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   Table of Contents - Current issue
Coverpage
April-June 2021
Volume 4 | Issue 2
Page Nos. 83-218

Online since Tuesday, April 13, 2021

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EDITORIAL  

What are the factors influencing interns' deciding on their specialties? p. 83
Samy A Azer
DOI:10.4103/jnsm.jnsm_31_21  
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VIEWPOINT Top

Experience from a medical college in Saudi Arabia on undergraduate curriculum management and delivery during COVID-19 pandemic p. 85
Mona Soliman, Saleh Aldhaheri, Khalid Fouda Neel
DOI:10.4103/jnsm.jnsm_146_20  
Coronavirus disease 2019 (COVID-19) was declared a pandemic by the World Health Organization on March 11, 2020. In response to the pandemic, the Kingdom of Saudi Arabia's Ministry of Education announced the suspension of educational activities. The pandemic has challenged universities worldwide to provide education virtually as an immediate response to prolonged lockdown periods. This article highlights the College of Medicine's experience at King Saud University, Saudi Arabia, in managing undergraduate medical education in response to the pandemic situation. We describe the process of implementing the curriculum's delivery online during the lockdown and the decisions regarding the final assessment for all years. Furthermore, we highlight the steps taken to prepare for the new academic year 2020–2021 as a blended learning approach in light of the COVID-19 situation.
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PERSPECTIVE Top

Encouraging medical students to become self-directed learners through conduction of small-group learning sessions p. 90
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/jnsm.jnsm_142_20  
In the field of medical education, learning among medical students is found to be deeper and more effective, when it happens in small groups. This is primarily because the small-group learning environment enables students to become self-directed learners and also gives them an opportunity to collaborate with other members of the group. An effective small-group learning session will depend upon the discussion skills of the teacher and the students and essentially includes appropriate questioning, listening patiently to the responses of others, responding to the raised questions in a polite and meaningful manner, explanation of the given problem, ensuring active preparation for the session, and smart opening and closure of the sessions. In conclusion, the conduction of an effective small-group learning sessions helps the medical student to become self-directed learner and improve their critical thinking and clinical reasoning skills. It is quite essential that all the medical colleges should include small-group learning sessions within their teaching schedule and help the students to acquire subject competencies.
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HOT TOPIC Top

COVID-19 vaccine in the Kingdom of Saudi Arabia: A true operation warp speed Highly accessed article p. 92
Mazin Barry, Ahmed S BaHammam
DOI:10.4103/jnsm.jnsm_8_21  
As of January 2021, 1 year has passed since the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) was first discovered, which is the cause of the coronavirus disease-2019 (COVID-19) pandemic that has infected almost 100 million people worldwide and caused almost two million deaths. In 2020, in an unprecedented scientific achievement, several vaccines were developed, underwent clinical trials, and were distributed worldwide. This was made possible, in part, by Operation Warp Speed, which promoted mass production of multiple vaccines through different technological platforms, relying on preliminary evidence to allow faster distribution as soon as clinical trials confirmed one or more of those vaccines to be safe and effective. The Kingdom of Saudi Arabia (KSA) was one of the very first countries in the world to grant emergency use authorization to the BNT162b2 vaccine, a new type of modified RNA vaccine developed by Pfizer-BioNTech. Here, we review various COVID-19 vaccines and the success of the vaccine rollout in KSA.
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SYSTEMATIC REVIEW Top

Glycemic control among patients with diabetes and comorbid depression in gulf countries: A systematic review p. 99
Saad Mohammad Alsaad, Turki A Binmoammar, Sondus Hassounah, Ali H Mokdad, Salman Rawaf
DOI:10.4103/jnsm.jnsm_139_20  
Background: People with diabetes suffering from depression are at greater risk of suffering from an episode of diabetic burnout which can have adverse outcomes on their health. Objectives: The primary objective is to review the relationship between depression and glycemic control among patients with diabetes in the Gulf Cooperation Council (GCC) countries. Methods: MEDLINE, EMBASE, PsychINFO, and GLOBAL HEALTH databases were systematically searched without language restriction to identify relevant studies that examined the relationship between glycemic control and depression among patients with diabetes in (GCC) countries. Reference lists and Google Scholar were also searched for additional studies. Research was conducted by two reviewers independently and disagreements were resolved by discussion. Results: Our search revealed nine studies were published between 2004 and 2018 and a total of 2199 subjects with diabetes. Majority of the participants were diagnosed with type 2 diabetes mellitus (DM). Out of the 9 articles included in the synthesis, only five of them have reported a significant association between depression and glycemic control; on the other hand, four articles showed nonsignificant association. The prevalence rates of depression among diabetic patients ranged from 12.5% to 61.8%. Conclusion: Depression was associated with poorly controlled HbA1c. However, this association was not significant across all studies. Considering the high rates of DM in these countries, better quality studies are needed to assess the depression comorbidity and its impact on glycemic control for better cost-effective treatments and to inform practice.
