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   Table of Contents - Current issue
Coverpage
January-March 2021
Volume 4 | Issue 1
Page Nos. 1-81

Online since Wednesday, January 6, 2021

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EDITORIALS  

The COVID-19 Vaccines: A magic bullet? p. 1
Muhammad Morshed
DOI:10.4103/jnsm.jnsm_160_20  
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The lessons learned from previous coronavirus infections should be used to contain future outbreaks p. 4
Aynaa Alsharidi, Khalifa Binkhamis
DOI:10.4103/jnsm.jnsm_161_20  
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REVIEW ARTICLES Top

Cardiopulmonary exercise testing in the clinical evaluation of patients with interstitial lung disease: A systematic review p. 6
Abdullah Rashed Alharbi
DOI:10.4103/2589-627X.303905  
Interstitial lung diseases involve multiple pathological mechanisms, including interstitial and alveolar destruction. In addition, pulmonary inflammation associated with the disease can reduce lung capacity and induce hypoxia, which becomes more significant with exercise. Cardiopulmonary exercise testing is used for diagnostic purposes and functional evaluation. This type of testing can measure the walking distance versus time to estimate the functional capacity of patients enrolled in rehabilitation programs. It can also assess cardiopulmonary functions in terms of carbon dioxide output, pulmonary gas exchange, as well as lung response influenced by exercise. Therefore, this systematic review aims to explore the clinical significance of using cardiopulmonary exercise testing in interstitial lung disease by reviewing the present medical literature. The literature review was carried out through Medline, Ovid, PubMed, and Google scholar databases, between 2010 and 2020. Searching terms included were a combination of “Cardiopulmonary exercise testing” AND “interstitial lung diseases.” After literature review, results were revised manually to include only original research articles evaluating the use of cardiopulmonary testing in interstitial lung disease. Selected trials mentioned the respiratory parameters evaluated. Seven articles were eligible for inclusion in this systematic review. The available data on cardiopulmonary exercise testing in interstitial lung diseases are explicitly still unclear. This finding opens the gates for future well-designed studies on this population.
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Advancing mental health nursing practice in the Kingdom of Saudi Arabia: Rethinking nursing care for consumers with psychosis p. 12
Norah Mohammed Alyahya, Ian Munro, Cheryle Moss
DOI:10.4103/JNSM.JNSM_35_20  
In this paper, the current mental health nursing care to recovery for consumers with psychosis in the Kingdom of Saudi Arabia (KSA) has been presented through one author's experience. This discussion showed major gaps in the practice. To advance this practice, it was important to understand the background of contemporary research about the role and work of nurses caring for consumers with psychosis and assisting with recovery. In addition, the perspectives of mental health nurses about their practice of care for psychosis globally were also provided. Finally, these global matters had been translated within the KSA context into advance mental health nursing care and recovery for psychosis in the aspects of education and practice. The emphasis on gender-focused research as an imperative need has been recommended.
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HOT TOPIC Top

COVID-19 pandemic preparedness and mitigation plan: Department of internal medicine experience from a clinical perspective p. 16
Assim A Alfadda, Abdulrazaq Albilali, Eman Alqurtas, Abdullah Alharbi, Aishah Ekhzaimy, Taim Muayqil, Mohamed Bedaiwi, Mazin Barry, Nahla Azzam, Abdulrahman Aljebreen, Arthur Isnani, Ahmed Bahammam, Ahmed Bin Nasser, Thamer Nouh, Musa Alzahrani, Khalid Alsaleh, Talal Alfaadhel, Naif Alotaibi, Khalid Alayed, Mohammad Alkhowaiter
DOI:10.4103/jnsm.jnsm_109_20  
During the current COVID-19 pandemic, timing and preparedness for healthcare facilities are fundamental. This descriptive article narrates the Department of Internal Medicine at the College of Medicine and King Saud University Medical City (KSUMC) response before and during the COVID-19 outbreak by focusing on the preparedness and mitigation plans the department implemented for its clinical services. A COVID-19 taskforce was created to implement the pathways for healthcare workers' workflow organization, plan the effective use of isolation facilities and personal protective equipment, and enhance liaisons between departments in the medical city. Telehealth was utilized for outpatient services, and medications were delivered to patients via courier. Aerosol-generating procedures were conducted after thoroughly reviewing the clinical indications and time-related risks. Medical day unit services followed a strict multistep screening protocol and rescheduled nonurgent investigations and therapeutics when possible. The Department of Internal Medicine prepandemic preparedness helped significantly mitigate the pandemic impact on KSUMC. Prioritizing in-hospital clinical care according to the patients' conditions, full adherence to infection control measures, clear and efficient communication between departments, and utilizing telehealth were the key elements in maintaining state-of-the-art clinical care during the pandemic.
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ORIGINAL ARTICLES Top

