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   Table of Contents - Current issue
Coverpage
May-August 2022
Volume 10 | Issue 2
Page Nos. 97-182

Online since Friday, April 29, 2022

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REVIEW ARTICLE  

Thymectomy in myasthenia gravis: A narrative review p. 97
Danah Aljaafari, Noman Ishaque
DOI:10.4103/sjmms.sjmms_80_22  
Myasthenia gravis (MG) is a rare condition caused by autoantibodies against acetylcholine receptors on postsynaptic membrane that leads to weakness of skeletal muscles. About 7 of 10 patients with MG have thymic hyperplasia and about 1 of 10 patients have thymoma. Thymectomy has increasingly been used as a treatment modality for MG. Several observational studies have shown that thymectomy results in improvement in MG and a randomized trial has established that thymectomy leads to a better outcome in non-thymomatous generalized MG. However, thymectomy is yet controversial in some disease subtypes and there are potential concerns regarding the selection of the ideal surgical approach to achieve complete removal of the thymic tissue to achieve stable remission rates. This review highlights the role of thymectomy in non-thymomatous and thymomatous MG, the effectiveness of various thymectomy methods, postoperative myasthenic crisis, and remission after thymectomy.
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ORIGINAL ARTICLES Top

Non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) lowers the risk of malignancy in The Bethesda System for Reporting Thyroid Cytopathology Diagnostic Categories p. 105
Hatim Al-Maghrabi, Mohamed Tashkandi, Waleed Khayyat, Amer Alghamdi, Mohammed Alsalmi, Alhussain Alzahrani, Hadi Al-Hakami, Mohammed Alqarni
DOI:10.4103/sjmms.sjmms_202_21  
Background: The introduction of non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) has been shown to decrease the risk of malignancy (ROM) in The Bethesda System for Reporting Thyroid Cytopathology. This knowledge may alter the management of patients with thyroid nodules. Objectives: To correlate cytological diagnosis with histological diagnosis for establishing the ROM of all Bethesda system categories after the introduction of NIFTP. Methods: This was a retrospective cohort study. All consecutive fine-needle aspiration cytology (FNAC) specimens collected from January 1, 2013, to December 31, 2017, at King Abdullah Medical City, Jeddah, Saudi Arabia, were assessed, and patients who underwent surgical excision of thyroid nodules were further analyzed. The ROM and overall ROM for each Bethesda category were calculated with and without considering NIFTP as a malignant tumor. Results: Overall, 1066 FNAC specimens were collected, of which 281 had a surgical correlation. Our cases included 18 (6.4%) non-diagnostic (ND), 109 (38.8%) benign, 28 (9.9%) atypia/follicular lesion of undetermined significance (AUS/FLUS), 39 (13.8%) follicular neoplasm or suspicion for follicular neoplasm (FN/SFN), 20 (7.1%) suspicion for malignancy (SM), and 67 (23.8%) malignant (POM) cases. After considering NIFTP diagnosis on resection specimens, the ROM decreased as follows: ND, 38.8% to 27.7% (P = 0.2388); benign, 21.1% to 11.9% (P = 0.0343); AUS/FLUS, 50% to 39.2% (P = 0.2089); FN/SFN, 53.8% to 33.3% (P = 0.0336); SM, 85% to 75% (P = 0.2147); POM, 95.5% to 88% (P = 0.0582). Conclusion: The introduction of NIFTP would significantly decrease the ROM of thyroid FNAC in both benign and FN/SFN categories of the Bethesda system.