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MINI-REVIEW Top

Employment of ethnography research to ensure effective delivery of medical education and clinical training p. 109
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/jnsm.jnsm_149_20  
Ethnography is one of the qualitative approaches, wherein the researcher gets submerged into the study setting that has to be explored. An extensive search of all materials related to the topic was carried out in PubMed and a total of five articles were selected based upon the suitability with the current review objectives. The ethnography approach gives a sense of freedom to the researchers to understand in depth the multiple variables in clinical settings or in the delivery of medical education, as the approach remains open ended. In fact, the generated evidence helps the administrators or teachers to understand the dynamics and the root cause of the problem, which then can be effectively sorted out. In conclusion, the application of ethnography empowers the administrators to get a better understanding of the issues in the delivery of medical education and health care. The need of the hour is to encourage training of faculty members in qualitative research, as a trained ethnographer can utilize their skills for the better understanding and effective resolution of the issues impacting effective curriculum delivery.
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ORIGINAL ARTICLES Top

Determining factors affecting the medical interns' choice of specialties among governmental universities in Riyadh Highly accessed article p. 112
Ahmed Tariq Al Suwaidan, Lama Abdullah Al Luhidan, Khaled Abdullah Al Barrak, Rehab Abdullah Al Mubrick, Hessah Ibrahim Al Suwaidan, Rawan Abdulaziz Al Shammari, Rima MHD Belal Barakeh, Moath Khalid Al-Ghusoon, Bander Munir Al Rwaily, Sulaiman Abdullah Al Shammari
DOI:10.4103/JNSM.JNSM_54_20  
The nature of experience during the medical study at university may play an essential role in choosing the specialty. Background: The aim of this study is to determine the effect of national universities in general and on medical interns' career choice, taking into consideration the gender difference. Furthermore, to find out when national universities educate their students about the different specialties. Methods: This was a cross-sectional study that included 234 Saudi medical intern students from four different medical colleges in national universities in Riyadh. These were King Saud University, Princess Nourah Bint Abdulrahman University (PNU), Imam Mohamed Bin Saud Islamic University, and King Saud bin Abdulaziz for Health and Science (KSAU-HS) with consideration of gender differences and availability. All participants who are selected randomly completed an online questioner with a unique code. Results: Around two-thirds (66%) of the participants ensured that their national universities had a positive influence in choosing the specialties dividing equally between both genders. According to the participants' perceptions, all the items of the medical education system did not affect in choosing the specialty except three of them that have a positive effect which are elective experience (43.59%), clinical year (40.6%), and the personality of instructor (38.46%). Furthermore, one-third (33%) of the participants emphasized that their universities educated them about the specialties in the 3rd year. The most common decisive factor was an elective experience of 19.36%, whereas the most common negative factors were improper block duration and the personality of the instructor by 14.52%. Conclusion: Most national universities had a positive effect on their students' career choice, and they educated pregraduate students about specialties.
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Valporic acid-induced hepatotoxicity in rats: Protective effect of selenium p. 118
Elias Adikwu, Ebiladei Liverpool
DOI:10.4103/jnsm.jnsm_123_20  
Background: The use of valproic acid (VPA) as therapy for epileptic and other neuropsychiatric disorders may cause hepatotoxicity. Selenium (Se), a component of selenoproteins, which performs important enzymic functions, may protect biomolecules from damage. This study assessed the protective effect of Se against VPA-induced hepatotoxicity in Wistar rats. Methods: Thirty-two adult Wistar rats of both sexes (160 ± 20 g) were divided into four groups of n = 8. Groups 1 (Control), 2, and 3 were orally administered with normal saline (0.2 mL), Se (0.1 mg/kg/day), and VPA (200 mg/kg/day) for 30 days, respectively. Group 4 was orally administered with Se (0.1 mg/kg/day) and VPA (200 mg/kg/day) for 30 days. After treatment, the rats were weighed and anesthetized. Blood samples were collected and analyzed for serum biochemical parameters. Liver samples were weighed and assessed for biochemical markers and histology. Results: Body weight was significantly (P < 0.01) decreased, whereas liver weight was significantly (P < 0.01) increased in VPA administered rats. VPA caused significant (P < 0.001) increases in serum and liver aminotransferases, alkaline phosphatase, gamma-glutamyl transferase, lactate dehydrogenase, conjugated bilirubin, total bilirubin, total cholesterol, triglyceride, low-density lipoprotein cholesterol, and malondialdehyde levels when compared to control. VPA produced significant (P < 0.001) decreases in liver glutathione, catalase, superoxide dismutase, glutathione peroxidase and serum high density lipoprotein cholesterol levels when compared to control. Hepatocyte necrosis and fatty change were observed in VPA- administered rats. Se supplementation significantly (P < 0.01) reversed VPA-induced hepatotoxicity. Conclusion: Se seems effective against VPA-induced hepatotoxicity.
