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   Table of Contents - Current issue
Coverpage
July-September 2022
Volume 5 | Issue 3
Page Nos. 199-316

Online since Friday, July 8, 2022

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BRIEF REPORT  

Coronavirus disease 2019 in patients with sickle cell disease: A cross-sectional study from Jazan Province, Saudi Arabia p. 199
Abdulaziz Alhazmi, Wesam Ali Moafa, Jalal Madkhali, Othman Saifain, Faizah Alyahyawi, Ons Adhabi, Ahmad Ali Alharbi
DOI:10.4103/jnsm.jnsm_49_21  
Objectives: To assess the prevalence of coronavirus disease 2019 (COVID-19) infection among sickle cell disease (SCD) patients in Jazan region and to determine the impact of COVID-19 on the SCD population. Methods: This was an observational, descriptive, cross-sectional study using a self-administrated questionnaire directed to SCD patients in Jazan to assess the prevalence of COVID-19. The data were analyzed using a t-test and Chi-square test. Results: A total of 188 responses were received and only 96 SCD patients were included (mean age is 24 years). About half of the study samples (53%) of the study population were male. About 11% of patients with SCD were diagnosed with COVID-19. Vaso-occlusive crisis was reported in 73% and a single patient presented with acute chest syndrome. About three-fourths of patients (73%) were admitted to the hospital and most of them experienced mild symptoms and one patient was treated in the intensive care unit. Conclusion: SCD patients are at risk of SARS-CoV-2 infection. In the absence of comorbidities, patients with SCD are not at increased risk of COVID-19 mortality, but a higher admission rate is reported. SCD patients with COVID-19 may have a milder clinical course, compared to other populations with comorbidities such as diabetes and hypertension, and this may be due to proinflammatory adaptation of the immune system. Larger studies including epidemiological and molecular details are needed to enhance our understanding of how SARS-CoV-2 could affect patients with SCD.
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CASE SERIES AND LITERATURE REVIEW Top

Syncope and COVID-19: Case series and literature review p. 204
Ibrahim A Alranini, Tarek S Kashour, Ahmed S Al-Hersi, Wael A Alqarawi
DOI:10.4103/jnsm.jnsm_134_21  
COVID-19 infection can present with atypical symptoms such as syncope. We reported 2 patients who presented to our emergency department with syncope as a chief complaint. One patient did not have any other symptoms while the other patient developed severe pneumonia later during hospitalization. The cardiac workup including electrocardiogram, cardiac monitoring, and echocardiogram were unremarkable. Both patients were diagnosed with neurally mediated/reflex syncope secondary to COVID-19. No recurrence was reported during follow-up. We then performed a literature review and described previous cases focusing on clinical presentation and the likely mechanism of syncope.
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REVIEW ARTICLES Top

The genetic architecture behind congenital heart disease: A review of genetic and epigenetic factors p. 210
Maaged A Akiel
DOI:10.4103/jnsm.jnsm_126_21  
Congenital heart disease (CHD) is the most frequently reported cause among miscarriages. Moreover, Infants born with CHD suffer from lifelong morbidity and have high risk of sudden infant death. The incidence of CHD is 8:1000, around 1% of live births worldwide. A wide range of environmental risk factors such as exposure to teratogens increase the risk for CHD through alterations in genetic and epigenetic networks governing heart development. Yet, a small subset of CHD is caused by inherited Mendelian mutations, copy number variations, or chromosomal abnormalities. Next generation sequencing technologies and chromosomal microarray analysis deciphered the genetic make-up of CHD. This review explains the genetic make-up of CHD and highlights key molecular genetics, cytogenetics, and epigenetics findings in syndromic and isolated CHD through analysis of inherited and sporadic genomic alterations.