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Epidemiology of traffic injuries before, during and 1 year after the COVID-19 pandemic restrictions: National findings from the Saudi Red Crescent Authority Highly accessed article p. 111
Yousef M Alsofayan, Suliman A Alghnam, Ahmad M Alkhorisi, Hani A Almalki, Majed D Alsaihani, Monerah A Almazroa, Abdullah K Alharbi, Roaa M Hajjam, Fahad S Alhajjaj, Jalal M Alowais
DOI:10.4103/sjmms.sjmms_59_22  
Background: Road traffic injuries are a leading cause of death in Saudi Arabia. Studies have examined the impact of the COVID-19 pandemic on traffic injuries treated in healthcare institutions, but its impact on patients seeking emergency medical transport for traffic injuries remains unclear. Objective: This study aimed to determine changes in traffic injuries' distribution and outcomes among patients seeking emergency medical transport before, during, and after the COVID-19 restrictions were imposed in Saudi Arabia. Methods: This is a nationwide retrospective study of all injuries reported to the Saudi Red Crescent Authority (SRCA) between January 1st, 2020, and May 31st, 2021. The cases in the study were categorized based on the following three time periods: (1) Pre-restriction (January 1 to March 23, 2020), (2) restriction (March 24 to June 21, 2020), and (3) post-restriction (June 22, 2020, to May 31, 2021). Results: A total of 142,763 cases of traffic-related injuries were recorded at the SRCA during the study period: pre-restriction, 27,811 (19.5%); restriction, 14,414 (10.1%); post-restriction, 100,538 (70.4%). Males accounted for most cases throughout the study period, but a significant increase in the number of females was observed in the post-restriction period compared with the first two timeframes (12.2% vs. 3.4% and 3.4%, respectively; P < 0.01). During the restriction period, the rate of mortality was the highest, and rollover crashes were significantly higher (18.2% vs. 14.0% and 14.6%; P < 0.01). Overall, pedestrians were almost three times more likely to die following injuries than occupants or drivers (OR = 2.7). Conclusions: Further prevention programs to reduce traffic injuries are needed to improve traffic safety and improve population health.
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Psychometric properties and validation of the Arabic Maslach Burnout Inventory-Student Survey in Saudi dental students p. 117
Ibrahim AlShahrani, Alezi Braimoh Ifindon Eroje, Shreyas Tikare, Rafi Ahmad Togoo, Abd El-Nasser Mahmoud Soliman, G Rajesh Rao
DOI:10.4103/sjmms.sjmms_116_21  
Background: Few studies have studied burnout among dental students worldwide, and no such study is available from Saudi Arabia. In addition, an Arabic version of the Maslach Burnout Inventory-Student Survey (MBI-SS) has not yet been validated for use among students. Objectives: This study aimed to translate and validate an Arabic version of the MBI-SS questionnaire and to examine the psychometric properties of burnout among dental college students at a university in Saudi Arabia. Materials and Methods: This cross-sectional questionnaire study included all dental students at King Khalid University, Saudi Arabia, and was conducted between December 2019 and January 2020. After the MBI-SS questionnaire was translated, its face validity was determined and the test–retest reliability was assessed. Confirmatory factor analysis and reliability analysis were performed following the full-scale study to validate the Arabic MBI-SS. Results: A total of 433 dental students responded in the full-scale study (mean age: 21.9 ± 1.6 years). Emotional exhaustion was present in 32.3% (95% confidence interval: 28%–36.9%), cynicism in 33.7% (29.3%–38.4%), and poor academic efficacy in 34.2% (29.8%–38.9%) of the dental students. Emotional exhaustion and cynicism were significantly associated with academic level, a history of medication due to academic stress, and thoughts of quitting the course (for all, P < 0.05). The reliability of MBI-SS was found to be adequate for all three subscales: Emotional exhaustion, Cronbach's α = 0.827; cynicism, α = 0.855; academic efficacy, α = 0.704. Conclusions: All three subscales of burnout were highly prevalent in the study cohort. The Arabic version of the MBI-SS inventory was shown to be a valid and reliable tool for assessing the psychometric properties of burnout among dental students, and its use may aid in identifying burnout in the early stages.
