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Bader Alshamsan,1,2 Tasneem Alajlan,3,4 Ahlam Alsalhi,4 Unaib Rabbani5 1Department of Medicine, College of Medicine, Qassim University, Qassim, Saudi Arabia; 2Medical Oncology Department, Prince Faisal Cancer Center, King Fahad Specialist Hospital, Qassim Cluster, Qassim, Saudi Arabia; 3Health and Curative Programs Department, Public Health and Community Health Administration, Qassim Cluster, Buraidah, Saudi Arabia; 4Family Medicine Department, Almuntazah PHC, King Fahad Specialist Hospital, Qassim Cluster, Buraidah, Saudi Arabia; 5Family Medicine Department, Family Medicine Academy, Qassim Health Cluster, Buraidah, Saudi ArabiaCorrespondence: Bader Alshamsan, Department of Medicine, College of Medicine, Qassim University, King Abdulaziz Road, Buraydah, Qassim, 52571, Saudi Arabia, Email bshmsan@qu.edu.saBackground: Despite the availability of free screening mammograms (SMG) through the Breast Cancer Early Detection (BCED) Program in the Qassim region of Saudi Arabia, a notable gap exists between program implementation and the actual uptake of SMG. This study aims to assess the refusal rate, identify barriers to participation, and shed light on the factors influencing women’s decisions regarding SMG.Methods: A cross-sectional study was conducted among consecutive women aged 40– 69 participating anonymously in the BCED program in September 2023. The participants were administered a validated Arabic language survey encompassing breast cancer screening backgrounds and knowledge, reasons for refusal, and factors influencing SMG reconsideration. Logistic regression was employed to identify factors linked with SMG refusal using SPSS version 28.Results: Of the 2446 eligible women in the study, 576 (23.6%) declined to undergo SMG. The median age of participants was 49 years, primarily married (91.5%) and residing in central cities (60.3%). Previous mammogram history was reported by 21.4%, with only 12.9% performing regular SMGs every 1– 2 years. Married women had a 31% lower refusal likelihood to SMG compared to widowed/divorced women (Adjusted Odds Ratio [aOR] = 0.69, p = 0.02). Women residing in peripheral areas showed approximately 1.45 times higher odds of refusal compared to those in central cities (aOR = 1.45, p < 0.001), and women without prior history of SMG had 2.13 times higher odds of refusal (aOR = 2.14, p < 0.001).Conclusion: The refusal rate for SMG in the Qassim region aligns closely with rates observed in developed countries. Despite this progress, significant barriers to SMG uptake persist, and tailored interventions targeting specific demographic groups and addressing these barriers are essential to improving screening participation, promoting a culture of proactive screening behavior, and ensuring equitable access to screening services for all eligible women.Keywords: screening mammograms, breast cancer, Qassim, Saudi Arabia

Mohammad Fouad Mohammad Khatib Sambas,1 Unaib Rabbani,2 Manal Mansour Mezal Al-Gethamy,3 Saud Hasan Surbaya,4 Faisal Fuwaran Irmat Alharbi,5 Riyadh Ghazi Abdulrahman Ahmad,6 Hamzah Khalid Hamzah Qul,7 Safa Mohammed Saeed Nassar,8 Abdulaziz Khalid Mohammed Ali Maddah,8 Basel Ali Kabah Darweesh8 1Department of Infectious Diseases, King Abdulaziz Hospital, Makkah, Saudi Arabia; 2Family Medicine Academy, Qassim Health Cluster, Buraidah, Saudi Arabia; 3Department of Infection Prevention & Control, Alnoor Specialist Hospital, Makkah, Saudi Arabia; 4Training, Education and Research Department, Makkah Public Health, Ministry of Health, Makkah, Saudi Arabia; 5Department of Infection Control, King Abdulaziz Hospital, Makkah, Saudi Arabia; 6Department of Internal Medicine, Hera General Hospital, Makkah, Saudi Arabia; 7Endocrinology Unit, Department of Internal Medicine, King Abdulaziz Hospital, Makkah, Saudi Arabia; 8Department of Internal Medicine, Alnoor Specialist Hospital, Makkah, Saudi ArabiaCorrespondence: Unaib RabbaniFamily Medicine Academy, Qassim Health Cluster, Buraidah, Saudi ArabiaTel +966533268374Email rabbaniunaib@gmail.comMohammad Fouad Mohammad Khatib SambasDepartment of Infectious Diseases, King Abdulaziz Hospital, Makkah, Saudi ArabiaTel +966555524455Email dr_mfks@hotmail.comBackground and Objectives: Tuberculosis (TB) is a global public health issue. The emergence of multidrug-resistant (MDR) TB has further complicated the situation in the form of poor treatment outcomes and costs to individuals and health-care systems. We therefore aimed to measure the prevalence and associated risk factors of MDR TB among TB patients in Makkah city.Patients and Methods: This was a cross-sectional study conducted at Al-Noor Specialist Hospital, a public-sector hospital in Makkah. We included records of 158 confirmed TB patients from the list of all patients admitted in the hospital from January 2009 to January 2019 by systematic random sampling. Data were collected on socio-demographics, clinical profile and drug resistance patterns. Analysis was done in SPSS version 21.0.Results: The mean age of the participants was 43.4 ± 18.7 years, and two-thirds (66.5%) were male. About 40% of the patients had chronic disease while lung disease other than TB was present in 5% patients. About 13% of cases were extrapulmonary infections. Prevalence of drug resistance was found to be 17.1% among TB patients. Among the resistant cases, streptomycin (25.9%) and isoniazid (11.1%) were the drugs most commonly affected by resistance. Prevalence of MDR TB was 5% among TB patients. Age, smoking, lung disease and previous TB were significant factors associated with MDR TB.Conclusion: Prevalence of MDR TB, although comparable to current national estimates, is higher compared to previous reports. There is a need to reduce this burden through strengthening TB control programs to prevent further emergence of a public health threat of MDR TB. History of previous TB was the strongest risk factor in this study. This calls physicians, program managers and policy makers to focus on counselling and support of TB patients for compliance with the regimen to complete treatment without interruption.Keywords: MDR TB, prevalence, risk factors, Saudi Arabia

Monitoring water stored in lakes and reservoirs is much needed in various countries for energy generation, food security and mitigating floods, among recurrent global issues. Natural and human-made open water bodies do not all have monitoring systems, this lack of regular information generates uncertainties in modeling, and increases unaccounted time-bound residuals in water balances. A large amount of water bodies storage variations are not monitored around the World. Here we show that this can be changed by the creation and the implementation of the concept of water Level Virtual Gauges (wLVGs) based on slope tracks upstream of water bodies, correlated to publicly available satellite remote sensing information returning water levels bi-monthly on average, sometimes weekly. An operational RMSE is found to be 12-52 cm height, depending on the characteristics of the upstream slopes used to calibrate wLVGs. This methodology is simple enough to be implemented for all medium to large reservoirs, but is alsofound successful for smaller rural reservoirs in tropical/sub-tropical countries. We anticipate that this can open globally distributed pathways to monitor open water bodies across the World, improve public databases on water storages and give management information for non/less-monitored water bodies. [ABSTRACT FROM AUTHOR]

Faced with unreliable rainfall patterns, Australian farmers have developed on-farm water storage (OFS) solutions over the drought years. Recent thinking in water policy under the Commonwealth government considers extending the Cap over surface water to OFS as they are not currently covered under the Cap and eluded the effective water policy arrangements across users and the states. A unified approach to Cap implementation involving water diversions from the river system, OFS and other direct diversions and withdrawals as well as groundwater extractions is essential to enhance the scope and integrity of the Cap mechanism and bring diversions within the sustainable yield limits. This study lays ground for a detailed volume assessment calibration of each OFS within a water basin, within the prospect of using such information to enable a multi-source remote sensing monitoring system. [ABSTRACT FROM AUTHOR]