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Future trends of artificial intelligence in dentistry p. 221
Amara Swapna Lingam, Pradeep Koppolu, Fatema Akhter, Mohammed Malik Afroz, Nafeesa Tabassum, Maheen Arshed, Tahseen Khan, Sally ElHaddad
DOI:10.4103/jnsm.jnsm_2_22  
The subject of artificial intelligence (AI) has experienced magnificent development and growth over the past two decades. AI has gained amazing application in various fields including dentistry. AI is swiftly gaining the consideration of researchers around the world. The main benefit of AI is that it is based on natural language model and has become most convincing where readers can't even distinguish if it is a human written or system written. AI, which mimics human cognitive functions, is a forward leap in innovation, and has fascinated the minds of scientists over the globe. Dentists can use AI to guarantee better health-care result, quality therapy, and accomplish accuracy. AI can assist with anticipating the letdowns in clinical scenarios and illustrate dependable solutions.
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ORIGINAL ARTICLES Top

Knowledge, attitude, and practices of Saudi Dental students regarding oral/oropharyngeal cancer: A cross-sectional study p. 225
Bader Fatani, Abdulaziz Abdullah Alabood, Raghad Fahad Almuqrin
DOI:10.4103/jnsm.jnsm_105_21  
Background: Oral cancers are well known for their disastrous and fatal consequences. This type of cancer manifests itself in various forms, ranging from simple ulcerative lesions to proliferative growths. The reduction of morbidity and mortality of cancer can be achieved via its early recognition through screening and patient awareness and can improve the outcome of the disease comparatively. Even though most of the dentists who were surveyed said that they are inclined to provide head-and-neck examinations for their patients, studies show that dentists generally lack the knowledge required for diagnosing oral cancer lesions. Objective: This study aims to assess and evaluate the knowledge, attitude, and practices of dental students regarding oral cancer at King Saud University. Materials and Methods: The data were collected from the dental students at King Saud University in Riyadh, Saudi Arabia, from May 2021 to August 2021. The targeted subjects were dental students – male and female students older than 20 years – studying at King Saud University. Results: A sample of 206 dental students was analyzed. It was found that most dental students have heard about oral cancer (93.2%) and knew that it was preventable (77.7%). They also knew that it was treatable (93.7%) and has the ability to metastasize (93.2%). The relationship between the knowledge of oral cancer and the gender of the students was not statistically significant (all P > 0.050). There were significant relationships between oral cancer knowledge and age of the student (P < 0.001) and oral cancer treatability and age (P = 0.002). Similarly, oral cancer knowledge (P ≤ 0.001), treatability knowledge (P = 0.007), and metastasis knowledge (P = 0.030) were significantly related to the progression of academic years. Conclusion: Our study showed that dental students have significant knowledge and awareness regarding oral cancer including the clinical appearance, signs, and symptoms of oral cancer. Moreover, few dental students even considered themselves very well informed and qualified to detect oral cancer in patients. Therefore, we assume that increasing the dental students' clinical practice as well as their self-confidence could highly influence the early detection of oral cancer for patients in future.
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Knowledge, attitude, and practice of family medicine residents toward COVID-19 in Riyadh, Saudi Arabia p. 230
Sara I Altraif, Lamees I Almezaini, Hadeel K Alsaif, Ibrahim H Altraif
DOI:10.4103/jnsm.jnsm_120_21  
Objectives: The aim is to evaluate the knowledge, attitude, and practice (KAP) regarding prevention, diagnosis, and management of COVID-19 in family medicine residents in Riyadh, Saudi Arabia and also to examine the association of the residents' demographic variables with their COVID-19 KAP level. Methods: A cross-sectional survey conducted during July to August 2020 that targeted all family medicine residents who were enrolled in the Saudi board training programs in Riyadh. An online version of a specifically designed questionnaire was distributed to determine the residents' KAP toward COVID-19. Results: A total of 97 of 170 residents responded for a response rate of 57%. The most important results noted from this study are that participants had satisfactory knowledge of COVID-19; but, it was not associated with their demographic characteristics. Most participants demonstrated positive attitudes toward persons having risk factors for COVID-19 and who disclose their exposure (n = 82, 85%). Most participants exhibited good practices except participating in training programs concerning COVID-19 infection prevention and control (n = 46, 47%). Total knowledge scores were significantly affected by feeling tired, lack of confidence in defeating the virus, and persons with risk of COVID-19 infection. There was no significant association between the knowledge and practice. Conclusion: The results demonstrated that family medicine residents in Riyadh overall had good KAP on COVID-19 disease in Riyadh, Saudi Arabia. Such good KAP could help limit viral spread.