Knowledge, attitude, and practice study of laboratory staff toward Middle East respiratory syndrome Coronavirus p. 25
Nabeelah M Al-Motiri, Samina A Khan, Anas A Khan
DOI:10.4103/JNSM.JNSM_41_20  
Background: The Middle East respiratory syndrome coronavirus (MERS-CoV) is one of the most commonly prevalent and a highly pathogenic human coronavirus. The infection may lead to severe acute respiratory illness in a large proportion of affected individuals, with a high mortality rate. The processes and procedures involved in the management of patients could significantly improve the disease outcome. The purpose of the study was multifold: (1) to assess the actual knowledge, attitudes, and practices (KAP) toward MERS-CoV infection and (2) to determine the factors affecting KAP among the medical laboratory staff in Riyadh, Saudi Arabia. Both the aims would collectively help in designing effective policies in our fight against the evolving coronavirus disease. Materials and Methods: A cross-sectional anonymous survey was conducted among medical laboratory staff associated with tertiary health-care hospitals between October and December 2018. The participants were invited to complete a self-administered questionnaire about MERS-CoV infection. The association between KAP score and potential dependent variables was computed using multivariable linear regression model. Results: A total of 180 participants (57.8%) completed the survey. Our univariate analysis demonstrated that experience and education of an individual played a significant role in determining knowledge and attitude scores, respectively. On the other hand, practice score of an individual was shaped by age, profession, and department. Finally, our multivariate analysis regression analysis showed that staff with a bachelor's degree and those with a minimum laboratory experience of 15–20 years scored significantly higher KAP scores with respect to other individuals (P = 0.019 and P = 0.026). Conclusion: Our study identified alarming gaps in KAP toward MERS-CoV among different individuals. Furthermore, data collected in the present study might help to define strategies required to establish professional education programs for training medical laboratory staff.
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Monitoring the adherence to an adapted evidence-based clinical practice guideline on antiemetics in 669 patients with cancer receiving 1451 chemotherapy doses at a University oncology center in Saudi Arabia p. 33
Haya Fahad Al-Salloum, Yasser Sami Amer, Khalid Abdulrahman Alsaleh
DOI:10.4103/JNSM.JNSM_10_20  
Objectives: Chemotherapy-induced nausea and vomiting (CINV) is a common medication safety issue among cancer patients worldwide. However, there remains a research gap on adherence to the clinical practice guidelines (CPGs) for antiemetic medications to prevent and treat CINV in Saudi Arabia. Further, the adherence to our center's CPG for antiemetics for CINV at our center was never quantified before. Therefore, this audit was designed as an implementation and quality improvement intervention to fill the knowledge gaps. Methods: We conducted a retrospective cross-sectional observational study of the adult cancer patients attending the University Oncology Center at King Saud University Medical City. Data were extracted from the electronic health records' database for patients receiving chemotherapy in the months of February and November 2017. Results: Among the 669 adult cancer patients who received 1451 chemotherapy doses at our center, nearly 48% of the antiemetic prescriptions adhered to our adopted CPG's recommendations. The adherence of prescribers was more likely to moderate emetogenic agents such as doxorubicin and ifosfamide as compared to the high emetogenic agents such as cisplatin and cyclophosphamide >1500 mg/m2. Conclusions: Adherence to the antiemetics for CINV-CPG was suboptimal due to the unavailability of neurokinin1-receptor antagonists (NK1) antagonists and the lack of knowledge by prescribers. NK1 antagonists should be available to maximize the level of cancer care. Regular physician's education and training sessions must be conducted to familiarize them with the CPG evidence-based recommendations.
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Post-enucleation retinoblastoma: Outcome analysis and evaluation of prognostic features p. 40
Amani Al-Kofide, Hind M Alkatan, Yasser Khafaga, Khawar Siddiqui, Rafat Jafri, Mouhab Ayas, Saleh A AlMesfer
DOI:10.4103/JNSM.JNSM_58_20  
Background: The aim is to assess if International Classification for Retinoblastoma (ICRB) and American Joint Committee on Cancer Staging System (AJCC) for patients with advanced Retinoblastoma (RB) who underwent enucleation correlated in predicting the successful outcome of chemotherapy. Materials and Methods: Medical records of fifty-eight pediatric patients (age ≤14 years) who underwent enucleation at King Khalid Eye Specialist Hospital, and treated post enucleation at KFSH and RC from 2012 to 2016 were reviewed. Results: RB was unilateral in 30 (51.7%), bilateral in 26 (44.8%) and trilateral in 2 (3.4%). One (1.7%) had metastatic disease. Sixty-one enucleation was performed on 58 patients; unilateral in 55 (94.8%) and bilateral in the 3 (5.2%) cases. Disease was ICRB Group E in 43 (70.5%), Group D in 11 (18.0%), Group C and A in 3 (4.9%) each, and Group B in 1 (1.6%) at diagnosis (P < 0.001). The median age at diagnosis was the highest in Group E compared to other groups (P = 0.254). All patients received chemotherapy. Nine (18.8%) patients classified as Group D or E as per the ICRB classification turned out to be pT1 or pT2a (low-risk), while one classified as Group C was of stage pT1. Probability of 5-year overall survival for the whole cohort was 93.0% (±4.0%); 94.5% (±3.8%) for Group E (2 mortalities) and 80.0% (±17.9%) for Stage D with one event of mortality (P: 0.972). Conclusion: Older children presented with ICRB Group E. Group E eyes had a high pTNM risk group than Group D. ICRB tends to correlate with pTNM. The ICRB classification is essential for decision making on enucleation; however, AJCC pTNM classification plays a pivotal role in deciding on postenucleation adjuvant treatment.