Background and Objectives: Coronavirus disease 2019 (COVID-19) is associated with various manifestations even after infection resolution. This study aimed to assess the prevalence of post-COVID-19 fatigue and its predictors., Methods: We conducted a nationwide cross-sectional study among Polymerase Chain Reaction test confirmed COVID-19 cases in Saudi Arabia from July 2021 to February 2022. We collected data through telephonic interviews covering socio-demographics, comorbidities, body mass index, smoking, illness severity, and COVID-19 vaccination status. We assessed fatigue using Fatigue Severity Scale while depression was assessed using Patient Health Questionnaire-2. Logistic regression was employed to analyze the relationship between post-COVID-19 fatigue and depression., Results: The analysis included 361 participants with a mean age of 37 ± 10.5 years, among whom 43% were female. Approximately 10% had comorbidities, and 21% were current smokers. Nearly two-thirds (68%) of the participants reported mild illness. The prevalence of perceived fatigue was 22.7%, while fatigue measured by the Fatigue Severity Scale was 14.4%. The multivariable logistic regression model revealed that COVID-19 severity and depression were significant predictors of post-COVID-19 fatigue; adjusted odds ratio 1.87 (95% CI: 1.10 to 3.18) and 14.3 (95% CI: 4.55 to 45.0), respectively., Conclusion: Our findings suggest a higher prevalence of perceived fatigue compared to that measured by the Fatigue Severity Scale, underscoring the importance of using a valid assessment tool for fatigue among COVID-19 patients to ensure proper management. The significant association between post-COVID-19 fatigue and depression highlights the need for psychological assessment of COVID-19 patients to enhance their post-infection quality of life., Competing Interests: Declarations. Consent to Participate: Verbal informed consent was obtained prior to the interview. Competing Interests: Ziad A. Memish who contributed to the research is the editor-in-chief of the journal. Other than this, the authors have no relevant financial or non-financial interests to disclose., (© 2024. The Author(s).)

Background and objectives Problematic use of smartphones among healthcare workers can affect their performance, patient care, safety, care outcomes, and patient satisfaction. The aim of this study was to determine the prevalence of problematic use of smartphones and the relationship between the problematic use of smartphones and sleep quality among healthcare workers in Qassim, Saudi Arabia. Methods We enrolled 393 healthcare workers conveniently selected online for this cross-sectional survey. We assessed the problematic use of smartphones using the short version of the Smartphone Addiction Scale. For sleep quality, we used the Pittsburgh Sleep Quality Index (PSQI). Linear regression was used to assess the association of problematic use of smartphones with sleep quality. IBM SPSS Statistics, version 23.0 (IBM Corp., Armonk, NY) was used for analyses. Results The prevalence of smartphone addiction (SMA) was 59.0%, and 30.5% were at high risk for addiction. The mean PSQI score was 11.56 ± 2.1 out of 21. It was found that female gender was associated with poor sleep quality (adjusted B = 0.45, p-value = 0.049). On the other hand, SMA was also significantly associated with poor sleep quality (adjusted B = 0.90, p-value = 0.016). Conclusion There is a high prevalence of problematic use of smartphones among healthcare workers, which is associated with poor sleep quality. Given the significant occurrence of problematic smartphone use among healthcare professionals and its detrimental effects on sleep quality, it is crucial for public health initiatives to devise and execute suitable preventive measures, such as smartphone use policies at work and education of workers., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Qassim Regional Ethics Committee issued approval 607/44/12551. Ethical committee approval was obtained from the Qassim Regional Ethics Committee, No. 607/44/12551, on March 15, 2023. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Aldukhayel et al.)

Objective: This study was undertaken to evaluate the role of regional social vulnerability in geographic disparity for patients listed for liver transplantation with non-hepatocellular carcinoma (HCC) model for end-stage liver disease (MELD) exceptions., Summary and Background: Prior work has demonstrated regional variability in the appropriateness of MELD exceptions for diagnoses other than HCC., Methods: Adults listed at a single center for first-time liver-only transplantation without HCC after June 18, 2013 in the Scientific Registry of Transplant Recipients database as of March 2021 were examined. Candidates were mapped to hospital referral regions (HRRs). Adjusted likelihood of mortality and liver transplantation were modeled. Advantaged HRRs were defined as those where exception patients were more likely to be transplanted, yet no more likely to die in adjusted analysis. The Centers for Disease Control's Social Vulnerability Index (SVI) was used as the measure for community health. Higher SVIs indicate poorer community health., Results: There were 49,494 candidates in the cohort, of whom 4337 (8.8%) had MELD exceptions. Among continental US HRRs, 27.3% (n = 78) were identified as advantaged. The mean SVI of advantaged HRRs was 0.42 versus 0.53 in nonadvantaged HRRs ( P = 0.002), indicating better community health in these areas. Only 25.3% of advantaged HRRs were in spatial clusters of high SVI versus 40.7% of nonadvantaged HRRs, whereas 44.6% of advantaged HRRs were in spatial clusters of low SVI versus 38.0% of nonadvantaged HRRs ( P = 0.037)., Conclusions: An advantage for non-HCC MELD exception patients is associated with lower social vulnerability on a population level. These findings suggest assigning similar waitlist priority to all non-HCC exception candidates without considering geographic differences in social determinants of health may actually exacerbate rather than ameliorate disparity., Competing Interests: R.M.C. is supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under award number K08DK125769. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives Long-term metformin is associated with vitamin B12 deficiency. There is a significant misunderstanding among both physicians and patients regarding vitamin B12 indications. This study aims to identify knowledge gaps and attitudes toward vitamin B12 among diabetic patients. Materials and methods A cross-sectional study was conducted among type 2 diabetic patients visiting four primary healthcare centers in Buraidah, Saudi Arabia. The data were collected using a structured self-administered questionnaire. Data were collected on diabetes and vitamin B12 knowledge and attitude toward vitamin B12 supplementation. Logistic regression analyses were used to assess the predictors of knowledge and attitude. Results Of the 388 participants, 192 (49.5%) were male. About 84.5% of the total diabetics were on metformin. Nearly three-fourths (72.7%) were taking vitamin B12. A large proportion, 160 (41.2%), believed that it is necessary to take vitamin B12 for every diabetic patient. Nearly half, 193 (49.7%), did not know the factors affecting vitamin B12 deficiency. Young (less than 39 years) diabetics were more likely to perceive that vitamin B12 is recommended for all diabetics, OR (95% CI) [6.26 (1.86-21.06)], as compared to participants aged more than 59. Similarly, younger patients were more likely to assume vitamin B12 necessary, OR (95% CI) [3.71 (1.26-10.89)]. Conclusion We found the knowledge and attitude of diabetic patients regarding vitamin B12 to be poor. It is, therefore, recommended that primary health care providers educate their patients about vitamin B12 supplementation to reduce the number of medications and financial burden. Further large-scale studies are also needed to generate stronger evidence of the problem., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Alomar et al.)

Objective: To evaluate the factors associated with idiopathic pulmonary fibrosisrisk., Methods: The case-controlstudywas conductedfromJanuary 5, 2017,toSeptember 4, 2018, attheprivate-sectorAga Khan University Hospital and the public-sector Jinnah Postgraduate Medical Centre, two large tertiary care centres in Karachi, andcomprisedadultpatientsof eithergenderwithdiagnosedidiopathicpulmonary fibrosis, asdefinedby the IndianChest Registry. Subjects without idiopathic pulmonary fibrosis but registered with the department of pulmonology of the two hospitalswere enrolledas controls.Datawas collectedusinga structuredquestionnaire, andanthropometricmeasurements were noted for each subject. Gastroesophageal reflux disease was assessed using GerdQ. This wasfollowed by serological evaluations and spirometry. Data was analysed using SPSS 21., Results: Of the 459 subjects, 154(33.6%)were cases and305(66.4%)were controls.Amongthe cases, 81(52.6%)were females and 73(47.4%) were males with mean age 66.1±10.9 years. Among the controls, 162(53.1%) were females and 143(46.9%) were males with mean age 64.6±11.1 years(p>0.05.)The most common ethnicity wasUrdu-speaking; 89(58%) among the cases and 150(49%) among the controls (p<0.05). Ethnicity, number of persons in the household per room, and type of house were significantly associated with the risk of developing idiopathic pulmonary fibrosis(p<0.05)., Conclusions: Ethnicity,type of house and the number of personsin a household perroom were found to be the significant risk factorsfor idiopathic pulmonary fibrosisIPF.