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Epidemiological and clinical characteristics of fatalities from COVID-19 in Saudi Arabia: A multicentric, retrospective study p. 124
Ahmed A Alahmari, Jalal Alowais, Anas A Khan
DOI:10.4103/jnsm.jnsm_107_20  
Background: Although Saudi Arabia harbors a large number of confirmed cases with coronavirus disease 2019 (COVID-19), the Kingdom is characterized by a low case fatality rate, compared to that of other parts of the world. Patient-specific factors can play a role in this observation. Thus, we conducted the present retrospective study to investigate the epidemiologic characteristics of all fatalities resulting from COVID-19 infection in Saudi Arabia as of April 27, 2020. Materials and Methods: The present study was a multicentric, retrospective study that retrieved the data of all confirmed COVID-19-related deaths in Saudi Arabia from March 2 to April 27, 2020. Only records of the cases who underwent reverse transcription-polymerase chain reaction laboratory tests to confirm the presence of COVID-19 were retrieved. The data of COVID-19 fatalities in Saudi Arabia were obtained from the Health Electronic Surveillance Network of the Ministry of Health. Results: Up to April 27, 2020, 147 cases of COVID-19-related deaths were reported in Saudi Arabia. Almost two-thirds of them were aged above 50 years and majority of them were male (83.7%). Health-care workers represented 3.1% of the dead cases (n = 4 cases). The vast majority of the cases were from Makkah (44.9%) and Madinah (21.8%). Among males, the number of Saudi cases was much lower than non-Saudi cases with 22 and 101 deaths, respectively. Over 80% of the included cases had reported signs and symptoms before death, mainly fever and cough. Out of the 129 cases who had available data regarding comorbidities, 104 cases (80.6%) had one or more comorbidities. The median (interquartile range [IQR]) time from the onset of symptoms till test result confirmation was 5.5 (5) days, while the median (IQR) time from sample collection till test result confirmation was 1 (2) day. On the other hand, the median time from symptom onset till hospitalization and that till death was 1 (3) and 7 (8) days, respectively. Conclusion: COVID-19 is a growing pandemic with unprecedented spread rate and profound impact on the health of specific subsets of affected patients. In the present report, we demonstrated that fatalities from COVID-19 in Saudi Arabia are more common in older age groups, male patients, and non-Saudi residents. Besides, the presence of comorbidities is highly prevalent among fatalities from COVID-19 in Saudi Arabia. The Saudi health-care system has the advantage of fast-track diagnosis, which, in return, could have contributed to the low case fatality rate observed in the Kingdom. Further studies are required to identify the independent predictors of mortality for patients with COVID-19.
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Hand hygiene perception and handshaking practices among pediatric inpatient caregivers: A cross-sectional study at a teaching hospital in Saudi Arabia Highly accessed article p. 130
Mohamad-Hani Temsah, Fahad M Alsohaime, Ayman Al-Eyadhy, Gamal Hasan, Abdulrahman Alarfaj, Hazim Bajri, Talal Al-Judi, Gosay Al-Mazyad, Abdulrahman Al-Shammari, Majeed Jawad, Mark S Sklansky, Sarah Al-Subaie, Ali Mohammed Somily
DOI:10.4103/JNSM.JNSM_80_20  
Background: Direct or indirect hand contact plays a significant role in health-care-associated infections. Family members of pediatric patients may have various hand hygiene practices. We aimed to evaluate the perceptions of hand hygiene and handshaking practices among family caregivers of hospitalized children in a tertiary care hospital. Methods: A cross-sectional study was conducted using a pretested two-part questionnaire for a randomly selected caregiver of hospitalized children at King Khalid University Hospital, Riyadh, Saudi Arabia, between January 21 and March 8, 2018. The survey data were analyzed using SPSS version 21. Results: One hundred and eighty caregivers voluntarily participated in the study. The mean age was 35.1 years, and female parents comprised 85.6% of the sample. The majority of participants (82.8%) did not receive any previous formal education on hand hygiene. Most of the participants (relative importance index of 84.6%) had correct answers on a modified version of the World Health Organization “Perception Survey for Health-Care Workers.” However, handshaking avoidance was low in general, with caregivers reporting their handshaking practices did not change even when dealing with people who have flu-like symptoms. There was no significant correlation between the participants' characteristics and handshaking avoidance practice, except for those who were working in the medical field, who showed a significantly higher handshaking avoidance. Conclusion: Formal education for hospitalized children's caregivers on hand hygiene and handshaking practice is lacking. Information on appropriate hand hygiene and potential risks of infection spread is required, especially for those parents without a previous medical background.