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Assessing the satisfaction of students with the learning methods used during the coronavirus pandemic in Saudi Universities p. 239
Khaleel I Alyahya, Ahmed Fathalla Ibrahim El Fouhil
DOI:10.4103/jnsm.jnsm_131_21  
Objectives: The aim was to assess Saudi students' satisfaction with two methods of lecture delivery used during coronavirus pandemic, namely live online sessions (LOS) and recorded online lectures (ROL), and students' perspectives regarding distance and traditional education. Materials and Methods: A cross-sectional study was conducted on 600 Saudi students from 22 Saudi universities during December 2020. A questionnaire, formed of both multiple choices and open-ended questions, was designed at the Department of Anatomy, College of Medicine, Riyadh, Saudi Arabia, and distributed via social media applications. Collected data were statistically analyzed. Results: Participants were satisfied with both methods and recommended to implement both of them. They had better outcomes with ROL, felt it more appropriate for preparation for exams, and for enhancement of focus ability. Students of health and sciences colleges had more preference of LOS regarding satisfaction and implementation, and of ROL for preparation for examinations and enhancement of focus ability. Students of humanities colleges preferred ROL in all aspects. Being time saving and giving more flexibility for learners, students suggested implementation of distance learning for selected theoretical courses. Using better technologies for communication and training teachers and students on ways to use educational programs is recommended. Traditional practical classes should be small, more interactive, recorded, and available on website. Conclusion: Students were satisfied with both methods with more preference of one of them in some aspects and suggested continuous innovation in learning.
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Patient bill of rights knowledge and perceived practice among females visiting a patient safety event at King Saud University p. 247
Rufaidah Mohammad Dabbagh, Nada A Alyousefi, Norah A Alrowais, Shatha A Alduraywish, Maha Saja, Lemmese Alwatban, Shahad Al-Qahtani, Areej Al-Nomi
DOI:10.4103/jnsm.jnsm_141_21  
Objectives: This study aimed to assess the level of knowledge about the patient bill of rights (PBR) among visitors of the King Saud University (KSU) “Patient Safety Day” event and the associated demographic features, to measure the level at which these PBR items were observed among the visitors during their medical care experiences, and to assess the perception of the importance of the PBR items from the participants' perspectives. Materials and Methods: A cross-sectional survey among visitors of the KSU “Patient Safety Day” event was conducted, using interview-based questionnaires. The questionnaire was adapted from the items assessed in previous studies exploring knowledge of PBR. All analyses were conducted using a statistical analysis system. Results: Around 198 individuals participated in the surveys (response = 95.2%) and the majority of them were students. Only 28.6% of them reported being aware of the PBR mainly from hospital posters (27.3%) and by a treating physician (1.8%). Results of the survey did not yield significant associations between the knowledge of PBR and each of the levels of completed education and participant status. The faculty and staff had greater odds of knowing about PBR compared to the students (odds ratio = 1.93, 95% confidence interval = 0.60, 6.00). Conclusion: The study showed that only about a quarter of the participants reported being aware of the PBR. This necessitates increasing the efforts of health-care facilities to educate their patients about PBR. Hospital posters may be the best way to introduce these PBR to patients. However, this does not replace the need for direct communication about PBR by treating health-care teams.
