfort often commence with increasing physical activity levels. In Saudi Arabia, levels of physical activity prior to the COVID-19 pandemic were low. This cross-sectional study aims at estimating the prevalence of MSDs among Saudi physicians, as well as determining the pattern and level of physical activity post lockdown and examining their association., Methods: Physical activity levels were assessed via the International Physical Activity Questionnaire and MSDs were assessed via the Nordic Musculoskeletal Questionnaire. Chi-squared tests with significance levels of <.05 were performed to explore bivariate associations. Unadjusted and adjusted odds ratios (ORs) along with their 95% confidence intervals (CIs) were given by binary logistic regression analyses., Results: A total of 3492 physicians participated in this study, and over half of them (63.55%) reported low physical activity. Risk of MSDs increased with aging and with increasing BMI ( P for trend <.05). Females were more likely to report MSDs (OR = 1.23, 95% CI = 1.07-1.86), as well as physicians with a chronic condition (OR = 1.52, 95% CI = 1.24-1.37) and those who work in shifts (OR = 1.18, 95% CI = 1.03-1.37). Moderate activity conferred a non-significant protective effect (OR = 0.95, 95% CI = 0.79-1.13), whilst high physical activity had a non-significant increased risk of MSDs in this population., Conclusion: Physical activity in this population is astonishingly low, while prevalence of MSDs is relatively high. Significant factors include age, sex, shift work, and the presence of chronic conditions. Current results warrant the consideration of preventive measures for physicians.

Introduction: Primary care plays an integral role in modern healthcare systems. More so in a country that is currently undergoing a reform of its health system. Their remains barriers that hinder patients from seeking medical assistance from primary physicians. This study aims to examine the overall satisfaction of patients toward Primary Healthcare Centers (PHCs) in Saudi Arabia, as well as its association with potential barriers from a sample of patients who presented at the emergency department (ED) for non-urgent cases., Methods: This cross-sectional study sampled 403 patients from King Fahd Hospital of the University. A piloted questionnaire was utilized that included questions on sociodemographics, satisfaction of PHCs, as well as organizational, socioeconomic, access, and patient-doctor relationship barriers using a Likert-scale item response. Chi-squared and Fisher's Exact tests were used to compare categorical variables, and multivariable logistic regression was used to assess the association between overall satisfaction and all factors and barriers., Results: The sample consisted of 48.1% males and 51.9% females. Only 5.2% of the patients were hospitalized. Of the total sample, 28.3% reported being always satisfied with PHC services. The most reported barriers were organizational barriers and socioeconomic barriers. The regression analysis found that being a female, highly educated, have high organizational, and patient-doctor relationship were independent predictors for low overall satisfaction with PHCs., Conclusion: Findings from this study should allow healthcare planners and policy makers to reduce the impact of these barriers by finding solutions that would target them. This may include strictly implementing policies such as proper implementing of triaging in EDs as well as promoting services that are being provided free of charge at these centers.

Background: To assess the prevalence of depression among medical students in their clinical years (fourth, fifth, and sixth years) in a government university in Eastern Province, Saudi Arabia, and its association with the students' sociodemographic characteristics, academic factors, perceived health problems and their perceived readiness to their future specialties., Methods: A cross-sectional study was conducted among 527 clinical-year medical students. The Patient Health Questionnaire (PHQ-9) and questionnaire designed by the researchers to collect data on sociodemographic and academic variables were used as research instruments. Statistical analyses were conducted using Stata Statistical Software V.15. Descriptive statistics, the χ test, and both an ordered logistic regression and a binary logistic regression analysis were performed., Results: The prevalence of depression was found to be 39.27%, according to the results of the PHQ-9. Both the ordered logistic regression and the binary logistic regression analyses revealed that the odds of severe depression were high among women, and students who perceived that they were not yet ready for their future specialties. The more senior the medical students were, the less likely it is that they have severe depression. A similar association was found for students who perceived that they did not have psychological problems. However, students' grade point average was not statistically significantly associated with depression., Conclusions: The prevalence of depression was high among the medical students examined. Policy makers should establish screening programmes, provide counselling for students who need it and deliver early interventions in detected cases., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Sleep is often challenging for medical students because of the considerable amount of learning they have to do. The aim of this study was to identify the patterns of sleep quality and daytime sleepiness among medical students in Saudi Arabia and to identify the possible factors associated with poor quality of sleep and daytime sleepiness., Materials and Methods: This cross-sectional questionnaire-based study was conducted at College of Medicine, Imam Abdulrahman Bin Faisal University, Saudi Arabia. The questionnaire included the prevalidated Pittsburgh Sleep Quality Index (PSQI) to measure sleep quality and the Epworth Sleepiness Scale (ESS) to measure daytime sleepiness. Covariates included sociodemographic characteristics and academic performance. Bivariate and multivariate logistic regression analyses were used to obtain adjusted and unadjusted odds ratios (ORs)., Results: The sampled population comprised 36.7% males and 63.30% females. The mean global PSQI score was (standard deviation (SD)=4.66), while the mean global ESS score was 8.03 (SD=4.66). Further analysis showed that 80.60% had poor sleep quality and 37.80% of the students suffered from excessive daytime sleepiness. Multivariate regression showed that poor sleep quality was significantly associated with poor academic achievement (adjusted OR = 3.33, 95% confidence interval [CI] = 1.28-8.63). Furthermore, excessive sleepiness significantly increased the odds of poor academic performance (adjusted OR = 4.58, 95% CI = 1.09-20.81)., Conclusions: The results on daytime sleepiness were found to be within the ranges reported worldwide; poor sleep quality was found to be among the highest ever reported. Both sleep quality and daytime sleepiness significantly affect academic achievement., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Journal of Family and Community Medicine.)

