Background: Emergency medical professionals often encounter situations when dealing with patients that can affect their mental health. In Saudi Arabia, there is paucity of data regarding the mental health of paramedics involved in prehospital care. Objectives: To determine the prevalence and predictors of stress, anxiety and depression symptoms among paramedics working at Saudi Red Crescent Authority (SRCA) stations in Riyadh, Saudi Arabia. Methods: This cross-sectional, questionnaire study included all paramedics working in the prehospital medical services of 21 SRCA stations in Riyadh (N = 300) between March and June 2017. Sociodemographic data were collected using a self-reporting questionnaire, and the Arabic version of the Depression Anxiety and Stress Scale-21 was used to identify the states of stress, anxiety and depression. Bivariate analysis using chi-square test and multivariate logistic regression analysis were performed to determine the association between sociodemographic factors and mental health. Results: In total, 240 emergency medical professionals responded (response rate = 80%). Of these, 30.5% had stress, 40% had anxiety and 26.7% had depression. All cases of stress were of mild-to-moderate level, while 5.1% of the respondents had severe-to-extremely severe anxiety and 1.3% had severe depression; there were no cases of extremely severe depression. Number of mission calls was identified as a predictor for stress and anxiety; intake of medications for noncommunicable diseases as a predictor for stress and depression; hours of sleep/day for anxiety and depression and use of stimulant beverages other than tea, coffee and energy drinks as predictors for anxiety. Conclusion: This study demonstrates that stress, anxiety and depressive symptoms are relatively common in paramedics working at SRCA stations in Riyadh. The authors suggest that the above-mentioned predictors should be monitored in paramedics and interventions should be made when necessary.

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Background: Few studies have compared the safety and efficacy of azilsartan medoxomil (AZL-M) and telmisartan in hypertensive patients, especially using ambulatory blood pressure monitoring (ABPM). Objective: The objective of this study was to compare the efficacy and safety profile of AZL-M and telmisartan in hypertensive patients using ABPM and clinic blood pressure (BP) monitoring. Materials and Methods: This prospective, randomized, open-label, blinded endpoint, parallel-arm study included 700 patients, aged 18–70 years, with clinic and 24-h mean ambulatory systolic BP (SBP) of 150–180 mmHg and 130–170 mmHg, respectively. They were randomized equally into two groups: Group A received AZL-M 40 mg and Group T received telmisartan 40 mg; the dose was force titrated to 80 mg after 2 weeks if the response rate was not achieved. BP (clinical and ambulatory) was measured after 12 weeks and compared with baseline measurements. Results: AZL-M significantly reduced the 24-h mean ambulatory SBP (Group A: 112.74 ± 7.58 mmHg; Group T: 113.96 ± 8.52 mmHg;P < 0.0001) and diastolic BP (Group A: 71.39 ± 5.89 mmHg; Group T: 67.29 ± 6.79 mmHg;P < 0.0001) compared with telmisartan at week 12. The clinic SBP significantly decreased in Group A at weeks 4 (−30.69± −0.33 mmHg) and 12 (−39.69± −1.09 mmHg) (for both, P = 0.0001). Dose titration was done in 99 and 128 patients from Group A and Group T, respectively (P = 0.012). Headache was the most common adverse drug reaction (Group A: 21; Group T: 27) and fatigue the least. Conclusion: This study found that AZL-M has greater antihypertensive efficacy than telmisartan, with comparable side effects. In addition, ABPM was shown to be a feasible method for such studies.