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Detailed demographics and the prevalence of comorbidities in ovarian cancer patients in Western Region of Saudi Arabia p. 254
Syed Sameer Aga, Refal Jaha, Rawaa Khan, Dhiyaa Junaydi, Alqassem Y Hakami, Muhammad Anwar Khan, Hashem Alsaab
DOI:10.4103/jnsm.jnsm_158_21  
Objectives: The study was carried out to report the descriptive demographics, comorbidities, and adverse effects in women with ovarian cancer attending the King Abdulaziz Medical City (KAMC), Jeddah, Saudi Arabia. Materials and Methods: The current retrospective study was conducted at King Saud Bin Abdulaziz University for Health Sciences between the months of July and August 2021. The study sample included all the patients that had been admitted in the Princess Noorah Oncology Center in KAMC and fulfilling the two inclusion criteria (a) age not <18 and (b) confirmed histological or cytological diagnosis as per the International Federation of Gynecology and Obstetrics guidelines. A comprehensive review of the charts was conducted by a team of researchers for the extraction of data which included detailed demographics, tumor characteristics, comorbidities, and adverse effects. Results: A total of 119 ovarian cancer patients were identified, out of which 90 were included in the analysis. Most of the patients were aged above 40 years. A total of 67 of 90 (74.44%) tumors were of higher stage (II+IV) and 54 of 90 (60.0%) were located bilaterally. Among the comorbidities, we found that diabetes mellitus, hypertension, dyslipidemia, asthma, and hypothyroidism were the top five ones. Furthermore, most of the patients (82.1%) underwent a surgical intervention for the primary treatment of the tumor. The top adverse effect of the chemotherapy was the gastrointestinal ones (40.3%), followed by renal and metabolic disorders. Conclusions: Patients with ovarian cancer were of higher age and with advanced stage of the disease contrary to the reported trends in world literature. Almost all reported with one of more of the comorbidities and majority had surgical intervention as first line of treatment.
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Self-perception of dental esthetics, malocclusion, and oral health-related quality of life among 13–15-year-old schoolchildren in Bengaluru: A cross-sectional study p. 262
Jesline Merly James, Manjunath P Puranik, KR Sowmya
DOI:10.4103/jnsm.jnsm_167_21  
Introduction: Malocclusion is one of the common public health problems worldwide. The study aimed to assess the self-perception of dental esthetics, malocclusion, and oral health-related quality of life (OHRQoL) and to determine the relation between them among 13–15-year-old schoolchildren in Bengaluru. Materials and Methods: In this cross-sectional study, 540 children were selected equally from government, aided, and private schools in Bengaluru. Self-perception of dental esthetics was measured using Oral Aesthetic Subjective Impact Scale (OASIS), whereas malocclusion and OHRQoL were assessed using Dental Aesthetic Index and Oral Health Impact Profile-14 (OHIP-14), respectively. Descriptive and analytical statistics was done using the SPSS 22. Analysis of variance, Kruskal‒Wallis test, and Pearson correlation test were used. P < 0.05 was considered statistically significant. Results: The prevalence of malocclusion was found to be 29.63%. Among schoolchildren, the mean OASIS scores (self-perception) and OHIP-14 scores were 14.62 ± 6.93 and 9.04 ± 8.07, respectively. There was a significant difference among government, aided, and private schoolchildren regarding “definite malocclusion” and mean OHIP scores. Overall, there was a significant weak correlation between the severity of malocclusion and OHIP scores ([r = 0.259], [P = 0.01]) as well as between the severity of malocclusion and OASIS scores ([r = 0. 192], [P = 0.02]). Conclusion: The severity of malocclusion significantly correlated with self-perception of dental esthetics and OHRQoL among schoolchildren. Hence, there is a relation between self-perception of dental esthetics and malocclusion as well as malocclusion and OHRQoL.
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Parental perceptions, attitudes, and practices regarding their children's oral health in Kerala, India – A cross-Sectional study p. 268
Pooja Latti, Deepa Ramesan, Subramaniam Ramanarayanan
DOI:10.4103/jnsm.jnsm_21_22  
Introduction: Oral diseases in children, if left untreated can frequently lead to significant pain, interference with talking, eating, loss of school hours, and general health problems. Parents have an important role to play in the initiation and reinforcement of oral health-related behaviors for preventing and controlling oral diseases. Parental attitudes and perceptions have a direct influence on their children's oral health. The survey was conducted to investigate the parental perceptions, attitudes, and practices regarding their child's oral health. Methodology: A cross-sectional questionnaire-based survey was conducted among parents of primary school students (two government and two private) in Paravur town of Ernakulam district, Kerala. Data collection was done during the Parents–Teachers Association meeting. The prevalidated questionnaire, translated into local language Malayalam, consisted of 12 questions assessing the parental attitude and practice toward oral health and dental treatment. The data were tabulated and analyzed with Chi-square test. Results: The final sample comprised 414 parents; 105 men and 309 women. Less than 30% of the participants had taken their child for a dental visit in the past year. Over 43% had visited the dentist for treatment of decayed teeth. More than 53% of the parents reported that their children brushed their teeth twice daily. More than 93% agreed to supervise their child's brushing. About 30% of the parents are willing for routine dental checkups for their children more than three times a year. About 30% select the toothpaste and toothbrush as per recommendations from the dentist. Over 78% considered consulting a dentist as the first response to a dental complaint of the child. Conclusions: The study showed a positive attitude and perception of parents regarding the oral health of children in terms of money, time, and dental clinic visits.