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Clinical characteristics and outcome of candidemia: Experience from a tertiary referral center in Saudi Arabia p. 125
Hind Alhatmi, Sarah Almansour, Reem Abanamy, Abdullah Akbar, Mohammed Abalkhail, Ahmad Alharbi, Abdulrahman Alsaedy, Ebrahim Mahmoud, Bassam Alalwan, Sameera AlJohani, Omar S Aldibasi, Mohammad Bosaeed, Adel Alothman
DOI:10.4103/sjmms.sjmms_625_21  
Background: Candida bloodstream infections cause significant excess morbidity and mortality in the health-care setting. There is limited evidence regarding Candida species causing invasive infections in Saudi Arabia. Objective: To identify Candida species causing bloodstream infection and determine the clinical outcome and factors associated with mortality in a tertiary center in Saudi Arabia. Materials and Methods: This retrospective study included all cases of positive blood culture for Candida in patients admitted to King Abdulaziz Medical City, a tertiary care center in Riyadh, Saudi Arabia, between January 1, 2013 and June 30, 2019. Results: A total of 532 patients with candidemia were identified (male: 55.4%; mean age: 54 ± 26.2 years). The most common Candida species isolated was Candida albicans (26.7%), followed by Candida glabrata (22.7%), Candida parapsilosis (22.2%), and Candida tropicalis (18.4%). Non-albicans candidemia was more common in patients with diabetes (76.7%; P = 0.0560), neutropenia (89.8%; P = 0.0062), recent exposure to fluconazole (85.7%; P = 0.0394), and active chemotherapy (83.1%; P = 0.0128). In non-albicans, susceptibility to fluconazole varied from 95.9% with C. tropicalis to 41.5% with C. parapsilosis; nonetheless, all species were highly susceptible to echinocandins. The overall 30- and 90-day mortality rates were 39.9% and 56.4%, respectively. The mortality rate was nonsignificantly higher with non-albicans species at 30 days (41.2% vs. 35.9%; P = 0.2634) and 90 days (58.2% vs. 51.4%; P = 0.1620). Conclusion: This study found a changing pattern in the Candida species causing bloodstream infections and an epidemiological shift toward more non-albicans Candida species in Saudi Arabia.
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Prevalence and correlates of attention deficit hyperactivity disorder among college students in Jeddah, Saudi Arabia p. 131
Waleed Ahmed Alghamdi, Faten N Alzaben, Hashem H Alhashemi, Saeed Sami Shaaban, Khawlah M Fairaq, Ahmed S Alsuliamani, Bsmah A Mahin, Radwan A Ghurab, Mohammad Gamal Sehlo, Harold G Koenig
DOI:10.4103/sjmms.sjmms_654_21  
Background: Childhood attention deficit hyperactivity disorder (ADHD) is commonly diagnosed in Saudi Arabia, but there is negligible evidence regarding adult ADHD in college students. Objective: To determine the prevalence and correlates of ADHD among undergraduates at King Abdulaziz University, Jeddah, Saudi Arabia. Methods: In this cross-sectional study, 2280 undergraduate students from 11 colleges at King Abdulaziz University, one of the largest university in Saudi Arabia, were approached in person with a questionnaire that elicited information regarding demographics, education, psychiatric history, health behaviors, and ADHD. A validated Arabic version of the Adult ADHD Self-Report Scale was used. Results: A total of 2059 students (90%) completed the questionnaire (mean age: 21.2 years). Almost one-tenth (11.9%) of the sample met the criteria for adult ADHD; only 6.5% had been diagnosed with ADHD in childhood and <1% (0.8%) had taken medication for the same. Multivariate analyses revealed that high family income, low grade in the last semester, parental divorce, diagnosis of childhood ADHD, prior diagnosis of depression, greater severity of current depression and anxiety, and cigarette smoking increased the likelihood of adult ADHD. Conclusion: A notable proportion of students in this study had suspected adult ADHD. Early evaluation of students with ADHD and identification of those at risk may potentially help in improving their academic performance and quality of life.
