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Abdulaziz Alalshaikh,1 Bader Alyahya,1 Mohammed Almohawes,2 Mosaed Alnowiser,2 Mohammed Ghandour,2 Mohammed Alyousef,2 Fahad Abuguyan,1 Abdulaziz Almehlisi,1 Fawaz Altuwaijri,1 Mohammed Alageel1,3 1Emergency Medicine Department, King Saud University, Riyadh, Saudi Arabia; 2College of Medicine, King Saud University, Riyadh, Saudi Arabia; 3Emergency Medicine Department, The University of British Columbia, Vancouver, BC, CanadaCorrespondence: Abdulaziz Alalshaikh, PO Box 7805, Riyadh, 11472, Saudi Arabia, Tel +966553993950, Email aalalshaikh@ksu.edu.sa Bader Alyahya, Tel +966555141174, Email balyahya@KSU.EDU.SAPurpose: To assess the views of emergency medicine physicians (EMPs) on the practice of providing unnecessary medical management in the emergency department.Methods: All EMPs in Saudi Arabia were approached to participate in this cross-sectional study. A self-administered online survey that collected the participants’ demographic information and opinions regarding the unnecessary management provided by EMPs in Saudi Arabia was conducted between December 2020 and February 2021. SPSS 22.0 was used to analyze the data.Results: A total of 181 EMPs returned the questionnaire. More than 80% of the participants believed that EMPs order unnecessary tests or procedures at least a few times per week. The major reasons for ordering unnecessary medical tests or procedures were “concern about malpractice issues” (60.8%), “not having enough time with a patient for meaningful discussion” (47%), and “just to be safe” (46.4%). More than 55% of the respondents also believed that EMPs are in the best position to address the problem of unnecessary testing.Conclusion: Most of the EMPs who participated in this study recognized that ordering unnecessary tests is a serious problem that happens on a daily basis. Many factors and reasons were described by the participants, and multiple possible solutions were suggested to help overcome the issue. Evaluating physicians’ perspectives on the issue is a key step in addressing the problem and implementing appropriate interventions.Keywords: emergency medicine physician, unnecessary investigation, Saudi Arabia, overdiagnosis, over-testing

Lemmese Alwatban,1,2 Mai S Alageel,3 Lina A Alshehri,4 Norah Saud Alfehaid,5 Reem Abdullah Albahlal,6 Norah Hejji Almazrou,7 Raghad Almubarak7 1Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia; 2University Family Medicine Center, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia; 3Department of Family Medicine, King Fahad Medical City, Riyadh, Saudi Arabia; 4Department of Neurosurgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia; 5Department of Anesthesiology, King Fahad Medical City, Riyadh, Saudi Arabia; 6Department of Radiology, King Saud Medical City, Riyadh, Saudi Arabia; 7College of Medicine, King Saud University, Riyadh, Saudi ArabiaCorrespondence: Lemmese Alwatban, Department of Family and Community Medicine, College of Medicine, King Saud University, P.O. Box 2925, Riyadh, 11461, Saudi Arabia, Email lalwatban@ksu.edu.saPurpose: Burnout is an occupational stress syndrome that gives rise to emotional exhaustion (EE) depersonalization (DP) and reduced personal accomplishment (PA). Increasing rates of burnout among health care professionals has been reported globally. Saudi Arabia appears to be among the highest in prevalence with reports of higher than 70%. Medical residents in training are the highest group at risk. The literature has repeatedly linked burnout among residents with poor academic performance on training exams, impaired quality of life, career choice regret and intentions to abandon medicine. In this study, we explore the factors that contribute to resident burnout, their experiences with burnout and how they choose to mitigate it.Methods: A qualitative design was used to conduct this study in the city of Riyadh, Saudi Arabia. A total of 14 residents from surgical and non-surgical programs were interviewed through in-depth interviews. Interpretive thematic analysis was used in coding and generated coding templates. Categories were repetitively reviewed and revised, expanding to include new data as it emerged and collapsing to remove redundant codes. Categories were organized into the final themes and sub-themes.Results: All participants demonstrated a shared thread of shame in reaching the level of burnout. Three main interlinked themes were identified: Burnout stigma cycle, amalgamated causes of burnout and self-coping with burnout. One of the concerning findings in our study is the participants’ pursuit of self-coping strategies and the avoidance of formal help, creating a cycle of suffering in silence.Conclusion: The literature has repeatedly reported high levels of burnout among residents in training. This study has added another dimension to those findings through the exploration of residents actual accounts and appears to link burnout with suboptimal training and working conditions. We have highlighted the pivotal role stigma and shame play in completely preventing residents from seeking professional help.Keywords: resident training, burnout, stigma, self-coping