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Depression, anxiety, and stress among the community during COVID-19 lockdown in Saudi Arabia p. 273
Sulaiman A Alshammari, Razan Sultan Alotaibi, Ashwaq Ali Almajed, Thikrayat Abdulhafeeth Omar
DOI:10.4103/jnsm.jnsm_62_21  
Objectives: (1) We aimed to measure the levels of depression, anxiety, and stress among the Saudi population during COVID-19 lockdown and their association with different personal characteristics. (2) The secondary aims included assessing the perceived social and physical impacts of COVID-19 lockdown on individuals and the different coping strategy practices during this tough period. Methods: A cross-sectional study was conducted between May and June 2020 in Saudi Arabia. We collected data from both sexes aged 18 years and older using social media. The online questionnaire collected data on their sociodemographic, physical, and social conditions, and the presence and control of chronic diseases as well as their evaluation according to the Depression, Anxiety, and Stress Scale-21. Results: Of the 878 participants, 56.6% were female, 54.6% were aged between 35 and below, 52.6% were married, and 97.4% had a secondary school and above. Approximately a quarter of the participants or relatives had been diagnosed with COVID-19. Moderate-to-severe depression, anxiety, and stress were reported in 32.6%, 28.7%, and 22.6% of the participants, respectively. The younger than 35 years, unmarried, not working, and the previous diagnosis of COVID-19 were associated with higher scores of depression, anxiety, and stress. In addition, the participants reported several coping strategies such as doing physical exercise, hobbies, chatting over social media, watching TV/movies, playing electronic games, increasing religious prayers, and getting psychosocial help. Conclusion: A quarter of the participants reported a moderate-to-severe psychological impact. They adopted various strategies to reduce the adverse lockdown effect. In a future pandemic, health-care providers and policymakers can focus on potential risk factors and coping strategies to prevent, intervene early, and treat sufferers.
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A comparative histological analysis of human pulp following direct pulp capping with propolis or biodentine p. 281
Nehad A Ahmad, Nevin A Gad, Marwa H Abdulmonaem
DOI:10.4103/jnsm.jnsm_74_21  
Introduction: Pulp exposure in permanent teeth conventionally has been treated with calcium hydroxide pulp capping. The purpose of this study was to evaluate the histological finding of healthy human pulp tissue after pulp capping using new materials, Biodentine (BD) and Propolis (Pr). Materials and Methods: Forty intact human premolars scheduled for extraction for orthodontic reasons were mechanically exposed. Teeth were divided into four groups of ten teeth each and capped with Pr and BD. The final restoration was done with glass ionomer restorative material. The teeth were then extracted on the 15th or the 45th day and subjected to processing for histological evaluation by an image analysis software. Results: Differences in inflammatory response and dentine bridge formation of the exposed pulp to the different materials. The BD group, at all evaluation periods, exhibited a thick newly formed reparative bridge of dentin that totally obliterating the site of exposure. At the exposure site, cell inclusions and mineralization, variable numbers of odontoblast-like cells, preserved pulp tissue, marked numerous collagen fibers, and blood vessels, were observed. On the other hand, the Pr group did not show any presence of dentin bridge or calcified material and intermediate to acute inflammation after the 15th day. On the 45th day, Pr showed an entire newly formed bridge of reparative dentin tissue, complete pulp degeneration with multiple edematous spaces, hyperemic blood vessels, vacuolated odontoblasts, extravasated red blood cells, multiple mineralized structures dispersed just underneath the dentin bridge and through the pulp tissue, and newly ill-defined odontoblasts. Conclusion: For pulp capping, BD has a better dentin bridge formation and pulp preservation than pr in the human teeth.