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Background: Spleen tyrosine kinase (SYK) is an important enzyme in the proliferation and differentiation of all hematopoietic tissues. Its role as a cancer driver is well documented in liquid tumors; however, cumulative evidence has suggested an opposite role in other tumor types. Objectives: To systematically assess the expression of SYK, its prognostic value and epigenetic status in different cancers using bioinformatics tools. Methods: In this bioinformatics study, Oncomine database and cBioPortal were used to study the SYK gene expression, Kaplan–Meier plotter to study its prognostic value and MethHC to assess the SYK gene methylation in various cancers. Results: From 542 unique analyses of the SYK gene, it was found to be overexpressed in bladder, breast and colon cancers but downregulated in leukemia, lymphoma and myeloma. Compared with normal tissues, breast and brain tumors showed an overexpression of the SYK gene, whereas lymphoma and leukemia had lower expression. The Kaplan–Meier survival analysis revealed that SYK expression in pancreatic, gastric, liver and lung patients were correlated with better overall survival. Using cBioPortal, prostate cancer was found to have the highest SYK gene mutation frequency, and the mean expression was highest in diffuse large B-cell lymphoma, acute myeloid leukemia and thymoma. Using the MethHC database, SYK promoter hypermethylation was found to be significantly higher in breast, renal, liver, lung, pancreatic, prostatic, skin and stomach cancers compared with the normal tissue (P < 0.005). Conclusion: The results of this study indicate the potential use of SYK as a diagnostic and therapeutic target for different type of cancers. However, further experimental data are required to validate these results before use of SYK in clinical settings.

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Background: Frequencies of normal and abnormal heart sounds have previously been reported, but the acoustic analyses of the frequency responses of conventional and amplified stethoscopes for different heart sounds have not yet been reported. Objectives: To compare the acoustic analysis of frequency responses of three stethoscopes (conventional and amplified) for measuring simulated heart sounds. Materials and Methods: This exploratory study used Starkey SLI-ST3, Cardionics E-Scope II (both electronic) and Littmann Classic S.E. II (conventional) stethoscopes, as they share the same basic design with twin ear tubes coupled to ear tips and chest piece options (bell vs. diaphragm modes). Acoustic analyses using the diaphragm were performed in a soundproof booth and frequency response curves at 85 (the largest), 250, 400, 550 and 1050 Hz were compared for three different digitized heart sound simulations: normal, aortic valvular stenosis (AVS) and pulmonic valvular stenosis. Results: Amplified stethoscopes provided the most amplification of normal and abnormal heart sounds across all five frequencies compared with the conventional stethoscope. The Starkey SLI-ST3 stethoscope was better at amplifying normal heartbeats than the Cardionics E-Scope II and Littman Classic S.E. II; however, it came last for amplifying normal heartbeats of ~85 Hz. Cardionics E-Scope II had advantages in amplifying abnormal heartbeats (i.e., aortic valvular stenosis and pulmonic valvular stenosis) over the other two stethoscopes. Conclusion: This study showed that amplified stethoscopes provided better amplification of normal and abnormal heart sounds across the five measured frequencies. Therefore, health professionals should interpret manufacturer claims regarding gain (dB) and frequency (Hz) with caution, and those with hearing loss should carefully investigate the “audio performance” of the stethoscopes. Future research should focus on these effects through coupling with hearing aids.

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Background: Nonalcoholic fatty liver disease (NAFLD) is a common cause of chronic liver disease (CLD). NAFLD is also related to obesity and metabolic syndromes, which are common in Saudi Arabia. However, it is yet unclear what proportion of CLD cases is because of NAFLD in Saudi Arabia. Objective: To investigate the prevalence and clinical characteristics of NAFLD among patients with CLD in Saudi Arabia. Materials and Methods: This retrospective study included all patients with any CLD who had successfully undergone transient elastography (FibroScan) examination at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, between April 2015 and April 2018. These CLD patients were then grouped as NAFLD and non-NAFLD patients. Serum hemoglobin, alanine aminotransferase, gamma-glutamyl transferase, albumin and bilirubin levels; platelet count and international normalized ratio within 1 month after the FibroScan examination were assessed. For NAFLD patients, glycated hemoglobin levels and abdominal ultrasound examination results were also assessed. Statistical analysis was carried out using Student's t-test and linear regression. Results: The prevalence of NAFLD among CLD patients was 22.5% (111 of 494 CLD patients), and it was the third most common CLD after chronic hepatitis B and C. Compared with non-NAFLD patients, NAFLD patients had significantly higher mean age (53.65 ± 12.7 vs. 48.07 ± 14.6 years;P < 0.001), mean serum alanine aminotransferase level (61.84 vs. 50.23 IU/L;P < 0.001) and mean controlled attenuation parameter (297.83 vs. 238.41;P < 0.001). NAFLD patients also had a higher rate of ultrasound-detected features of cirrhosis (16.2% vs. 3.7%,P < 0.001), but there was no significant difference in fibrosis severity. In addition, their mean glycated hemoglobin level (6.85) was elevated (range: 5–13). Age and platelet count were significantly correlated with presence of cirrhosis. Conclusion: NAFLD is the third most common CLD in Western Saudi Arabia, and it is associated with older age and metabolic syndromes, with one-third of the patients having advanced fibrosis or cirrhosis.