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Pulse oximeter with longer averaging time and missed chronic hypoxia in preterm infants Highly accessed article p. 46
Nasser Saleh Alharbi, Ahmad S Al-Katari, Khalid Al-Tirkawi, Wafa Al-Faki, Mohammad Al-Ghamdi, Shaikh M Iqbal
DOI:10.4103/JNSM.JNSM_105_20  
Background: Targeted oxygen saturation in preterm infants has been an area of debate for decades. Mild chronic hypoxia exposes some infants to significant comorbidities like pulmonary artery hypertension (PAH). The pulse oximeters vary in technical properties and setting; pulse oximeters with shorter SpO2 averaging time may provide a more accurate oxygen assessment. Aim: To evaluate the readiness of preterm infants for discharge based on the current unit's protocol which uses standard pulse oximetry with an averaging time of 20s, as opposed to a pulse oximeter with a shorter averaging time (2s). Methods: The study was a prospective observational pilot study included all infants <32 weeks' postmenstrual age (PMA) with no cardiovascular or respiratory pathology other than related to prematurity, such as bronchopulmonary dysplasia (BPD) and persistent ductus arteriosus. All infants underwent Echocardiography studies after the 2nd week of life and after 36 weeks to exclude PAH. All infants older than 36 weeks PMA who were off oxygen and ready to be discharged home as per unit's protocol underwent final oxygen assessment for a minimum of 6 h using motion resistant oximeter with a SpO2 short averaging time of 2s. Results: Thirty-five infants underwent the oxygen pulse oximetry testing. Of them, 42% were found to have chronic hypoxia (defined as 5% of recorded time with SpO2 ≤ 90%) and fulfilled the diagnostic criteria for BPD. Conclusions: A significant number of infants at 36 weeks' PMA with chronic hypoxia were missed using the current unit's oxygen assessment. With the prevalence being higher in infants diagnosed with BPD, a future study must be conducted to investigate the correlation between missed chronic hypoxia in infants with BPD and late-onset PAH.
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Remineralization effect of diode laser, Nanoseal®, and Zamzam water on initial enamel carious lesions induced around orthodontic brackets p. 50
Sara Mohamed Hosny Elkabbany, Asmaa A Mosleh, Noha I Metwally
DOI:10.4103/jnsm.jnsm_125_20  
Purpose: This in vitro study was conducted to evaluate the remineralization effect of laser, Nanoseal®, and Zamzam water on initial enamel carious lesions of premolar induced around orthodontic brackets. Materials and Methods: A total of 40 premolars divided randomly into four groups were submitted to three phases: (1) placement of orthodontic brackets; (2) demineralizing solution; and (3) remineralization (Group L; teeth were irradiated with 980 nm diode laser for 30 s, Group N; Nanoseal® was applied to teeth according to manufacturer's instructions, Group Z; teeth were immersed in Zamzam water for 3 days then rinsed with deionized water, and Group C; control with no treatment). In each phase, elemental analysis (calcium and phosphorus) was measured using a scanning electron microscope/energy dispersive X-ray analysis. The data were tested using the Bonferroni test and Tukey's test. Results: There was a decrease in calcium ion content in Groups C and L in the third phase (−1.62% and − 0.1%, respectively) than the first one. On the other hand, an increase in calcium ion was shown in Groups Z and N (1.1 and 1.6%, respectively). An increase in phosphorus ion was obvious in all experimental groups ranging from 0.6% to 3.7%, with Group N having the highest increase of phosphorus ion from the first to the third phase. Conclusions: Using Nanoseal® and Zamzam water proved to be better than a diode laser for the treatment of initial carious lesions. The use of diode laser helps to remineralize enamel but in a lower percentage than other tested agents.
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Fibonacci's mathematical sequence predicts functional and actual lengths of the phalanges of the hand p. 58
Andrew S Miller, Rhodri Gwyn, Dhritiman Bhattacharjee, Louisa N Banks
DOI:10.4103/JNSM.JNSM_65_20  
Background: Fibonacci described a mathematical sequence starting 0, 1, 1, 2, 3, 5, 8… where each sub sequential number is the sum of the two preceding numbers. The golden ratio (Phi, Φ = 1.618) is the ratio of two consecutive numbers in the sequence. Here, we investigate whether there is a relationship between these mathematical sequences or ratios and functional or actual lengths of the digits. Methods: Two hundred radiographs of the hand were reviewed by three independent reviewers (interobserver correlation r >0.98), and the actual and functional phalangeal lengths were measured. Results: Both the functional and actual lengths of the phalanges of the little finger followed Fibonacci's sequence. The index, middle, and ring fingers followed a mathematical sequence related to the Fibonacci's sequence. We were not able to demonstrate any direct relationship between phalangeal length and the golden ration (Φ). The sum of lengths of the distal and middle phalanx equals the length of the proximal phalanx with great accuracy. Conclusions: This is useful in many surgical situations (congenital deformities, polytrauma to the hands, and arthroplasty).
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BRIEF REPORTS Top