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Prevalence of sports injury and its association with warm-up in males visiting the fitness centers in Riyadh, Saudi Arabia Highly accessed article p. 135
Sultan Alaqil, Adel Alzahrani, Saud Alahmari, Faisal Alqarni, Saeed Alqahtani, Ambreen Kazi
DOI:10.4103/JNSM.JNSM_87_20  
Background and Objective: Regular exercise has a positive effect on the well-being of individuals; however, improper utilization of exercise facilities may result in sports/exercise-related injuries leading to increased burden on the health system. The objective of this study was to measure the prevalence of sports injury and explore its association with warm-up in males visiting the fitness center in Riyadh, Saudi Arabia. Materials and Methods: A cross-sectional study was conducted on 521 males, while they were visiting the fitness/sports center in Riyadh city. The interviews comprised of questions on sociodemographic information, sports/exercise-related injury, warm-up, and its type and duration, medical history, smoking status, height, and weight of the participants. Multivariate logistic regression analysis was conducted to measure the association between sports injury and warm-up. Results: The mean age and body mass index (BMI) of the participants was 24.0 (±6.7) years and 25.8 (±5.8) kg/m2, respectively. Regular exercise was reported by 63% (n = 330) of the participants, whereas 43.4% (n = 228) mentioned some kind of sports/exercise-related injury during the last 1 year. Regualr warm-up was reported by 45% (n = 236) of the participants. The multivariate logistic regression analysis found no significant association between sports injury and warm up [0.73 (0.41, 1.31)]; and the age category 31–50 years had 2.06 (95% confidence interval [CI]: 1.15–3.69) times higher odds for the injury in comparison to younger ages (16–25 years). Low income group (<5000 SAR) had odds of 2.04 (95% CI: 1.28–3.24) in comparison to >10,000 SAR. The participants following the diet plan for weight loss also showed higher odds (1.61 [95% CI: 1.06–2.43]) for reporting sports injury in comparison to those without diet plan. The association was adjusted for BMI. Conclusions: Prevalence of exercise/sports-related injury among fitness club visitors is significantly high. Awareness about sports injury and proper gym training should focus on young adults visiting the fitness center with the purpose of weight loss.
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Cyberbullying among young Saudi online gamers and its relation to depression Highly accessed article p. 142
Mohammed AlJaffer, Khalid Alshehri, Malak Almutairi, Abdullah Aljumaiah, Abdulaziz Alfraiji, Mohammed Hakami, Muhammad Al-Dossary, Tehreem Irfan
DOI:10.4103/JNSM.JNSM_78_20  
Background: There is a worldwide interest that has been dedicated to discovering the impact of online video games on mental health among young gamers and its association with the risk of cyberbullying. Many studies have suggested that cyberbullying is associated with the development of depression. To our knowledge, there are no studies that have been carried out in Saudi Arabia that addressed such a topic. Objective: The objective of this study is to estimate the prevalence of cyberbullying among Saudi online video gamers, and it is associated risk to the development of depression. Methods: Using an anonymous online questionnaire posted on social media, a total of 143 caregivers of young Saudi gamers agreed to complete the questionnaire. The questionnaire examined multiple factors including addressing the act of cyberbullying for their association with developing depression. The Patient Health Questionnaire-9 was used to evaluate for depression. Results: Out of 143 gamers, 30 reported being cyberbullied as disclosed by their caregivers, half of which showed depressive symptoms. This had a statistical significance of P = 0.00001. Online chatting was associated with an increased risk of being cyberbullied. Conclusion: The trend of cyberbullying among young gamers is alarming. Depression and suicidality are strongly associated with such phenomena. The impact on emotional and behavioral changes among this group of individuals is encouraged to be further addressed and investigated.