Background: Slipped capital femoral epiphysis (SCFE) is usually seen in patients with high body mass index (BMI) and endocrine diseases. SCFE is exceedingly rare among Cerebral palsy (CP) patients due to spasticity present in those patients. Percutaneous in situ fixation is the treatment option for SCFE patients. According to the literature, there's no single case report with SCFE in a spastic CP patient with no prior history of trauma, seizure episodes, or endocrine disease., Case Presentation: We report a case of an 11-year-old spastic cerebral palsy (CP) patient with a physical status of level 5 motor function on the gross motor function classification system. He was brought by his mother to the clinic complaining of bilateral hip pain. The mother denied any history of trauma or any seizure episodes. The pain had started spontaneously. Physical examination showed severe spasticity and bilateral hip abduction with external rotation. Drehmann's sign was positive. Bilateral hip radiographs revealed bilateral partial open femoral capital physis with evidence of SCFE bilaterally. Also, the Southwick angle was measured, and it was severe. The patient was taken to the operating room and treated with closed reduction and percutaneous in situ fixation. He was seen multiple times following surgical intervention, reporting pain relief, and showing complete wound healing., Conclusion: This report concludes that paraplegic spastic CP patients may present with SCFE spontaneously without trauma, seizures, or an underlying endocrine disease. Also, severe spasticity might potentially be a risk factor for SCFE, although further investigations would be necessary to establish a conclusive link., (© 2024. The Author(s).)

Background and Objectives: Hyponatraemia increases the morbidity and mortality risks of orthopaedic patients. When undergoing spine surgery, hyponatraemic patients have high risks of pneumonia and of staying in hospital for up to 1 day longer compared with non-hyponatraemic patients. This study aims to assess the occurrence of adverse events among patients with pre-operative hyponatraemia after undergoing lumbar surgery., Materials and Methods: A retrospective cohort study was conducted. Patients who underwent spinal surgery in 2011 to 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Multivariate analysis was conducted to demonstrate the difference in post-operative complication rates between hyponatraemic patients and normonatraemic patients. Post-operative adverse events, need for blood transfusion and length of stay were considered as clinical outcome data., Results: A total of 58,049 patients were included; pre-operatively, 55,012 (94.8%) were normonatraemic and 3037 (5.2%) were hyponatraemic. Multivariate analysis showed that hyponatraemic patients had higher rates of adverse events, blood transfusions and urinary tract infections. Specifically, 632 (20.8%) hyponatraemic patients developed adverse events, compared with 6821 (12.4%) normonatraemic patients; the hyponatraemic patients received transfusions, compared with 6821 (7.4%) normonatraemic patients; and 97 (3.2%) hyponatraemic patients developed urinary tract infections, compared with 715 (1.3%) normonatraemic patients. Finally, an extended length of stay beyond 6 days occurred in 604 (19.9%) hyponatraemic patients, compared with 4676 (8.5%) normonatraemic patients., Conclusions: Our study identified an association between pre-operative hyponatraemia and post-operative adverse events in spinal surgery patients. However, it is unclear whether hyponatraemia caused the higher adverse event rate., Competing Interests: The authors declare no conflicts of interest. All authors certify that they have no affiliations with or involvement in any organisation or entity with any financial or non-financial interest in the subject matter or materials discussed in this manuscript.

Background: Osteochondromas, classified as a new benign subtype of lipomas and characterised by chondroid and osseous differentiation, are rare lesions that have been infrequently reported in previous literature. The maxillofacial region was reported as the most frequent localization, with infrequent occurrence in the lower limb. This paper represents the first documented case report of osteochondrolipoma in the foot., Case Presentation: A 51-year-old male patient presented with a chief complaint of right foot pain at the plantar aspect, accompanied by the observation of swelling between the first and the second metatarsal shafts. His complaint of pain and swelling started 10 and 4 years prior, respectively. Since their onset, both symptoms have progressed in nature. Imaging revealved a large mass exhibiting a nonhomogenous composition of fibrous tissue and bony structures. Surgical intervention through total excision was indicated., Conclusion: Osteochodrolipoma is a benign lesion that can affect the foot leading to decreased functionality of the foot due to the pain and swelling. Surgical excision is the recommended approach for this lesion, providing both symptomatic relief and confirmation of the diagnosis through histopathological examination., (© 2024. The Author(s).)

Background: The Harris Hip Score (HHS) questionnaire has been translated and validated into many languages including Italian, Portuguese, and Turkish but not Arabic. The goal of this study was to translate HHS into the Arabic language with cross-cultural adaptation to include and benefit Arabic speaking communities as it is the most widely used instrument for disease-specific hip joint evaluation and measurement of total hip arthroplasty outcome., Methods: This questionnaire was translated following a clear and user-friendly guideline protocol. The Cronbach's alpha was used to assess the reliability and internal consistency of the items of HHS. Additionally, the constructive validity of HHS was evaluated against the 36-Item Short Form Survey (SF-36)., Results: A total of 100 participants were included in this study, of which 30 participants were re-evaluated for reliability testing. Cronbach's alpha of the total score of Arabic HHS is 0.528, and after the standardization, it changed to 0.742 which is within the recommended range (0.7-0.9). Lastly, the correlation between HHS and SF-36 was r = 0.71 ( P < .001) which represents a strong correlation between the Arabic HHS and SF-36., Conclusions: Based on the results, we believe that the Arabic HHS can be used by clinicians, researchers, and patients to evaluate and report hip pathologies and total hip arthroplasty treatment efficacy., (© 2022 The Authors.)