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Evaluation of the use of electronic growth charts customized for race and national values p. 286
Amr A Jamal, Abdullah A AlHokair, Mohamad-Hani A Temsah, Fahad Alsohime, Ayman A Al-Eyadhy, Mohamad El-Mouzan, Shabana Tharkar
DOI:10.4103/jnsm.jnsm_89_21  
Background: As compared with traditional paper-based charts, population-specific Saudi Growth Charts (SGC) integrated into electronic health records offer several functionalities. However, few studies have explored clinicians' perceptions and practices related to the recording of growth parameters as they adapt to the electronic methods. Objective: The objective of this study is to estimate clinicians' use of the recently adapted electronic SGC versus other known electronic international growth charts. Methods: This cross-sectional survey was performed on 116 pediatricians serving at the university medical center. An online questionnaire that included the types of growth charts used, clinicians' confidence level with the electronic interface, and documentation practices for children's growth parameters was uploaded using the SurveyMonkey® platform, and participants were invited to participate through an e-mailed link. Data were analyzed using the IBM software Statistical Package for the Social Sciences version 22.0. (SPSS Inc., Chicago, IL, USA) for Windows®. Results: Most of the pediatricians (76.7%) reported using electronic-based growth charts in preference to paper-based charts, whereas 17.3% preferred using both. Seventy-five percent agreed that the SGC can accurately diagnose underweight Saudi infants and children, as compared with 56% for the World Health Organization and 44% for the Centers for Disease Control and Prevention growth charts. Height, weight (body mass index), and nutritional status were the most documented parameters. Multivariate linear regression analysis showed physicians with longer experience in pediatric clinical practice years demonstrated lesser documentation of growth parameters. In addition, physicians caring for more number of children per week were more likely to frequently document growth parameters (P = 0.003). Conclusion: The integration and implementation of the electronic version of SGC have been encouraging, and the SGC shows promising results in recording child growth parameters for Saudi children with minimum discrepancies in interpretation as compared to the other international growth charts.
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The prevalence and associated factors of self-reported symptoms of computer vision syndrome among high school teachers in Riyadh: A cross-sectional study p. 292
Afnan Younis, Laila Alsabbagh, Dimah Alaraifi, Ghaida Alsanad, Ahad Algrain, Rema AlDihan, Fatimah Albassam
DOI:10.4103/jnsm.jnsm_99_21  
Background: Computer vision syndrome (CVS) is a group of visual and musculoskeletal symptoms that are associated with the use of computers and electronic devices. The use of computers is increasing in the field of education which puts teachers at higher risk of CVS. The severity of CVS symptoms can affect teachers' quality of life and productivity. Aim: This study aims to estimate the prevalence of CVS and its symptoms among Riyadh high school teachers in 2020. The secondary objectives were to determine the factors associated with CVS among high school teachers and to compare between the symptoms of CVS in male and female school teachers. Subjects and Methods: This is an observational cross-sectional study. Data were collected by self-administered questionnaire from teachers working in public high schools in Riyadh, Saudi Arabia, using a multistage random sampling technique. Data analysis including descriptive statistics and Chi-square test was performed using SPSS. Results: The prevalence of experiencing one or more symptoms of CVS among high school teachers was 94.6%. The most common symptom was neck and shoulder pain, reported by 84.9% of high school teachers. Male teachers were 80% less likely to have CVS (odds ratio [OR] = 0.213, 95% confidence interval [CI] [0.079–0.578]). The risk of CVS was higher in those who use electronic devices for more than 5 h (OR = 3.4, 95% CI [1.015–11.4]). Male teachers experienced less headache (OR = 0.504, 95% CI [0.344–0.75]), less neck and shoulder pain (OR = 0.326, 95% CI [0.186–0.57]), and less eyestrain (OR = 0.495, 95% CI [0.308–0.796]) in comparison to female teachers. Conclusion: Female high school teachers are having higher odds of developing CVS than male teachers. School teachers need awareness programs about CVS.