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Anxiety among otolaryngology residents during the Coronavirus Disease of 2019 pandemic in Saudi Arabia: A descriptive cross-sectional study p. 148
Hessah Saad Alsayahi, Abdulaziz Yousef Alturki, Nouf Mohammed Almansour, Zuhour Abdullah Alqahtani, Hatim Ibrahim Alassaf, Arwa Mohammad Alabdulsalam, Aseel Abdulkarim Alfahhad, Roba Mohsin Altameem, Fahad Z Alotaibi
DOI:10.4103/JNSM.JNSM_90_20  
Background: Otolaryngologists are among the health professionals most commonly working on the front lines against coronavirus disease of 2019 (COVID-19). They are at high risk of exposure, as well as physical and psychological stress. Nevertheless, the psychological influence of working during the pandemic still needs to be explored. Objective: This study aims to assess the anxiety symptoms among otolaryngology residents in Saudi Arabia during the novel coronavirus (COVID-19) pandemic. Materials and Methods: A cross-sectional qualitative study was carried out via a survey sent to otolaryngology residents in Saudi Arabia. The questionnaire collected demographic data and included questions using the 7-item Generalized Anxiety Disorder (GAD-7) scale to evaluate the residents' anxiety toward working during the pandemic. Data analysis was conducted using R v 3.6.2. Results: Ninety-three otolaryngology residents completed the online questionnaire with a response rate of 42.5%. Of them, 30.1% had been in contact with confirmed COVID-19 patients. More than two-thirds of the respondents (68.8%) suffered from anxiety based on the GAD-7 scale; in the results, 45.2% had mild anxiety, 12.9% had moderate anxiety, and 10.8% had severe anxiety. Almost 24% of the respondents suffered from anxiety with a score of 10 or greater on the GAD-7 used as a cutoff point. Anxiety was more prevalent in married residents compared with single ones (18.9% vs. 5.45%, P = 0.002). In addition, it was prevalent in 40% of smokers compared with 5.13% of nonsmokers (P = 0.001). Conclusion: Anxiety levels among otolaryngology residents were high during the COVID-19 pandemic.
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The multiple mini-interviews: The experience from a saudi postgraduate residency program toward a more objective selection process p. 154
Khalid Mohammed Alayed, Walid Alkeridy, Musa Alzahrani
DOI:10.4103/JNSM.JNSM_83_20  
Purpose: The multiple mini-interview (MMI) is a validated technique used in the admissions process in some undergraduate and postgraduate schools and is reported to reduce subjectivity in selecting postgraduate applicants. No studies have been conducted in Saudi Arabia concerning the MMI. The authors report their experience of transitioning from traditional interviews to the MMI and the results of a post-MMI survey undertaken by participating applicants and interviewers. Materials and Methods: The authors did retrospective analysis after MMI had been conducted at the College of Medicine, King Saud University, Riyadh, Saudi Arabia, in 2019, in coordination with an internal medicine residency program. They implemented MMIs totaling four stations of 10 min each that focused on the domains of communication, attitude, knowledge, and a mini-interview personalized for each candidate. Ten questioners interviewed 99 applicants, of whom 68 undertook a post-MMI survey. Results: In terms of their perceptions and experience, the applicants and interviewers responded positively to the transition from traditional interviews to the MMI. MMI was seen to be more objective, 75% of applicants felt it was associated with less anxiety, and 79% believed it provided a better portrayal of their abilities. Conclusion: The use of the MMI in selecting postgraduate applicants in Saudi Arabia is feasible and acceptable. Furthermore, it may give an improved objective portrayal of applicants' abilities and reduce their interview-associated anxiety.
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Saudi knowledge and awareness of drinking tea as natural fighter against COVID-19: A cross-sectional study p. 159
Ghalia Shamlan
DOI:10.4103/JNSM.JNSM_93_20  
Objective: Stressful period as COVID-19 pandemic and quarantine affect human health indirectly by weakening the immune system which lead to increase the risk of having viral infection. Tea in all its kind considered as a strong antioxidant that helps to enhance the immune system and body defense against COVID-19 infection. The aim of this study is to assess the knowledge of participants toward the benefits of drinking tea during COVID-19 pandemic. Methodology: A cross-sectional study including 2368 participants who answered a structured survey. The survey had some information about basic demographic characteristics including age, education, gender, physical examination level, and place of residence. The second part of the survey will be measuring knowledge about drinking different kind of tea to booster immunity against COVID-19. Results: Both gender have participate in this study with a ratio of 2:1 female more than male both within the age group of 30–50 years and 76.4% have higher educational level, 78.2% married and majority 55.8% and 30.4% from central and western areas of Saudi, respectively. The majority 69% consider drinking tea is part of their daily habit and mostly 44.3% drinking black tea, with 15% increase of tea consumption during the quarantine and that consumption increased to more than five cups a day by 2.2%. Regarding the source of knowledge about immune boosting benefits of tea majority specified their source is self-developed, family tradition and media during the quarantine period. The association between body mass index (BMI) and drinking tea showed strong significance among normal overweight groups and statistical significance of increase consumption related to high BMI categories. Conclusion: Saudi traditional tea drinking habit and knowledge of health benefits of such a routine have helped them during the threatening time as COVID-19 pandemic and stressing time of quarantine.