Readmission rates of heart failure and their associated risk factors in a tertiary academic medical City in Riyadh, Saudi Arabia p. 64
Dalal A Aldihan, Mohammad A Alghafees, Rana O Alharbi, Raghad S Allahidan, Razan H AlOmar, Areej F Alenazi, Ihab F Suliman
DOI:10.4103/JNSM.JNSM_57_20  
Background: Readmissions remain a persistent challenge in the care process of heart failure (HF). This study aimed to assess the 30 and 90-day readmission rates of HF and the associated risk factors. Materials and Methods: This retrospective cohort study targeted adult patients admitted for HF to King Abdulaziz Medical City between January 2016 and December 2018. The primary outcome variables were 30- and 90-day readmissions. Descriptive statistics were used for the continuous variables, which displayed the mean, standard deviation, and minimum and maximum values. The binary logistic regression technique was used to investigate risk factors for 30- and 90-day readmissions. Results: The 30- and 90-day readmission rates were 39.6% and 37.6%, respectively. Hypertension (P < 0.001), chronic kidney disease (P = 0.03), hypothyroidism (P = 0.04), and pulmonary diseases (P < 0.001) were all deemed as risk factors for readmission within 30 days. Body mass index (P = 0.03), dyslipidemia (P = 0.04), chronic kidney disease (P = 0.03), arrhythmias (P = 0.007), and pulmonary diseases (P < 0.001) were all deemed as significant predictors of readmission within 90 days. Conclusion: The 30- and 90-day readmission rates were 39.6% and 37.6%, respectively. Hypertension, chronic kidney disease, hypothyroidism, and pulmonary diseases were significant predictors for 30-day readmission. Body mass index, dyslipidemia, chronic kidney disease, arrhythmias, and pulmonary diseases were significant predictors for 90-day readmissions. These predictors must be taken into consideration to develop strategies to reduce readmission rates and mitigate a burden on health-care resources and patients' morbidity.
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Injection laryngoplasty in the treatment of vocal cord sulcus vocalis p. 69
Manal A Bukhari, Mariam S Al-Amro, Sami E Al Harethy, Khalid H Malki, Tamer A Mesallam, Mohamed Farahat
DOI:10.4103/JNSM.JNSM_66_20  
Objective: The objective is to review all cases of sulcus vocalis that were treated surgically with injection laryngoplasty and study their demographic data, ways of presentation, endoscopic evaluation, modality of treatment, and voice outcome. Materials and Methods: This is a retrospective study of 60 patients with sulcus vocalis who were treated surgically at King Abdulaziz University Hospital, King Saud University. The collected data included information on gender, age, symptoms, time of onset, endoscopic examination, surgical management, and voice outcome. Results: A total of 60 patients were included in this study, of which 53.3% were male and 46.7% were female. The mean age was 27.4 (11.06 standard deviation). Childhood presentation was positive in 61.7% of the cases and 8.3% had family history. There was a significant improvement in postoperative glottal gap and voice handicap index (VHI) after injection laryngoscopy and there were many positive significant correlations. The first correlation was between the preoperative and postoperative glottal gap (Spearman rank correlation coefficient r = 0.368). The second was between preoperative VHI and postoperative glottal gap (Spearman rank correlation coefficient r = 0.595). The third was between preoperative and postoperative VHI (Spearman rank correlation coefficient r = 0.832). The follow-up period ranged from 6 months to 5 years. Conclusion: Injection laryngoplasty is a promising surgical modality of treatment for sulcus vocalis, which shows significant improvement in voice outcome postoperatively. The management is still challenging and there is still no unified method for treating such condition.
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CLINICO-PATHOLOGICAL PEARLS Top