Narrow-complex tachycardias are commonly seen on shift in the emergency department. Although a portion of patients present with hemodynamic instability because of arrhythmia, it is important to know that the tachycardia can be a result of an underlying condition. Rapid identification of the type and etiology of the arrhythmia is vital to directing appropriate management strategies and disposition decisions., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Posterior lumbar fusions are a common and successful procedure, yet surgical site infection (SSI) is still prevalent and causes significant morbidity. Obesity is a well-established risk factor for SSI. Still, the accuracy of the body mass index (BMI) caused some to suggest other metrics that are more representative of the thickness of the soft-tissue envelope in the surgical site., Methods: A retrospective review of all cases that developed SSI following posterior lumbar fusion over the past 5 years was done. An age and gender-matched control group was formed from the lumbar fusion cases that did not develop SSI. Demographic and clinical data were collected, and morphometric measurements of the soft-tissue envelope were performed at the level of L4 for all cases on standing x-ray imaging and magnetic resonance imaging (MRI)., Results: A total of 366 patients underwent posterior lumbar fusion, 26 of whom developed SSI. BMI and skin to spinous process measurements on x-ray imaging-not MRI-were found to be significantly associated with SSI. Regression analysis further confirmed the strength of the association., Conclusion: While BMI and MRI measurements are useful, wound depth measurements on x-ray imaging can be predictive of SSI in lumbar fusion cases., Clinical Relevace: Wound depth measurements are predictive of lumbar wound infection. The information within this study can help surgeons better predict and manage infections of posterior lumbar wounds., Competing Interests: Declaration of Conflicting Interests: The authors report no conflicts of interest or financial disclosures with respect to the research, authorship, and/or publication of this article., (This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2022 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.)

This study aimed to translate and adapt the Intermittent and Constant Osteoarthritis Pain questionnaire into the Arabic language and evaluate the validity and reliability of this scale for participants with knee or hip osteoarthritis. This questionnaire was translated based on the Manufacturers Alliance for Productivity and Innovation protocol. The test-retest reliability was calculated using the Intraclass Correlation Coefficient. Then, Cronbach's alpha was used to assess the internal consistency of Intermittent and Constant Osteoarthritis Pain questionnaire. After that, the criterion validity was evaluated against the Knee injury and Osteoarthritis Outcome Score. A total of 90 participants were included in this study, of which 29 participants were re-evaluated for reliability testing. The Intraclass Correlation Coefficient of the Knee Intermittent and Constant Osteoarthritis Pain questionnaire were 0.841, 0.923 and 0.911 for the total, constant, and intermittent knee pain, respectively. Cronbach's alpha was 0.88, 0.93 and 0.94 for the total score, the intermittent knee pain and the constant knee pain, respectively. Eventually, criterion validity was r=0.24(P<0.05). Intermittent and Constant Osteoarthritis Pain in Arabic is a valid and reliable instrument to be used in Arabic-speaking patients with knee/hip osteoarthritis., Competing Interests: Conflict of Interest The authors declare that they have no conflict of interest.

Purpose: Narcolepsy is an uncommon neurological disorder characterized by excessive daytime sleepiness (EDS) and multiple other symptoms. Due to the under-recognition of narcolepsy symptoms, patients are often misdiagnosed. This study aimed to assess the types of specialties visited and the diagnoses received by Saudi patients prior to their narcolepsy diagnosis., Methods: The study included 55 consecutive patients with type-1 and type-2 narcolepsy who attended the narcolepsy clinic between August 2017 and December 2017. Narcolepsy was diagnosed according to the International Classification of Sleep Disorders-third edition criteria. We evaluated sociodemographic data, the specialties visited, and diagnoses and treatments received prior to visiting a sleep specialist., Results: The mean diagnostic delay was 9.1 ± 8.4 years (1-43 years). Multiple linear regression analysis identified early onset as the only predictor of a delayed diagnosis (β coefficient = - 0.262, p = 0.03). EDS was the main symptom that prompted patients to seek medical consultation, and only one patient had been (1.8%) referred with the diagnosis of narcolepsy. In the study group, 82% of the patients were misdiagnosed with a mental or neurological disorder or were thought to be afflicted by "envy," "evil eye," or "black magic" before receiving a correct diagnosis. No significant differences were detected between patients with narcolepsy type-1 and narcolepsy type-2., Conclusions: Delays in diagnosing narcolepsy remain a major problem for Saudi patients with this disorder. We found that Saudi patients with narcolepsy had visited several medical specialists and faith healers and were misdiagnosed prior to visiting a sleep specialist.