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Prevalence of workplace-related violence among otorhinolaryngology residents in Riyadh, Saudi Arabia p. 165
Ahmed Saleh Alsaleh, Abdulrahman Ibrahim Almotairi, Bader Mohammed Alim, Ahmad Salman Alroqi
DOI:10.4103/jnsm.jnsm_102_20  
Background: Violence is one of the prevalent public health concerns that healthcare staff face; a serious problem needs to be focused. Objective: The objective of the study is to estimate the prevalence of workplace-related violence among ear, nose, and throat (ENT) residents in Riyadh, capital of the Kingdom of Saudi Arabia, and to identify the common types, perpetrators, and precipitating risk factors of workplace violence (WPV). Design: This was a cross-sectional, self-administered questionnaire study. Settings: The study was conducted at King Saud University Medical City. Subjects: The study subjects were Riyadh's ENT residents. Intervention: All Riyadh's ENT residents were invited to participate in the survey in which 80 out of 90 residents participated. Our questionnaire included two domains: one includes demographic data and other includes occupational characteristics and some details related to violence. Main Outcome Measures: (1) Prevalence of WPV among Riyadh's ENT residents. (2) Identification of types and risk factors of WPV. Results: More than half of our sample had been through a violent experience before, with 60% experiencing it at least once. Most of the violent experiences were with the adult age group of 25–55 years. Male and companions of the patients were found to the most common offenders, and the most leading factors for violence are misunderstanding and miscommunication being at the top of the list at 20%. Conclusion: As more than half of the sample has experienced violence, hence, this issues needs to be focused on through different ways, including improving resident's communication skills and improving the reporting system for violent behaviors.
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Malnutrition in cancer patients receiving chemotherapy in a single oncology center p. 170
Khaled Alsaleh, Firas A Almomen, Abdullah Altaweel, Omar Barasain, Abdullah Alqoblan, Abdulrahman Binsalamah, Abdulrahman Almashham
DOI:10.4103/jnsm.jnsm_99_20  
Background: Cancer patients face a high risk of developing malnutrition due to cancer itself and as an adverse effect of receiving chemotherapy rounds. Objectives: The aim of this study is to estimate the prevalence of malnourishment in cancer patients receiving chemotherapy in an oncology center in Riyadh, to identify the biometric characteristics that are associated with changes due to receiving chemotherapy, and to identify possible associated risk factors affecting nutritional status. Methodology: A cross-sectional study was conducted at an oncology center in Riyadh, Saudi Arabia, in 2018. The scored patient-generated subjective global assessment (PG-SGA), which is a global tool used to assess the nutritional status in cancer patients, was distributed among 126 patients, with 116 (92.1%) patients responding, and of which 110 (87.3%) were ultimately selected for participation. We assessed the associated risk factors of malnutrition, and inquired about cancer type, location, age, current residence, and social support. Past laboratory results (albumin, hemoglobin, mean corpuscular volume, and creatinine) were obtained from the patients' records. Results: Fifty-seven of the participants (51.8%) were malnourished according to the PG-SGA scoring system (Class B and C PG-SGA), and the other 53 participants (48.2%) were well-nourished (Class A PG-SGA). Out of the 57 malnourished patients, 39 (68.42%) were moderately malnourished (Class B PG-SGA), and 18 (31.58%) were severely malnourished (Class C PG-SGA). Conclusion: There is a statistically significant correlation between chemotherapy, cancer, and malnourishment. Intervention is required to improve the detection of the condition and increase both awareness and nutritional status of the affected patients.
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Attitudes of Saudis toward social media use during emergencies and disasters: A community-based study p. 175
Mashal Mnahi Al Shebani, Anas A Khan
DOI:10.4103/jnsm.jnsm_98_20  
Introduction: Social media is the most commonly used method of communication during emergency and disaster events. The prompt contribution of social media in emergency management has lately captured the imagination of governmental organizations and researchers. This study explores the attitudes of Saudis toward social media use during emergency and disaster events. Materials and Methods: A cross-sectional study was conducted via an electronic questionnaire sent to all Saudis across all regions of Saudi Arabia. Data were collected using a valid self-administered questionnaire. The questionnaire solicited demographic details of survey participants and their attitudes toward social media, particularly regarding emergency and disaster events. Results: A total of 385 respondents were included in this study. Respondents reported that they used TV news channels (89%), followed by local radio (82%), online news (61%), and social media (43%). Most respondents used WhatsApp (61.0% always and 20.0% frequently). Significant differences in the general use of social media among participants from different age groups (P < 0.001), gender (P < 0.012), and education levels (P < 0.0001) were noted. About 35% of respondents used social media for information during emergencies and disasters. Of the participants who used social media in this context, 86% sought information regarding weather conditions or warnings/advisories. A majority of the participants indicated that the information extant on social media during emergencies and disasters is available more quickly and is more accessible when compared with other channels (86.4%, 77.6%). A majority of the participants exhibited a positive attitude toward the future use of social media for information on emergencies and disasters (81.8%, mean = 4.16). Approximately 57.7% of participants stated that they were unaware of Facebook Safety Checks, and 35% of them were unaware of Twitter Alerts. Conclusion: This study revealed that the attitudes of Saudis toward the use of social media either for general use or during emergencies were similar to those in other studies.