A challenging diagnosis of B-ketothiolase deficiency mimicking type 1 diabetes mellitus p. 74
Amal Ali Al-Hakami, Malak Ali Alghamdi, Khalid Sumaily, Reem Abdullah Al-Khalifah
DOI:10.4103/JNSM.JNSM_31_20  
Beta-ketothiolase (BKT) deficiency is a disorder of ketone body metabolism and isoleucine catabolism. Patients with BKT deficiency have intermittent ketoacidosis attacks. In this report, we describe an unusual case that mimicked type 1 diabetes presentation. The patient is a 1-year-old boy who presented with clinical and biochemical evidence of diabetes ketoacidosis (DKA). After the resolution of DKA, he was commenced on subcutaneous insulin regimen. Insulin requirements decline over few weeks to 0.3 U/kg/day, and due to normalization of blood glucose coupled with frequent hypoglycemic episodes, insulin was stopped for few months. Later, he developed two additional DKA episodes with intermittent period of no insulin requirement. At 2 years of age, he presented with ketoacidosis and hypoglycemia. The unusual presentation of ketoacidosis accompanied with hypoglycemia prompted genetic testing. Genetic testing revealed a novel homozygous mutation in the ACAT1 gene. The patient was advised to avoid prolonged fasting and started on a low-protein diet. Since then, he had developed mild episodes of ketosis with illness required intravenous hydration. In conclusion, the pediatrician should maintain a high index of clinical suspicion when dealing with children presenting with unusual diabetic ketoacidosis. Delayed diagnosis of BKT, failure of management of acute crisis, and the unnecessary use of insulin can lead to high morbidity and mortality.
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LETTERS TO THE EDITOR Top

Adherence to the biosafety protocol while processing samples of Corona Virus Disease 2019 p. 78
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/JNSM.JNSM_84_20  
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Childhood Vitamin D deficiency: Time for policy change p. 80
Reem Abdullah Al Khalifah, Yossef Alnasser
DOI:10.4103/JNSM.JNSM_69_20  
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