Technology is instrumental in delivering health services, especially telehealth during the COVID-19 pandemic. This article aimed to explore the role of telehealth as a public health approach to support responses to address the COVID-19 pandemic in Pakistan. We developed this article by mapping existing telehealth initiatives developed and implemented during the COVID-19 pandemic in Pakistan. The initiatives were identified searching online portals such as Google Scholar, PubMed, and websites of various governmental and non-governmental agencies. The services are categorized into teleconsultation and follow-ups, online vaccine registration, information dissemination, high-risk subset tracking, virtual Health Care Worker (HCW) and medical student training, and tele-psychological counseling. The teleconsultation category offers online registration and follow-ups. Information dissemination services include federal helpline, SMS alerts, and social media campaigns. The high-risk subset tracking services include app-based COVID-19 checks and online surveys. Virtual HCW and medical student training services include tele-ICU support, COVID-19 critical care courses, and COVID management courses. The tele-psychological counseling services offer helplines for emotional support, proactive counseling for COVID-19 patients, and mental health support and psychiatry services. Telehealth interventions provided novel solutions amid health and social crises such as the COVID-19 pandemic. Health care systems need to expand telehealth services and ensure that health care organizations deliver effective and safe medical care. However, future research should focus on assessing the impact of telehealth on population health., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Asthma is a chronic disease that affects the quality of life of patients, and asthma exacerbations are often a reason for hospitalization and activity limitations. Obesity has been linked to asthma as a risk and exacerbating factor. Evidence suggests that weight reduction has a positive effect on asthma control. However, there is also debate on the role of the ketogenic diet in asthma control. Here we present a case of asthma who reported markedly improved asthma after starting a ketogenic diet in the absence of any other lifestyle change. Over the four months on the ketogenic diet, the patient reported losing 20 kg of weight, reduction in blood pressure (without antihypertensives), and complete alleviation of asthma symptoms. This case report is important as the control of asthma after a ketogenic diet is not studied well in humans and therefore needs to be studied extensively., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Al-Rebdi et al.)

Airports could serve as hotspots for the spread of the COVID-19 infection. We aimed to assess the awareness, attitude, and behaviors of non-Saudi travelers about COVID-19 and their satisfaction with preventive measures at Saudi airports. A cross-sectional study was conducted among non-Saudi travelers arriving in Saudi Arabia at two international airports. Data were collected using a questionnaire in Arabic, Hindi, and Urdu languages. Awareness, attitude, behavior scores, and satisfaction levels were calculated. Linear regression analyses were done to assess the predictors of awareness, attitude, and behaviors. A total of 633 participants were included in the study. The mean awareness, attitude, and behavior scores were 16.3/22, 18.3/24, and 3.2/5, respectively. Nationality, education, and income were significant predictors of awareness. Nationality was the only significant predictor of attitude, while gender and nationality were predictors of behaviors. Overall satisfaction with preventive measures was: transportation (94%), lounges and corridors (96%), counters (98%), and airport staff (97%). There was overall good awareness and attitude among travelers. Behavior scores were relatively low, which needs to change as air travel poses a threat to the spread of infectious diseases. Airport authorities need to manage passengers properly to ensure adequate distancing to prevent the potential transmission of infections.

Background Hospital staff, especially nurses, face violence of various forms in the workplace. This study aimed to assess the burden of verbal/physical abuse against nurses and their attitude towards such events in Buraidah, Saudi Arabia. Methods A cross-sectional study was conducted among nurses working in three public sectors and two private sector hospitals, and five primary healthcare facilities in Buraidah. Data was collected using a structured online questionnaire, disseminated among nurses through nursing departments of participating facilities. Data were analyzed using SPSS version 21.0. Results A total of 369 nurses participated in the survey, with a mean age of 34 (±6.9) years. About two-thirds, 68% (250) of respondents, had experienced at least one verbal/physical abuse incident during one year. The most common perpetrators were patients (44.4%). Sixteen percent of participants reported taking no action against the incident. Those working in private facilities were 80% less likely to experience abuse than those in public facilities, adjusted OR 0.20 (95% CI: 0.08-0.47). Conclusions There was a high burden of verbal/physical abuse against nurses, and they, therefore, suffer from disturbing memories. However, a little more than half do not officially report it to the managers, with only a small fraction seeing some action taken. Occupational health practitioners should take action to improve the policy and procedures related to workplace violence (WPV) in healthcare facilities. Further research is needed to characterize incidents to understand the patterns and develop interventions for the prevention of such events., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Sayed et al.)

Objective: We assessed the association of formaldehyde, carbon monoxide (CO), and particulate matter (PM 2.5 ) with respiratory symptoms, asthma, and post-bronchodilator reversibility., Methods: We included 1629 adults in a community-based cross-sectional study in Karachi in 2015. Data were collected using the American Thoracic Society respiratory questionnaire and spirometry (available for 930 participants). YesAir eight-channel monitor was used for measuring concentrations of formaldehyde and CO, whereas PM 2.5 was measured using UCB PATS., Results: Higher levels of formaldehyde and CO were associated with cough, phlegm, and wheeze, whereas those of PM 2.5 were associated with shortness of breath and presence of any of the respiratory symptoms (combined), as well as a "lower" risk of cough, phlegm, and bronchitis., Conclusion: Poorer household air quality was associated with poorer respiratory health in this population; however, further studies with a robust exposure assessment are required., Competing Interests: Conflict of Interest: None declared., (Copyright © 2022 American College of Occupational and Environmental Medicine.)

Context: Evidence-based medicine (EBM) is essential for safe and cost-effective care provision to the population., Aims: To assess the awareness, attitude and practices and barriers among primary care physicians about EBM in Buraidah, Qassim., Settings and Design: Cross-sectional study in Primary Health Care centers (PHCCs) of Buraidah, Qassim., Materials and Methods: The study was conducted among physicians working in PHCCs of Buraidah. Data were collected online through Google forms., Statistical Analysis Used: Descriptive analysis was carried out to measure the frequencies and proportions. Chi-square test was used to compare barriers based on gender, academic degree, and experience categories., Results: A total of 96 out of 144 physicians (66.7%) responded to the invitation. About 82.3% of the participants welcomed the promotion of EBM and 92% of the physicians knew about concept of EBM. About 94.8% of the physicians agreed that EBM will improve patient outcomes. The reported barriers were; patient load (87.5%), time availability (70.8%), computer availability (33.3%), internet availability (45.8%), and 56.3% stated updated clinical letters, journals, or guidelines are not available., Conclusions: This study found that there was high self-reported knowledge about the EBM concept; however, the knowledge about tools was poor. A number of barriers were found such as patient load, time, availability of clinical guidelines and journals and other resources such as internet and computers. Primary care physicians should be trained and facilitated for EBM., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Family Medicine and Primary Care.)

Objective: Literature on the perceptions and experiences of postgraduate trainees and trainers regarding online methods of learning is scarce. We aimed to assess the perceptions and experiences of family medicine trainees and trainers regarding online learning during the novel coronavirus (COVID-19) pandemic in Qassim, KSA., Methods: This was a mixed-method study involving trainees and trainers at the Family Medicine Academy, Qassim. Quantitative data were collected using structured questionnaires from 36 trainees and 26 trainers. Qualitative data were collected through in-depth interviews with trainees ( n = 4) and trainers ( n = 3). Descriptive analysis was performed on the quantitative data, while thematic analysis was performed on the qualitative data., Results: Among the trainees, 39% perceived online learning to be less effective than traditional classroom learning. Moreover, 61% and 64% of the respondents were concerned about the motivation and quality of online learning, respectively. Lack of direct contact with other students was the most commonly perceived concern among 80% of trainees. Among the trainers, the majority were either dissatisfied or neutral about participation and interaction, speakers' and students' motivation, the quality of online learning, and the online teaching experience. Qualitative data showed that online methods provide the advantages of learning from other institutions and flexibility, as well as a viable alternative during crises. However, there were issues with interaction, participation, and trainers' online teaching skills., Conclusion: Online learning has provided an opportunity to continue training during the COVID-19 crisis. However, there are widespread concerns regarding its effectiveness among trainees and trainers. There is a need to train trainers in online teaching and adopt interactive methods to increase trainees' interaction, motivation, and participation., (© 2022 [The Author/The Authors].)