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Spontaneous intracerebral hemorrhage among hypertensive patients in Saudi Arabia: Study from a tertiary center p. 139
Aishah Ibrahim Albakr
DOI:10.4103/sjmms.sjmms_73_22  
Background: Spontaneous intracerebral hemorrhage (ICH) is the second most common cause of stroke, yet there is paucity of evidence regarding the same from Saudi Arabia. Objectives: To describe the clinical characteristics of spontaneous ICH as well as determine the role of gender in ICH and the usefulness of the ICH scoring system for assessing the 30-day mortality risk. Patients and Methods: This retrospective study included all patients diagnosed with spontaneous ICH at King Fahd Hospital of the University, Al Khobar, Saudi Arabia, between April 01, 2014, and April 30, 2019. Data regarding clinical characteristics, risk factors, and radiological features of ICH were extracted. Further, gender-related differences were determined. The 30-day mortality rates were assessed using the ICH score. Results: A total of 148 patients were diagnosed with spontaneous ICH during the study period. Of these, 100 (67.5%) were male and the overall mean age was 60 ± 15 years. About 48% of the male patients were aged ≤50 years compared to 27% of the female patients (P = 0.016). Impaired renal function (35.8%) and diabetes (33.7%) were the most frequent risk factors; hemiparesis (51%) and language impairment (42%) were the most common presenting symptoms; and basal ganglia (40.5%) was the most common location. The 30-day mortality rate was 30%. The mean ICH score at presentation was significantly high in those who died within 30 days of presentation (2.2 ± 1.6; P < 0.0001). Each increase in the ICH score was associated with an increase in mortality rate (P < 0.001 for trend). Conclusion: Patients with spontaneous ICH were found to have a high prevalence of vascular risk factors and mortality rate. The ICH scoring system was shown to be a useful clinical tool for evaluating the 30-day mortality risk.
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Situation-Background-Assessment-Recommendation technique improves nurse–Physician communication and patient satisfaction in cataract surgeries p. 146
Yu Chen, Hung-Yi Chen, Gwo-Ping Jong
DOI:10.4103/sjmms.sjmms_602_21  
Background: Implementation of the Situation–Background–Assessment–Recommendation (SBAR) communication technique has been shown to increase nurse–physician communication and collaboration. However, data regarding its implementation in ophthalmology settings are limited. Objective: The purpose of this study was to evaluate the impact of implementing SBAR on nurse–physician communication and on the safety and satisfaction of patients undergoing cataract surgery. Materials and Methods: This cross-sectional study was conducted in the Ophthalmology Department of Zhongshan Hospital, Xiamen University, Xiamen, China, from April 2016 to December 2018. SBAR was implemented through a 1-h course that was repeated every 2 months for 2 years. All nurses and physicians completed the Physician–Nurse Communication Satisfaction Questionnaire before SBAR implementation and 1- and 2-year post-implementation. In addition, all patients who underwent cataract surgery during the defined pre-implementation and 1- and 2-year post-implementation periods were invited to complete a patient satisfaction questionnaire. Results: In total, 10 nurses and 6 physicians completed all three pre- and post-implementation surveys. In addition, 1215 patients undergoing cataract surgery participated: 358 in the pre-implementation phase, 425 in the 1-year post-implementation, and 432 in the 2-year post-implementation. Physician–nurse communication significantly improved in both 1- and 2-year post-implementation periods compared with the pre-implementation phase (P < 0.01). In addition, there was a significant increase in patient satisfaction scores (P < 0.01) and a decrease in medical complaints and malpractices (P < 0.01) between the pre- and post-implementation phases. Conclusion: SBAR is a useful tool for enhancing nurse–physician communication and for improving the safety and satisfaction of patients undergoing cataract surgery.