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Extent and feasibility of the application of the clinical pathway, clinical guideline, and practice protocol in eastern province Saudi Arabian Hospitals: A cross-sectional survey study p. 299
Zahra AL Qamariat, Khawlah Alkhalifah, Safia Alqarni
DOI:10.4103/jnsm.jnsm_9_22  
Background: Diversity in clinical practice may become a problem and increase the risk of errors. Several tools have been suggested to reduce this diversity and improve unification in clinical practice. These tools include the clinical pathway, clinical guidelines, and practice protocol. They have been proven effective. However, there are different barriers to their application. Methods and Data Analysis: A cross-sectional survey in the Eastern Province of the Kingdom of Saudi Arabia aimed to identify the availability of the clinical pathway, clinical guidelines, and practice protocol and their benefits, as well as barriers in their development and utilization. Both quantitative and qualitative analyses were used to evaluate the study results. Findings are presented as numbers and percentages. Results: Clinical pathway, clinical guidelines, and practice protocol are available to a large extent in the Eastern Province. The study showed some difficulties in the development and implementation of these tools, such as insufficient training and leader support. It also provided some suggestions to overcome these barriers. Conclusion: The availability of clinical pathway, clinical guidelines, and practice protocol has helped unify practice and reduce errors in the clinical setting. The barriers can be overcome by different solutions.
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CASE REPORT Top

Atypical presentation of pallister–Hall syndrome with central precious puberty p. 309
Hala Gasim Omer, Amal Ali Alhakami, Malak Ali Alghamdi, Reem Abdullah Al Khalifah
DOI:10.4103/jnsm.jnsm_157_21  
Pallister–Hall syndrome (PHS) is a rare, autosomal dominant genetic disorder. The phenotypic features of the syndrome include hypothalamic hamartoma, polydactyly, craniofacial anomalies, and other malformations. This case report describes a 5-year-old girl with Central precocious puberty (CPP) due to the presence of suprasellar hypothalamic hamartoma. With a history of polydactyl, suspicion of PHS was made, and the genetic test showed a novel GLI3 gene mutation. CPP is treated with gonadotropin-releasing hormone agonist. In addition to CPP, an extensive endocrine evaluation revealed central hypothyroidism while other pituitary functions were intact. The variable clinical phenotype of PHS makes it challenging to diagnose early, especially in the sporadic form. However, suspicion of these cases and early diagnosis leads to a better outcome as many endocrine features may evolve during follow-up, which necessitates interventions.
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PERSPECTIVE Top

Social distancing and lockdown due to COVID-19: Impact on sleep and mood of adolescents p. 313
Ruchi Singh, Sunil Chouhan, Ragini Shrivastava, Nirendra Kumar Rai, Silvya Isac
DOI:10.4103/jnsm.jnsm_81_21  
The unprecedented situation of countrywide lockdown with closure of physical schools, social distancing, and home confinement which arose due to COVID-19 pandemic had a significant impact on the sleep and mood of all age groups. Adolescence is the age of transition from childhood to adulthood. Students in this phase are anxious with planning for future and thus fall an easy prey to unhealthy lifestyle including irregular sleep cycle and eating habits. Freedom to follow self-decided sleep schedule with extensive use of digital media and sedentary lifestyle during the pandemic further added to the trend of unhealthy lifestyle among them. This perspective is aimed to explore the effect of nationwide or regional lockdowns enforced for curtailment of COVID-19 infection on the mood and sleep habits of adolescents. There were some positive as well as negative impacts on the sleep quality and mood of adolescents. Although home confinement gave a lot of opportunities to follow own sleep schedules and eating habits such as those on weekends or vacations, it also increased the separation stress from their peers, anxiety and fear of disease, erratic sleep schedule, and screen time among adolescents.
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