Background: Coronavirus Disease (COVID-19) pandemic can affect mental health. Heads of the household are at higher risk of this effect because of their financial and social responsibilities. This study aimed to assess the psychological well-being and its associated factors during the COVID-19 pandemic among heads of households in Pakistan. Methods: We conducted an online survey in May 2020. A convenience sampling strategy was used to enroll the heads of the households from all regions of Pakistan. A validated English and Urdu version of the WHO-5 well-being scale was used to assess well-being. The prevalence of poor well-being and its associated factors among heads of the households was measured using logistic regression. Results: A total of 509 heads of households participated in the survey. About 35% of the participants were dependent on financial sources other than salary. The news was considered a source of fear as 70% assumed that avoiding such news may reduce the fear. The most common coping strategies used during lockdown were; spending quality time with family, eating healthy foods, adequate sleep and talking to friends on the phone. The prevalence of poor well-being was found to be 41% (95% CI: 36.62-45.51). Individuals with any chronic illness were at a higher risk of poor wellbeing adjusted odds ratio of 1.64 (95% CI: 1.04-2.59). Worriedness was also found to be associated with a higher risk of poor wellbeing adjusted OR 1.13 (95% CI: 1.06-1.19). Reading books showed a protective association with poor mental wellbeing adjusted OR 0.64 (95% CI: 0.42-0.98). Conclusion: There was a high prevalence of poor mental wellbeing among heads of households in Pakistan. Worriedness related to the pandemic and having chronic illness were significant predictors of poor psychological wellbeing. Actions are required in the form of targeted mass psychological support systems for the heads of the families to improve their mental health during the COVID-19 crises., Competing Interests: The authors declare that they have no competing interests., (© 2022 Iran University of Medical Sciences.)

Background Nocturnal enuresis (NE) is troubling for children and their families. This study aims to investigate the prevalence of NE, its associated health problems, and the outcome of the provided management among children aged 6-18 years and to assess the impact of NE on the mental health of mothers in Northern Saudi Arabia. Methodology A retrospective cross-sectional study was conducted in Arar, Northern Saudi Arabia, among children aged 6-18 years old. Data were collected using a structured questionnaire including a Perceived Stress Scale (PSS). Means ± standard deviations (SDs) were used to represent quantitative data, and frequencies and percentages were used to represent qualitative data. Ordinal logistic regression was used to assess the association of NE with perceived stress. Results A total of 420 participants were included in this study. Nocturnal enuresis was reported in 24% of the respondents' children. Around 51% of the mothers know about the causes of NE. Nocturnal enuresis caused embarrassment and social shame to 71% of the mothers. Two-thirds (66%) of the mothers wake up the child at night for urination. Three-quarters (76%) of the participants reported improvement on decreasing fluid intake before sleeping. Of the mothers, 19% perceived low stress, 78% perceived medium stress, and 3% perceived high stress. NE was associated with a higher risk of stress (adjusted odds ratio (OR): 2.14; 95% confidence interval (CI): 1.05-4.37). Conclusion About a quarter of the children suffer from NE, of which a large proportion of mothers face embarrassment and shame. There was a significant association between NE and a higher level of stress. Mothers of children with NE should be provided with counseling and social support to ensure good mental health., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Alanazi et al.)

Background: Medical and dental students are the future of health workforce and a potential volunteer pool in the COVID-19 crises. This study aimed to assess the level and gender differences in the awareness, attitude and behaviours of medical and dentals students about COVID-19 in Pakistan., Methods: An online cross-sectional survey was conducted among medical and dental undergraduate students in Khyber Pakhtunkhwa province. Data was collected using a structured questionnaire having four sections: socio-demographics, knowledge, attitude and practices., Results: A total of 1770 medical and dental students participated and completed the questionnaire. About 1239 (70%) of the respondents were female and 1526 (87%) were MBBS students. We found that 1685 (95%) of the students had adequate knowledge. Majority, 1565 (89%) of the students was concerned about COVID-19 and 1480 (84%) believed that disease will ultimately be controlled. Only about 1129 (64%) of the participants in our study had adequate practices. Male gender was associated with higher risk of inadequate practices., Conclusions: There were good knowledge and attitudes about COVID-19 among medical and dental students. However, one third of the participants did not have adequate practices and female had better practices than male students. This gap in the knowledge and practice calls for urgent interventions to improve practices.

Background and objectives Coronavirus disease 2019 (COVID-19) pandemic has affected routine service delivery which might affect antenatal care (ANC) utilization among pregnant women. This study aimed to assess the proportion of missed appointments among pregnant women in the Qassim region of Saudi Arabia during the COVID-19 pandemic. Methods A facility-based cross-sectional survey was conducted among pregnant women admitted for delivery in Maternity and Children Hospital (MCH), Buraidah. Data were collected on socio-demographics, obstetric history, missed appointments and reasons for missing the appointment. Analysis was carried out in Statistical Package for the Social Sciences (SPSS), version 21.0 (IBM Corp., Armonk, NY). Medians with interquartile range (IQR) were presented for continuous variables and frequency and proportions for categorical variables. Logistic regression was used to assess the factors associated with the missed appointment. Results A total of 400 women were included in the study. About one-third (30%) of the women had missed at least one ANC appointment in their current pregnancy. The most common reasons for missing the appointments in primary care and hospitals, respectively, were: fear of infection 52% and 47%, facility not working usual 25% and 7.5%, fear of infection to child 19% and 17%. Family size and gravidity were the significant factors associated with missed appointments in our study. Conclusions Nearly one-third of women missed their ANC appointments during the COVID-19 pandemic. Major reasons were related to COVID-19 fear and its effect on services. This calls for proper health communication in the general population and delivering routine care with evidence-based guidelines to maintain continuity of care., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Rabbani et al.)

Acceptance of COVID-19 vaccines needs a health promotion approach to address various social, environmental and personal factors leading to vaccine hesitancy. We assessed the vaccine hesitancy rate and applied social cognitive theory (SCT) to understand COVID-19 vaccine rejection in Qassim, Saudi Arabia. A cross-sectional study was conducted among visitors of 10 randomly selected primary health care centers in Buraidah, Saudi Arabia. Data was collected by a self-administrated questionnaire. The variables were grouped into six constructs of SCT. Logistic regression was used to assess the predictors of vaccine rejection. Out of 486 participants included in the study, 30.5% rejected the vaccine. The most common reason for vaccine rejection was uncertainty about the vaccine's effectiveness (78%). Among various constructs of SCT, reciprocal determinism (nationality, income and suffering from COVID-19 infection), behavioral capability (knowledge about vaccine safety), self-efficacy (registered for vaccine), and observational learning (getting the vaccine after friends and family members) were significant predictors. Expectation and reinforcement constructs did not show significant association. There was high vaccine rejection in Qassim, KSA. This calls for further improving the mass education strategies. Social cognitive theory can be used to predict vaccine rejection and to develop strategies to increase the utilization of COVID-19 vaccines in Saudi Arabia.