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Virtual and traditional learning in undergraduate radiology education: A cross-sectional comparative study from Saudi Arabia p. 151
Aliaa H Ghoneim, Solafa H Ghoneim, Samaher A Bairaqi, Mariam Y Yassin, Alzahraa B AlAhmed, Kawthar M Aldhamen, Kawther A Alfaraj, Fatimah T Almayyad
DOI:10.4103/sjmms.sjmms_619_21  
Background: The coronavirus pandemic (COVID-19) resulted in disruption in the traditional teaching methods and lead to a wider adoption of virtual teaching. However, there is a lack of comparative studies regarding the use of either or the mixed mode for teaching radiology to undergraduate students. Objective: This study aimed to determine the barriers, performance, and overall satisfaction of undergraduate medical students and instructors undertaking virtual and traditional radiology learning across Saudi Arabia. Methodology: This cross-sectional questionnaire study included undergraduate students and instructors from across Saudi Arabia who had undertaken radiology either traditionally, through E-learning, or both in the 2019-20 academic year. The questionnaire elicited information regarding attendance, teaching methods, difficulties, knowledge acquisition, and satisfaction. Association between variables was assessed using Chi-square, in addition to a univariate analysis. Results: A total of 404 undergraduate students from 28 universities of Saudi Arabia responded, in addition to 20 instructors. Students preferred E-learning for the quality of the course and the time and effort spent as well as obtained higher grades than those in traditional learning. Traditional education was favored over E-learning for clarity of instructors' voice, ease of understanding image description by the instructor, and lack of technical barriers such as poor Internet connection. The form of education was significantly correlated with grades obtained (P < 0.001) but not with overall satisfaction (P = 0.067). The majority of the instructors (60%) considered E-learning to be helpful in balancing their workload and teaching responsibilities (P = 0.029) and would recommend it as a standard teaching method for radiology (85%). Conclusion: E-learning has potential advantages over traditional learning for teaching radiology to undergraduate medical students. However, further optimization is required to overcome the current deficiencies of this mode.
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Do mock medical licensure exams improve performance of graduates? Experience from a Saudi medical college p. 157
Mona Hmoud Al-Sheikh, Waleed Albaker, Muhammed Zeeshan Ayub
DOI:10.4103/sjmms.sjmms_173_21  
Background: All medical graduates in Saudi Arabia are required to pass a Saudi Medical Licensure Exam (SMLE) to be able to practice and/or enroll in postgraduate training. Mock exams are a useful preparatory tool, but no study from Saudi Arabia has assessed its impact on performance in the actual licensure examinations. Objectives: To evaluate the impact of a series of mock SMLEs with immediate personalized feedback on graduate scores and their performance in the actual SMLE. Methods: This retrospective study included medical students who graduated in the 2019-20 academic year from Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia, and undertook mock SMLE exams offered in August 2020. Three mock exams were constructed using the SMLE blueprint and were offered to graduates 1 week apart. Immediately after each exam, a personalized learning outcomes achievement report was sent to each graduate. Exam reliability was measured by the Kuder–Richardson formula, and were 87%, 94%, and 96% for the first, second, and third exam, respectively. Results: A total of 71, 70, and 61 students completed the first, second, and third exams, respectively. Across the three mock exams, the mean (±SD) score showed an increasing trend, from 87.6 (±33.4; range: 28–191) in the first test to 93.5 (±45.6, range 15–204) in the second and 96 (±42.6; range: 25–203) in the third. Forty graduates completed all three mock exams; of these, the scores of 25 (62.5%) students significantly improved in both the second and third exams compared to the prior test (P = 0.002). A nonsignificant positive correlation was found between the average mock and the actual SMLE scores for whom data were available (r = 0.29; P = 0.27). Conclusion: The performance of graduates improved in subsequent mock exams, and there was a nonsignificant positive correlation between the mock and actual SMLE exam results. This study presents the usefulness of using mock exams as a preparatory tool for licensure examinations in Saudi Arabia.