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Prevalence of constipation among peritoneal dialysis patients in Saudi Arabia: A single-center study p. 183
Ahmad Raed Tarakji, Hussam Zaid Alorabi, Yazeed Abdullah Alhusainy, Nasser Yousef Alhowaish, Abdullah Abdulaziz Alsebti, Hamad Sulaiman Aljutaili
DOI:10.4103/jnsm.jnsm_120_20  
Objectives: Constipation among peritoneal dialysis (PD) patients can lead to serious complications and impair the quality of life. The aim of this study was to determine the prevalence of constipation and its associated factors among PD patients in our center. Methods: A quantitative, cross-sectional study was conducted on PD patients at King Khaled University Hospital in Riyadh, Saudi Arabia, from November 2016 to January 2017. Results: A total of 36 PD patients were included; the male to female ratio was 1. Based on a self-reporting questionnaire, 15 PD patients (41.7%) reported suffering from constipation. However, the prevalence was the same using at least one of Rome III criteria (41.7%) and much lower using Bristol stool form Scale (11%). No significant difference was detected between PD patients with and without constipation in terms of dietary fiber intake, use of calcium and iron supplements, water intake, presence of diabetes and hypertension, or demographic profiles. Conclusion: The high prevalence of constipation among PD patients seen in our population is comparable to those seen in other studies.
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Effect of COVID-19 on awareness and consumption of dietary supplements in Saudi Arabia p. 190
Sulaiman Abdullah Alshammari, Leena Sami Alwakeel, Jumana Abdullah Alghtani, Laila Mahmoud Alsabbagh
DOI:10.4103/jnsm.jnsm_156_20  
Objectives: We aimed to determine the role of the COVID 19 pandemic on dietary supplements' awareness, beliefs and consumption. Methods: A cross-sectional online-based survey distributed through social media was done on 575 participants aged 18 and above and living in Saudi Arabia. The Questionnaire contains sociodemographic, prevalence, type, pattern, and habit of D. S. usage and the effect of COVID-19 on consumption. Data were analyzed using SPSS version 24. Results: The users of D. S. 145 (25.5%), aged between 18 and 25 years old, with higher education levels and higher income. 58% used D. S. before the march, and 66% of D. S. users declared that COVID-19 did not affect their consumption decision. Most D. S. used was vitamins/multivitamins among males and females and were not influenced by anyone to enhance overall health and wellness. D. S. users have used the designated dosage based on the information on the product (43%) and took it randomly without specific time (38%). Our participants agreed on D. S. being harmless, useful, and have an impact on sports performance. They also disagreed on the necessity of D. S. for all ages. Respondents believe Vitamin D is essential for immunity and Vitamin C has a role in cold/flu prevention. Conclusion: Most of our respondents get their information from nonmedical sources even though they displayed the right level of awareness and were mindful of D. S.'s limited role in health during the pandemic.
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Stress, sleep, and use of sleep aids among physicians during the COVID-19 pandemic p. 197
Deemah AlAteeq, Aljoharah Almokitib, Maya Mohideen, Nouf AlBlowi, Amel Fayed, Sultan M Alshahrani
DOI:10.4103/jnsm.jnsm_177_20  
Purpose: The aim of this study is to explore the use of sleeping aids among physicians in Saudi Arabia and its correlation with stress and insomnia during the COVID-19 pandemic. Materials and Methods: A sample of 1313 physicians was collected through an online cross-sectional convenience survey. The survey was E-mailed by the Saudi Commission for Health Specialties to the registered physicians in Saudi Arabia during the COVID-19 pandemic. It includes questions related to personal and sociodemographic characteristics, COVID-19, sleep-aid use, the Insomnia Severity Index, and the Perceived Stress Scale. Results: The participants were from various job levels (398 consultants, 1919 registrars, and 716 residents) and mainly from the central (38.2%) and Western (35%) regions. More than a third of them were using sleep aids (38.6%), which were mostly melatonin (75.7%). More than half of them had insomnia (67.1%), and the majority had moderate to high perceived stress (80.1%). Significant associations were found between insomnia and a number of personal and sociodemographic characteristics: Single status, young physicians, residents, smokers, and involvement in a COVID-19 management team. Other significant associations were found between stress and a number of personal and sociodemographic characteristics: Female sex, single status, young physicians, residents, working in the Ministry of Health, being on call 5–8 times/month, and involvement in a COVID-19 management team. Conclusions: Physicians in Saudi Arabia have had increased insomnia, stress, and use of sleep aids during the COVID-19 pandemic. Single, young physicians need more attention to support their psychological well-being.