Background and objective Patients' rights are an essential aspect of human rights. Thus, in Saudi Arabia, the Ministry of National Guard Health Affairs (MNGHA) established a Patients' Bill of Rights (PBR) and introduced it to the public about 30 years ago. This study aims to assess levels of awareness of PBR and to identify their information sources among visitors to primary healthcare centers (PHCCs). Methods This cross-sectional study included 358 visitors, aged 17 to 78, to three PHCCs at the National Guard Hospital in Riyadh, Saudi Arabia. The study was conducted between April and December 2017 using a self-administered questionnaire. The initial sample (convenience sampling) was refined to match the proportion of participants with the relative size of populations served by the centers. Descriptive statistics were used to determine the relationships between participants' demographic data and levels of awareness of patients' rights. Results Most participants (72.2%) were moderately aware of their rights, but the majority (65.3%) were unaware of the existence of the PBR. Healthcare providers were the main information source for patients' rights, although participants with the highest awareness scores obtained information from social media. Level of awareness was significantly associated with education, income, and regular hospital follow-ups. Conclusions The study results should motivate healthcare providers, stakeholders, and health organizations in Saudi Arabia to raise and maintain public awareness of patients' rights and to implement them., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Al-Rebdi et al.)

Universal health coverage is a global agenda and, currently for Pakistan, achieving this goal is a challenge because of a number of constraints. The current narrative review was planned to describe an overview of the provision of health insurance in Malaysia, Thailand and Singapore that have achieved universal health coverage, and to propose a roadmap for Pakistan. Literature search was conducted on Google Scholar and PubMed databases as well as on the World Bank website to retrieve relevant articles. The three studied countries achieved universal health coverage by gradually increasing allocation for health and through various mechanisms, such as health insurance schemes which covered different segments of the population, and partnerships with private-sector care-providers. Pakistan needs to prioritise health in policy agenda because health insurance is negligible in Pakistan. Additionally, Pakistan also needs to efficiently utilise partnerships with the private sector to further increase healthcare coverage.

Background: Health care workers (HCWs) working on frontlines in COVID-19 pandemic are highly vulnerable to deteriorating physical and mental health. The quality of life of health care workers plays an important role in their skilful delivery of work. Our study assesses their quality of life (QOL) during COVID-19 pandemic so that appropriate measures can be taken to improve their well-being., Methods: This was an online crosssectional survey among healthcare workers of COVID-19 designated government hospitals in districts Abbottabad, Manshera and Haripur, Khyber Pakhtunkhwa, Pakistan from 23rdJune till 25thJuly, 2020. QOL was assessed using validated WHO QOL BREF. Univariate and multivariate linear regression were used to assess the factors associated with QOL among HCWs., Results: A total of 362 HCWs participated in the study. The mean scores of physical, psychological, social relationships, environmental domains were 60.7 (±17.40), 59.70 (±17.30), 67.90 (±17.90), and 58.20 (±18.40) respectively. Hospital where the respondents were working was the consistent predictor of QOL scores in all four domains with generally lower scores associated with other hospitals compared to Ayub Medical Hospital. Years of experience were positively associated with psychological, social relationship and environmental domains. Designation was associated with social relationship domain only. The scores were lower for trainee medical officers (adjusted β - 11.5) and higher for house officer (adjusted β 10.0) and nurses and technicians (adjusted β 7.0) compared to heads of departments and specialists., Conclusion: Quality of life of health care workers has been affected negatively in hospitals of Abbottabad, Pakistan during COVID-19. This calls for hospital administrations, policymakers and the government to take necessary actions to protect the wellbeing of the backbone of the healthcare system.

Antimicrobial resistance (AMR) is a global threat that affects 700,000 lives every year and could lead to 10 million deaths every year by 2050. World Health Organization (WHO) has instituted a global action plan in 2015 to deal antimicrobial resistance in the 68th World Health Assembly. This paper aimed to review the situation analysis of current bottlenecks of the health system and provision of recommendations to improve the current regulatory mechanism for antimicrobial drugs in Pakistan. Antimicrobial Resistance (AMR) emerged as a threat practically in all nations of the world including Pakistan which is the world's sixth most populous country. This qualitative document analysis has been done by using Pakistan's National Policy on AMR. In 2004, total expenditure on pharmaceuticals was 1844 million US$ with a total pharmaceutical expenditure per capita of 11.3US$. Total number of pharmacists licensed was10,000 technician and assists were 20,000 and licensed pharmacies were 7000. There are only 0.9 pharmacists per 100000 populations are deployed. The health system and society are at risk of an emerging epidemic of AMR. This investigational analysis of AMR control, policy and regulation in Pakistan highlights some facts about misuse, availability of over the counter medicine, self-medications and low effect of existing approaches. Drug prescription monitoring law and policy investment is needed in the regulation of drugs to reduce unnecessary drug consumption and prescription, and strengthening quality parameters at several levels to control epidemic of AMR.

Background and Objectives: Corona Virus Disease 2019 (COVID-19) pandemic is a global health emergency. Health Care Workers (HCWs) with sound knowledge and practices can help curb the pandemic. This study aimed to assess the knowledge, attitude and practices of HCWs about COVID-19 and compare physicians and non-physicians in Saudi Arabia., Methods: An online survey was conducted among HCWs in Saudi Arabia in March and April 2020. Data were collected using a structured questionnaire having four sections including; socio-demographic and professional profile, knowledge, attitude and practices regarding COVID-19. Questionnaire link was sent through social media. Descriptive analysis was used for assessment of knowledge, attitude and practice and Chi-square test was used for comparing physicians and non-physicians. Data were analyzed using SPSS version 21.0., Results: A total of 398 HCWs completed the questionnaire. Only 45% of the participants had correct knowledge about the agent while about 97% knew that close contact with infected person is the most important risk factor. Only 63% had correct knowledge about the role of antibiotics in COVID-19 treatment. Majority of the HCWs were worried and most frequently reported worry was risk to family. Carrying infection to home was most commonly reported fear, 92%. Cleaning hands often or always was 11.5% and 87% respectively. About 71% wore mask during work. Knowledge was better among physicians compared to non-physicians while attitude and practices were comparable between the two groups., Conclusion: We found that there was poor knowledge about causative agent and role of antibiotics for COVID-19 but for mode of transmission and prevention there was good knowledge. There were widely prevalent worries and fears among the participants. Overall, there were good infection control practices among the HCWs. Interventions are needed to improve knowledge and address worries and fears of HCW., Competing Interests: The authors declare they have no conflicts of interest., (© 2020 The Authors. Published by Atlantis Press International B.V.)

Objectives: Falls and fall-related consequences are a major public health problem in the elderly. This study aimed to measure the prevalence of falls and fall-related risk factors among elderly individuals in Saudi Arabia., Methods: This cross-sectional study was conducted between January and October 2019 among 280 elderly patients aged >60 years old attending 10 randomly selected primary healthcare centres in Unaizah City, Qassim Province, Saudi Arabia. Data were collected using the validated 10-item Missouri Alliance for Home Care (MAHC-10) fall risk assessment tool., Results: A total of 269 participants were included in the study (response rate: 96.1%). The prevalence of falls over the preceding year was 31.6%. Females fell more frequently than males (34.5% versus 28.5%) and most falls occurred indoors (84.7%). Various risk factors were associated with fall risk including being aged >80 years (adjusted odds ratio [aOR]: 5.17, 95% confidence interval [CI]: 1.66-16.14), polypharmacy (aOR: 2.40, 95% CI: 1.01-5.71) and environmental factors (aOR: 2.79, 95% CI: 1.24-6.28). However, more educated participants had a lower risk of falling (aOR: 0.26, 95% CI: 0.09-0.77). There was also a significant association with the MAHC-10 fall risk score ( P = 0.043)., Conclusion: There was a high prevalence of falls among the elderly in Unaizah City. Various factors were associated with falls including advanced age, polypharmacy, age-related changes and environmental factors. As the majority of fall events occurred indoors, home safety improvements are recommended. Moreover, additional larger-scale research is necessary regarding fall-related risk factors and fall prevention initiatives among elderly individuals in Saudi Arabia., Competing Interests: CONFLICT OF INTEREST The authors declare no conflicts of interest., (© Copyright 2021, Sultan Qaboos University Medical Journal, All Rights Reserved.)