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CASE REPORTS Top

Extramedullary involvement of the ascending colon in relapsing acute lymphocytic leukemia: A case report p. 162
Zainab Ifthikar, Hamna Muthalib, Shamayel Mohammed, Feras A Alfraih, Hesham A Aljohany, Fahad I Alsohaibani
DOI:10.4103/sjmms.sjmms_543_21  
Acute lymphoblastic leukemia (ALL) accounts for <1% of adult cancers. Extramedullary relapse of ALL has been primarily reported in pediatric patients or hematopoietic stem cell transplant recipients, and the gastrointestinal (GI) tract is a less frequently reported site of extramedullary relapse. Here, we report a case of a 30-year-old male who was a known case of ALL with multiple relapses and allogenic stem cell transplantations. The patient presented with acute lower GI bleeding and was confirmed to have an extramedullary relapse of ALL in the ascending colon. As the patient already had early relapses after two hematopoietic stem cell transplants in the past, he was managed with palliative chemotherapy, consisting of vincristine, dexamethasone, and rituximab, following which the patient achieved complete remission. This case highlights the importance of recognizing uncommon presentations of ALL such as those involving the GI tract.
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An extremely rare case of Bonneau syndrome with novel cardiac and eye manifestations p. 166
Elhadi Husein Aburawi, Fozi Dakilah
DOI:10.4103/sjmms.sjmms_122_21  
Bonneau or cardio-ducto-polysyndactyly syndrome is an extremely rare, life-threatening developmental defect, which has only been reported in eight patients previously. Here, we describe one such case of Bonneau syndrome in a newborn with additional novel manifestations. This late preterm (35 weeks of gestation) neonate born to parents of consanguineous marriage following a pregnancy complicated by polyhydramnios was symmetrically small for date at birth (<3rd centile for weight, length, and occipitofrontal circumference). She had the typical Bonneau syndrome features such as facial dysmorphism and polysyndactyly in addition to novel eye manifestations (microphthalmia, cataract, and vitreous hemorrhage) and cardiac defects such as D-transposition of the great arteries and pulmonary valve stenosis. The chromosomal study was normal (46, XX). The multiple congenital anomalies made the cardiac defects inoperable, and the patient died at the age of 16 days due to uncontrolled cardiac failure. A very high index of suspicion is required by pediatricians/neonatologists to identify this very rare syndrome based on presentation with known features.
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Enhancing the esthetics of a maxillary central implant crown with a hybrid-abutment: A case report p. 170
Firas Khalid Alqarawi
DOI:10.4103/sjmms.sjmms_71_22  
Reducing the fabrication time and costs involved in classical methods of implant crown production are goals being constantly pursued. Consequently, computer-aided design and computer-aided manufacturing technologies have evolved considerably, offering improved and predictable outcomes in terms of esthetics and function. The aim of this case report is to demonstrate how hybrid-abutments can provide optimum esthetics and biomechanical foundations. A 57-year-old woman had a non-restorable tooth #8, which was indicated for extraction and immediate implant placement. Lithium disilicate (LD) crowns were used to restore the adjacent teeth #7, 9, and 10. A zirconia abutment was used to block the gray color of the titanium base. The zirconia abutment finish line was designed to be placed 1-mm apical to the free marginal gingiva of the adjacent tooth, and an LD implant crown was cemented on the hybrid-abutment. The technique demonstrated promising results, and after more than 18 months of follow-up following the implant placement, the surrounding soft tissue was well adapted around the implant crown. The hybrid-abutment enhanced the esthetics of the definitive restoration as well as saved time and cost by elimination of the casting step.
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LETTERS TO THE EDITOR Top

Pleural epithelioid hemangioendothelioma: Clinical course and response to treatment p. 175
Dana Al-Baali, Tamadhir Al-Mahrouqi, Yaqoob Al-Sawafi
DOI:10.4103/sjmms.sjmms_500_21  
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Endoscopic hemostasis of a bleeding diverticular Dieulafoy's lesion in the third portion of duodenum p. 177
Hameed Anam, Perisetti Abhilash, Inamdar Sumant, Anastasiou Jiannis
DOI:10.4103/sjmms.sjmms_523_21  
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ARABIC ABSTRACTS Top

Arabic Abstracts p. 179
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