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Impact of the Coronavirus Disease 2019 pandemic on an ongoing pragmatic pediatric clinical trial p. 205
Abrar F Hudairi, Fahad A Bashiri, Lujain K AL-Sulimani, Dimah AlSaqabi, Mohamed A A. Mohamed, Muddathir H Hamad, Reem Al Khalifah
DOI:10.4103/jnsm.jnsm_124_20  
Background: The coronavirus disease 2019 (COVID-19) pandemic has a significant negative impact on clinical trials. Therefore, maintaining an optimal trial conduct should be considered to minimize risks to trial integrity while ensuring the safety of trial staff and participants. In this study, we aimed to describe the impact of the COVID-19 pandemic on conducting an ongoing clinical trial, along with challenges and solutions encountered and required to continue the trial. Methods: This Phase IV pragmatic randomized superiority controlled open-label trial included children with epilepsy receiving Vitamin D supplementation at King Saud University Medical City, Riyadh, Saudi Arabia (clinicaltrials.gov registration number: NCT03536845). Children with epilepsy receiving chronic antiepileptic medications and with normal baseline 25-hydroxyvitamin D level were randomized to receive cholecalciferol 400 IU/day versus 1000 IU/day for 6 months. The primary outcome was the percentage of children with Vitamin D insufficiency at 6 months. The secondary outcomes included seizure control, bone mineral density, and safety. Results: Under COVID-19 public health emergency measures, exceptional methods were used, such as telemedicine, home visit for blood extractions, shipping of the study medication to the patient's home, using reminder text messages to follow patients' compliance, and using privacy-compliant platforms to connect the research team members. Conclusion: During the widespread pandemic, ethical dilemmas are of major concern, especially when conducting trials on vulnerable age groups. Therefore, actions should be proportionate and based on benefit-risk considerations, affecting the risk of bias from protocol deviation and overall results.
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CLINICO-PATHOLOGICAL PEARLS Top

A rare case of rectal adenocarcinoma and small-bowel neuroendocrine tumor in a young patient with long-standing Crohn's disease: A case report p. 209
Nahla Azzam
DOI:10.4103/jnsm.jnsm_114_20  
Background: The association of adenocarcinoma of the colon and neuroendocrine tumor (NET) of the small bowel has been previously described in Crohn's disease (CD), however the concomitance of both neoplasms is extremely rare. Here, the author reports a rare case of both rectal adenocarcinoma and small-bowel NET in a young male with long-standing CD. Case Report: The patient presented with clinical and radiological features of intestinal obstruction 2 years posttotal colectomy and end ileostomy for rectal cancer and found to have ileal NET. Conclusion: Small-bowel NET symptoms can mimic CD and is a rare entity, but physicians should suspect NETs in CD patients presenting with intestinal obstruction.
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Type B aortic dissection presenting as a left-sided hemothorax in a patient with a low-risk probability p. 212
Abduluah Alramyan, Fahd Alkhalifah
DOI:10.4103/jnsm.jnsm_129_20  
The differential diagnosis of isolated pleural effusion is very wide. Unilateral hemothorax carry the same wide differentials. Taking systematic approach can lead to diagnosis in the majority of cases. We presented a case of unilateral hemothroax in a gentleman with minimal symptoms and unhelpful clinical exam. Despite his low risk, he turned to have type B aortic dissection presenting as left sided hemothorax, which is a rare presentation. We presented the clinical course the patient went through and finished with brief discussion on thoracic aortic dissection and its relation to hemothorax.
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LETTERS TO THE EDITOR Top

Advising patient on peritoneal dialysis to fast Ramadan using 3As clinical decision support tool p. 215
Ahmad Raed Tarakji
DOI:10.4103/jnsm.jnsm_103_20  
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Vaccine against COVID-19: The holy grail and the elephant together in a room p. 217
Sanjeev Singh, Sruti Singha Roy, Abhisek Dutta
DOI:10.4103/jnsm.jnsm_157_20  
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