Background: Advantages and disadvantages associated with joint and nuclear family systems can affect quality of life (QOL). However, there is scarcity of literature about QOL among joint and nuclear family systems. This study aimed to assess the factors associated with QOL in joint and nuclear family systems., Methods: We conducted a population based cross sectional study in all 52 Union Councils (UCs) of District Abbottabad, Khyber Pakhtunkhwa province, Pakistan from March 2015 to August 2015. Multistage cluster sampling technique was used to select participants from both nuclear and joint family houses. The validated Urdu version of World Health Organization Quality of Life Questionnaire-Brief Version (WHOQOL-BREF) was used to assess quality of life among participants. Univariate and multivariate analyses were performed to explore the associations of different socio demographic variables with QOL among both family systems. Also a multilevel linear regression using backward analysis to obtain final model for each domain was performed to find out the variables that are associated with QOL score in each of family systems., Results: A total of 2063 participants were included in this study (51.0% joint family, 49.0% nuclear family) with the response rate of 97.4%. In multiple linear regression analysis of each domain for joint and nuclear family systems, rural residence compared to urban (p < 0.001), being female (p < 0.001), older age (p < 0.001), having comorbidity (p < 0.001) and lower socioeconomic status (p < 0.001) were found to be a strong predictor of poorer QOL. Furthermore, social capital (p < 0.001) had a positive effect on joint and nuclear family QOL scores., Conclusion: This study was the first of its kind which determined the factors of QOL in joint and nuclear families using the validated Urdu version of WHOQOL-BREF in Pakistan. Male gender, urban residence, younger age, higher socioeconomic status and social capital were positive predictors of QOL score while older age and presence of illness were associated with lower QOL scores among both family systems.

Background and Objectives: In order to curb the spread of coronavirus disease 2019 (COVID-19), the countries took preventive measures such as lockdown and restrictions of movements. This can lead to effects on mental health of the population. We studied the impact of COVID-19 on psychological well-being and associated factors among the Pakistani general population. Methods: An online cross-sectional survey was conducted between 26th April and 15th May and included participants from all over the Pakistan. Attitudes and worriedness about COVID-19 pandemic were assessed using a structured questionnaire. A validated English and Urdu version of the World Health Organization Well-Being Index (WHO-5) was used to assess the well-being. Factor analysis was done to extract the attitude item domains. Logistic regression was used to assess the factors associated with poor well-being. Results: A total of 1,756 people participated in the survey. Almost half 50% of the participants were male, and a similar proportion was employed. About 41% of the participants were dependent on financial sources other than salary. News was considered a source of fear as 72% assumed that avoiding such news may reduce the fear. About 68% of the population was worried about contracting the disease. The most common coping strategies used during lockdown were spending quality time with family, eating healthy food, adequate sleep, and talking to friends on phone. Prevalence of poor well-being was found to be 41.2%. Female gender, being unemployed, living in Sindh and Islamabad Capital Territory (ICT), fear of COVID-19, and having chronic illness were significantly associated with poor well-being. Similarly, coping strategies during lockdown (doing exercise; spending time with family; eating healthy food; having good sleep; contributing in social welfare work and spending time on hobbies) were also significantly associated with mental well-being. Conclusion: We found a high prevalence 41.2% of poor well-being among the Pakistani general population. We also investigated risk factors of poor well-being which included female gender, unemployment, being resident of ICT and Sindh, fear, chronic illness, and absence of coping strategies. This calls for immediate action at population level in the form of targeted mass psychological support programs to improve the mental health of population during the COVID-19 crises., 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 © 2021 Khan, Lodhi, Rabbani, Ahmed, Abrar, Arshad, Irum and Khan.)

Introduction: Since most hip fractures are treated surgically, it is imperative to find an optimum fracture-to-surgery time to decrease the potential complications and enhance postoperative outcomes. In comparison to the vast plethora of literature available on surgical delay and its implications on mortality, very little, if any, research is available on the impact of delayed surgery on postoperative ICU admission. The primary objective of our study is to examine the factors influencing post-surgical ICU admission in order to work on preventive strategies to reduce the potential associated morbidity., Material and Methods: Investigators did a nested case control study in a university hospital. A case was defined as a patient who had postoperative ICU admission while controls were patients who did not have postoperative ICU admission after hip fracture surgery. The primary outcome variable was postoperative ICU admission. The exposure variable was defined as the time to surgery which was categorized into two categories; early and late; the early surgery included patients who were operated within ≤ 48 h and the late included patients who had their surgery >48 h. Information on potential confounders including age, type of the procedure and comorbidities were also obtained. Result reported in-line with STROCSS criteria., Results: A total cohort of 1084 hip fracture surgeries were performed from January 2010 to December 2018. After screening for eligibility criteria, 911 patients were eligible for the final simple logistic regression analysis (48 cases and 863 controls). Our exposure variable i.e. time from admission to surgery showed no difference between cases and controls. The odds of being treated with Hemiarthroplasty among cases admitted in ICU was 2.42 times as compared to controls (aOR = 2.42; 95% C.I. 1.21-4.86)., Conclusion: Our study did not find an association between surgical delay and post-operative ICU admission after accounting for other covariates and potential confounders., Competing Interests: There are no conflicts of interest., (© 2020 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.)

Background Chronic diseases require long-term medication and adherence to medication is important for the control of disease as well as prevention of complications. Non-compliance may lead to worsening of the disease, which may affect patients' quality of life. This study aimed to assess the level of medication adherence and its association with quality of life (QOL) among hypertensive patients in Buraidah, Saudi Arabia. Methods A cross-sectional study was carried out in which 299 hypertensive patients were recruited from the randomly selected primary health care centers. Medication adherence was assessed by Hill-Bone Medication Adherence Scale, and quality of life was assessed by the World Health Organization's Quality of Life (WHOQOL)-BREF. Multivariate linear regression was used to assess the association of medication adherence with quality of life. Data was analyzed using SPSS version 21.0 (IBM Inc., Armonk, USA). Results The prevalence of poor adherence was found to be 38.8%. We did not find a significant association of medication adherence with any of the four (physical, psychological, social relationship, and environmental) domains of WHOQOL-BREF. However, poor medication adherence was associated with poor perceived overall QOL adjusted β=-0.012 (95% confidence interval [CI]: -0.021 to -0.002; p=0.018) and health adjusted β=-0.013 (95% CI: -0.025 to -0.002; p<0.018). Conclusion We found a high prevalence of non-adherence among hypertensive patients. This calls for developing interventions to improve compliance with medications to prevent complications of hypertension. Our study could not find a significant association of medication adherence with any of the domains of QOL, while poor adherence was associated with lower overall perceived QOL and health. Nonetheless, worsening of disease due to non-adherence may affect the QOL of patients. We recommend large scale prospective studies to explore the relationship between medication adherence and QOL., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Alsaqabi et al.)