Objective: To identify timing for initiation of anticoagulation therapy in acute ischemic stroke (AIS) with non-valvular AF as regards safety and efficacy by detecting the rate of intracranial haemorrhage (ICH) and recurrent ischemic symptoms (RIS) during follow-up., Methods: This is a prospective observational cohort study conducted at King Fahd Hospital of the University including 120 patients with AIS/TIAs from July 2016 till July 2018. We compared patients who received anticoagulants 1-6 days (Group I (45.83%), 7-14 days, Group II (35%), and > 14 days after the ischemic event (Group III (19.17%). Follow-up was at least 3 months and included identifying ICH or RIS., Result: ICH has occurred in 26.67% (n = 32) patients with a highly statistically significant association with time of treatment (P-value = .01) being higher in group I (n = 17) compared to only 1 case in group III. Subgroup analyses on the ICH patients (n = 32) has revealed statistical significant association with higher NIHSS score (P = .001). Also, the type of anticoagulants used between three groups pointed to an association existence (p = .02), however, the direction of this association cannot be determined. There was no statistical significant association between RIS (occurred in 4.16% (n = 5) with time of treatment (P = .754). Functional outcome at 3-6 months measured by mRS did not differ between 3 groups (worst mRS in group I)., Conclusion: Early initiation of anticoagulation after stroke, especially in cases of large infarction, is associated with significant risk of ICH. This risk is highest with warfarin and lowest with DOAC., Competing Interests: Declaration of Competing Interest We certify that there is no actual or potential conflict of interest in relation to this article. Declaration: Authors hereby declare that this manuscript has neither been published nor is under simultaneous consideration for publication elsewhere either in its entirety or in part in any language, except in the form of an abstract. Authors also declare that this manuscript does not contain any redundant or duplicate information, defined as text, data, tables or figures that overlap substantially with previously published information. Authors also report that written informed consent was taken for all individual participants (If prospective). Authors also declare that none of us has any conflict of interest. This study is not funded from any source., (Copyright © 2019 Elsevier B.V. All rights reserved.)

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

Background: Health and socioeconomic status (SES) are linked in studies worldwide. Measures of SES exist for many countries, however not for Saudi Arabia (SA). We describe two indices of area-based SES for SA., Methods: Routine census data has been used to construct two indices of SES at the geographically-delimited administrative region of Governorates in SA (n = 118). The data used included indicators of educational status, employment status, car and material ownership. A continuous measure of SES was constructed using exploratory factor analysis (EFA) and a categorical measure of SES using latent class analysis (LCA). Both indices were mapped by Governorates., Results: The EFA identified three factors: The first explained 51.58% of the common variance within the interrelated factors, the second 15.14%, and the third 14.26%. These proportions were used in the formulation of the standard index. The scores were fixed to range from 100 for the affluent Governorate and 0 for the deprived. The LCA found a 4 class model as the best model fit. Class 1 was termed "affluent" and included 11.01% of Governorates, class 2 "upper middle class" (44.91%), class 3 "lower middle class" (33.05%) and class 4 "deprived" (11.01%). The populated urbanised Governorates were found to be the most affluent whereas the smaller rural Governorates were the most deprived., Conclusion: This is the first description of measures of SES in SA at a geographical level. Two measures have been successfully constructed and mapped. The maps show similar patterns suggesting validity. Both indices support the common perception of SES in SA.