Introduction: Hip fractures are of major concern due to the aging population worldwide. Surgery on this vulnerable population carries high risk. Charlson comorbidity index (CCI), has been reported to predict the mortality in these patients. Investigators in this study aimed at studying the prediction effect of CCI on hip fracture surgery complications after controlling other patents' and procedures' related factors., Methodology: We conducted a retrospective cohort of 1045 patients with hip fractures who were treated surgically at our tertiary care and level 1 trauma Center between 2010 and 2018. Primary exposure was CCI and primary outcome was in-hospital and 30 days postoperative complications (major and minor). Cox proportional algorithm analysis was done at univariate and multivariable levels to report Crude Relative Risk (RR) and Adjusted Relative Risk (aRR), respectively. Results were reported in line with STROBE criteria., Results: Exposed group included 867 (83%) of patients with 340 (39%) males. Postoperative complications occurred in 449 (43%) of the patients in exposed group with (62) 6% patients admitted in ICU postoperatively. At multivariable model, CCI was significantly associated with postoperative complications; patients with moderate-severe systemic diseases were 1.45 times (95% CI: 1.05-1.99) at risk of developing postoperative complications as compared to patients with low CCI scores after controlling for other variables in the model. Other significant factors included ASA status and postoperative ICU admission., Conclusion: CCI can be a good predictor independent variable of postoperative complications after hip fracture surgery. These patients need extra care and counseling to reach an informed decision keeping in mind the benefits versus risks of surgery. We recommend multi-center studies for corroboration., (Copyright © 2020 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Introduction: Novel tobacco products are becoming more popular in the Middle East and especially in Saudi Arabia. We studied the prevalence of midwakh pipe (tobacco smoking pipe) use among students at Qassim University and evaluated factors associated with midwakh pipe usage., Methods: A cross-sectional study was conducted using a self-administered questionnaire to collect the data. The participants were male students from Qassim University, Al-Qassim, Saudi Arabia. Data were collected over the period from May to June 2018. A multivariable logistic regression model was used to identify sociodemographic factors and smoking history related to midwakh smoking., Results: A total of 316 responses were collected; 7.9% (n=25) were midwakh smokers at some point, and 3.8% (n=12) were current midwakh smokers. Multivariable logistic regression indicated that the significant predictors of midwakh smoking among male university students were having a friend who is a tobacco or midwakh smoker, and consuming other forms of tobacco other than midwakh., Conclusions: Having midwakh smoking friends, having friends smoking any other form of tobacco, and being a smoker could predict the use of midwakh among university male students in Saudi Arabia. Interventions are required to control this behavior to prevent smoking-related health consequences., Competing Interests: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported., (© 2020 Dewi D.M.S.K. et al.)

Background: The Hospital Anxiety and Depression Scale (HADS) is a widely used instrument to measure anxiety and depression symptoms., Aims: This study aimed to translate, validate and test the applicability of the Urdu version of the Hospital Anxiety and Depression Scale (HADS/UV) among pregnant women., Methods: The original English version of the HADS was translated into Urdu by three bilingual experts and retranslated to English using the forward-backward approach. The questionnaire was administered to a sample of 200 pregnant women availing obstetrics and gynaecology services for routine prenatal check-ups of Ayub Teaching Hospital, Abbottabad, Pakistan. Psychometric properties of the instrument, including reliability (internal consistency, test-retest analysis and interitems correlation), were tested. Face and content validity were also assessed. Content Validity Index (CVI) was determined using the average approach and Item-Level Content Validity Index (I-CVI) and Scale-Level Content Validity Index (S-CVI) were calculated accordingly. Construct validity was examined through exploratory factor analysis., Results: Cronbach's alpha coefficient has been found to be 0.82 for the anxiety subscale and 0.64 for the depression subscale, while overall alpha of the HADS/UV is 0.84. The Urdu version is content valid, and the S-CVI of anxiety subscale, depression subscale and HADS/UV are 0.947, 948 and 0.947, respectively. Test-retest reliability is 0.884 and 0.934 as measured by Pearson correlation and intraclass correlation, respectively. HADS/UV items correlated positively with the whole scale (p<0.001). Factor analysis with varimax rotation revealed that two factors explained 42.75% of the variance. Items' distribution was quite similar to the original HADS., Conclusion: The HADS/UV is a psychometrically sound instrument with satisfactory measurement, including good internal consistency. The instrument shows promise to be a sound tool to assess anxiety and depression in pregnancy., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Focus on quality of postgraduate training has increased. One of the quality indicators is satisfaction of trainees with the residency programs. We aimed to assess the level of satisfaction of Saudi Board family medicine trainees with training program in Qassim., Methods: Anonymized online survey, using a structured questionnaire, was conducted among the current family medicine residents (n=60) in Qassim in 2019. Descriptive analyses were carried out to calculate frequencies of the responses. Satisfaction level was compared between basic (R1, R2) and advance (R3, R4) levels using Chi-square test., Results: About 67% (40) were basic level trainees. A higher proportion (>80%) of trainees was satisfied with the program director. Satisfaction with trainers ranged 45% to 85% for different items. About 79% of the trainees were satisfied with the training program organization. In the domain of training processes higher proportion (73-83%) was satisfied with supervision and feedback while a lower proportion (63- 68%) was satisfied with evaluations. Proportion of satisfied trainees in the domain of hospital rotations was lowest (43%) for academic activities in the hospitals. About family medicine rotations, a higher proportion (75%) was satisfied with academic activities. Higher proportion of trainees (78-86%) was satisfied with research facilitation and supervision. Mean score for overall satisfaction was 7.63 out of 10., Conclusions: The results of this study would help focus on certain domains to improve the quality of program. We recommend family medicine programs to regularly carry out such surveys for continuous quality improvement.

Background: Hip fractures account for one of the most debilitating conditions affecting the general population amongst the developed and developing nations. Investigators aimed to study the influence of the ongoing season i.e. whether patients operated upon in summer or winter, on post-operative complications occurring within 30 days of surgical procedure for hip fractures at a tertiary care hospital and level 1 trauma center., Materials and Methods: Investigators conducted a non-funded, non-commercialized retrospective cohort of 1045 patients with hip fractures managed surgically. Primary exposure was surgical procedures undertaken during the summer months (April-September). Our primary outcome was determining post-operative complication rates from January 2010 to December 2018 and evaluating impact of the season through univariate and multivariable regression analyses using Cox Proportional Hazard Algorithm with STATA V15. The work has been reported in line with the STROCSS criteria., Results: Age, ASA status, type of procedure, mechanism of injury and Charlson Comorbidity Index (CCI) were identified as significant associated factors with postoperative complications after hip fracture surgery. Although overall results revealed a rising rate of complications during the summer season with a relative risk (RR; 95% CI) of 1.1(0.89-1.32), univariate and multivariable analysis did not show any significant correlations., Conclusions: The results of this study did not demonstrate a significant seasonal variability in the rate of postoperative complications for hip fracture patients operated upon during the hot months of summer. More research is required to analyze postoperative complications in order to optimize patients' outcomes., Competing Interests: There are no conflicts of interest., (© 2020 The Author(s).)

Introduction: Induction of new residents and surgical trainees in most institutes occurs once a year. Fresh residents with no experience, may pose a threat to the surgical procedure outcome and there can be a potential increase in patients' morbidity and mortality as a result of this turnover. Literature is inconclusive about this effect. Our aim was to study the "new residents' induction effect" on postoperative complications after hip fracture surgeries., Methodology: This is non funded non commercialized study from a university hospital. Investigators studied a retrospective cohort of 1045 adult hip fracture patients who were operated at our tertiary care and level 1 trauma centre of a metropolitan city between 2008 and 2018. We defined primary exposure as the time period of new resident's induction (January-March) with the primary outcome in-hospital and 30days postoperative complications. Cox proportional hazard algorithm analysis was done at univariate and multivariable levels reporting Crude Relative Risk (RR) and Adjusted Relative Risk (aRR), respectively. Results were reported in line with STROBE criteria., Results: There were 274 (26%) patients in exposed group out of whom 109 (40%) developed postoperative complications. Interestingly, patients who had their surgeries during the induction period of new residents had 8% less risk of developing postoperative complications. However, result was statistically insignificant at both univariate and multivariable levels with RR; 95% C.I of 0.9 (0.78-1.22) and aRR; 95% C.I of 0.9 (0.78-1.22) after adjusting for the all other independent variables., Conclusion: The association of new residents' induction on postoperative hip fracture surgery complications, although protective, was insignificant after controlling for the potential confounding effect of patients' background and demographic characteristics. We recommend further multi-centre high powered studies to analyze this., (© 2020 The Authors.)

Background As per the International Society for Pediatrics and Adolescent Diabetes (ISPAD) census, diabetic ketoacidosis (DKA) is the most frequent cause of diabetes-related death. In developing countries, DKA-related mortality rate ranges from 6% to 24% (Onyiriuka AN, Ifebi E. Ketoacidosis at diagnosis of type 1 diabetes in children and adolescents: frequency and clinical characteristics. J Diabetes Metab Disord 2013;12:47) in contrast to 0.15%-0.31% in the Western world (Poovazhagi V. Risk factors for mortality in children with diabetic ketoacidosis from developing countries. World J Diabetes 2014;5:932-93.). In developing countries like Pakistan, the situation is more perplexing owing to uncertain or under-reported statistics about the spectrum of the disease and its prevalence, coupled with limited access to medical care and experts as well as less awareness. These limitations restrict our ability to develop interventions that are patient-centered. Our main objective was to determine the severity, clinical features, bio-chemical findings and outcomes of DKA in children aged 1 month to 16 years. Subjects and methods This retrospective study included the analysis of medical and laboratory records from patients' medical charts and the electronic database of all children aged 1 month to 16 years with newly diagnosed type-1 diabetes mellitus (T1DM) complicated with ketoacidosis, who presented to the emergency department (ED) at the Aga Khan University Hospital (AKUH), between January 2009 and December 2014. Results Diabetes mellitus complicated with DKA was the predominant diagnosis (n=113 [75.83%]) among endocrine diseases in children visiting the ED. Our study witnessed an increase in the incidence of DKA particularly after 5 years of age, with more severity in females. In our study, the mortality rate was 3.4%. Conclusions Considering the high incidence and mortality rate, it is emphasized that DKA should be considered in differential diagnosis. An awareness campaign for both general pediatricians and physicians as well as for the public is needed for better outcomes.

Background: This study was conducted in order to determine the prevalence of asthma and associated risk factors in the adult population of Karachi, Pakistan., Methods: This multi-stage, cross-sectional survey was conducted from May 2014-August 2015; comprising 1629 adults in 75 randomly selected clusters in Karachi, Pakistan. Definitions included: 'self-reported asthma', 'reversibility in FEV 1 ' and 'respiratory symptoms and reversibility in FEV 1 '., Results: Prevalence of asthma was 1.8% (self-reported) (95% CI: 1.0-2.6), 11.3% (reversibility in FEV 1 ) (95% CI: 9.4-13.3) and 6.6% (symptoms and reversibility in FEV 1 ) (95% CI: 5.1-8.1). Asthmatics were more likely to belong to the age group ≥38 years according to 'reversibility in FEV 1 ' and 'respiratory symptoms and reversibility in FEV 1 ' (AOR: 1.9, 95% CI: 1.2-3.3) and (AOR: 2.1, 95% CI: 1.1-4.2), respectively. Asthmatics were more likely to report history of allergies (AOR: 1.9, 95% CI: 1.2-2.9) and (AOR: 2.8, 95% CI: 1.7-4.8); and were exposed to environmental tobacco smoke (AOR: 1.6, 95% CI: 1.1-2.5) and (AOR: 1.9, 95% CI: 1.1-3.3) according to 'reversibility in FEV 1 ' and 'respiratory symptoms and reversibility in FEV 1 ', respectively. Asthmatics were more likely to report pack years of smoking ≥5 (AOR: 2.3, 95% CI: 1.1-4.7) according to 'respiratory symptoms and reversibility in FEV 1 '., Conclusion: This study reports a high prevalence of asthma among Pakistani adults and calls for developing appropriate public health policies for prevention and control of asthma in the country. Further studies should be conducted to determine the national prevalence as well as follow-up studies to identify preventable causes for adult asthma.

Background: Injuries are common among agricultural workers, and a large section of the population is employed in agriculture worldwide. We aimed to determine the incidence, patterns and associated risk factors of occupational injuries among the agricultural workers in a developing country. Methods: A cross-sectional study in Hyderabad, Pakistan was conducted from December 2012 to February 2013. Information was collected about incidence, pattern and associated risk factors of occupational injuries from 472 agricultural workers. Injury incidence and patterns for place, severity, type, agent, parts of body affected and work activity were calculated. Analysis was performed using SPSS version 19.0. Multivariate logistic regression was performed to calculate the adjusted odds ratio (OR) with 95% confidence interval, to identify the putative risk factors for occupational injuries. Results: Incidence of occupational injuries was 35.0 per 100 per year (95% CI: 28.9 - 42.7). Cuts (70%) and hand tools (71%) were the most common type and agent for injury, respectively. Majority of injuries occurred during harvesting (55%). Increasing age [AOR 1.03 (95% CI: 1.01 - 1.05)], income <6000PKR/month [AOR 2.27 (95% CI: 1.08 - 4.76)] and driving tractor [AOR 2.58 (95% CI: 1.25 -5.33)] increase the risk for injuries. Conclusion: There was a high burden of injuries among the agricultural workers in Pakistan. Large-scale studies are required to further characterize the risk of injuries and develop preventive strategies to protect agricultural workers.

Objective: To identify maternal factors associated with intrauterine growth restriction (IUGR)., Study Design: A case-control study., Place and Duration of Study: Neonatal Unit of The Aga Khan Hospital for Women (AKHW), Karimabad, from January 2014 to December 2015., Methodology: Cases were IUGR live born babies (n=90), while control were appropriate-for-gestational age (AGA) babies (n=180). Information recorded in pre-designed proforma included gestational age and birth weight of baby, demographics of mothers, pregnancy related medical and obstetric complications. Data were analysed through SPSS-19. Multivariable logistic regression was used to determine the maternal factors associated with the intrauterine growth restriction., Results: Maternal factors associated with IUGR after adjusting for confounders in the multivariable model included younger age (OR=0.9, CI=0.8-0.9), poor gestational weight gain (OR=3.0, CI=1.6-6.1) and history of previous abortion (OR=3.06, CI=1.1-8.0). Significant interaction was found between pregnancy-induced hypertension (PIH) and parity of mother, primary-para mother with PIH having an increased risk for IUGR babies (OR=10.1, CI=1.0-23.2)., Conclusion: Young age, primigravida status, low gestational weight gain, previous history of abortion, PIH and GDM have strong association with IUGR; hence, special consideration is essential to overcome these issues in order to improve maternal and neonatal health.

Facility-based, age- and residential area-matched case-control study was conducted in Sindh, Pakistan to determine association between biomass fuel use for cooking and pulmonary tuberculosis (TB). Cases were women with pulmonary TB, and controls were those suffering from other diseases. Current users of biomass fuel were at higher risk of pulmonary TB (adjusted matched odds ratio [mOR] = 3.0; 95% CI = 1.1-4.9) compared with nonusers. In comparison with former biomass users (women not using biomass for >10 years), recent biomass users (women who switched from biomass to nonbiomass ≤10 years ago), and current (lifetime) users were at a higher risk in a dose-response manner (adjusted mOR = 2.8, 95% CI = 0.9-8.2 and adjusted mOR = 3.9, 95% CI = 1.4-10.7, respectively). Population attributable fraction for TB related to biomass fuel use was 40.6% (95% CI = 35.5%-45.7%). This study strengthens the evidence that biomass fuel use for cooking is associated with pulmonary TB and risk increases with duration of exposure.

The study determined the risk zone and estimated the population at risk of adverse health effects for arsenic exposure along the bank of River Indus in Pakistan. A cross-sectional survey was conducted in 216 randomly selected villages of one of the districts along River Indus. Wells of ten households from each village were selected to measure arsenic levels. The location of wells was identified using global positioning system device, and spatial variations of the groundwater contamination were assessed using geographical information system tools. Using layers of contaminated drinking water wells according to arsenic levels and population with major landmarks, a risk zone and estimated population at risk were determined, which were exposed to arsenic level ≥10 µg/L. Drinking wells with arsenic levels of ≥10 µg/L were concentrated within 18 km near the river bank. Based on these estimates, a total of 13 million people were exposed to ≥10 µg/L arsenic concentration along the course of River Indus traversing through 27 districts in Pakistan. This information would help the researchers in designing health effect studies on arsenic and policy makers in allocating resources for designing focused interventions for arsenic mitigation in Pakistan. The study methods have implication on similar populations which are affected along rivers due to arsenic contamination.