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Background: Photobiomodulation (PBM) has been shown to have a positive effect on dental implant osseointegration and stability in in vitro and animal studies; however, its usefulness in dental implant clinical practice is yet unclear. Objective: The objective was to assess the clinical effectiveness of PBM on dental implants' osseointegration. Methods: Two reviewers independently conducted a comprehensive electronic search of articles published from inception up to January 10, 2020, in PubMed, Cochrane Library and Embase databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Randomized clinical trials (RCTs) and nonrandomized clinical studies that compared the effect of PBM on dental implant stability with control groups were included. Animals and in vitro studies studies as well as studies with confounders such as application of orthodontic were excluded. Risk of bias (using Cochrane Risk of Bias tool for RCTs and Risk of Bias in Non-Randomized Studies of Interventions tool for nonrandomized studies) was assessed by both authors. Owing to substantial heterogeneity, only a narrative synthesis of the included studies is presented. Results: Seven relevant clinical studies were included, and they used a variety of PBM parameters and devices. The posterior region of the jaw was found to be more frequently evaluated. For assessing the effect of PBM on implant stability, five studies used resonance frequency analysis and two used periotest; three studies additionally used biomarkers for assessment. Four studies found that PBM has a potential positive effect on the outcome of dental implant stability, whereas three studies reported that PBM has no effect on implant stability. Conclusion: The findings of this systematic review suggest that postoperative application of PBM may potentially have some positive effect on dental implant's osseointegration and stability. However, additional studies are required with uniformity in methods to provide a more robust assessment of this effect.

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Background: Malocclusion is known to cause plaque accumulation and periodontal breakdown. However, no previous study from Saudi Arabia has assessed this relationship in patients seeking orthodontic treatment for esthetics. Objective: The objective of this study was to investigate the relationship between malocclusion and periodontal disease in terms of gingival inflammation, probing pocket depth (PPD) and recession in patients seeking orthodontic treatment for esthetic improvement. Materials and Methods: This prospective cross-sectional study was conducted at the Outpatient Division of Periodontics, College of Dentistry, King Khalid University, Saudi Arabia, among consecutive new patients seeking orthodontic treatment for esthetic improvement between June and August 2018. Angle's class of malocclusion, various malalignments, plaque index (PI), gingival index (GI), adequacy of width of attached gingiva (WAG), response to fremitus test, PPD and gingival recession (GR) were recorded.P < 0.05 was considered statistically significant. Results: A total of 410 consecutive patients were included. Of these, 314 patients had Class I, 57 had Class II (division I), 25 had Class II (division II) and 14 had Class III malocclusions. In patients with all types of malocclusion, the majority had a PI and GI of score 2 (74.1% and 83.7%, respectively). Most of the patients (85.9%) had adequate WAG; similarly, 94.9% had a negative fremitus test, which shows the absence of trauma from occlusion. Mean PPD and GR in the maxillary and mandibular arches showed varying results. Conclusion: This study demonstrates a relationship between malocclusion and presence of periodontal disease in patients seeking orthodontic treatment for esthetic improvement in the southwestern region of Saudi Arabia. Therefore, in patients seeking orthodontic treatment, careful evaluation of gingival and oral hygiene along with adequacy of attached gingiva should be considered.

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Crouzon syndrome is a rare genetic disorder. We report a rare case of Crouzon syndrome in a very young infant with distinct features of craniofacial malformations. A 10-week-old male child presented with features of craniofacial dysostosis with abnormal shape of the skull, proptosis, hypertelorism, curved nose and frontal bossing. Radiological findings revealed a predominant premature fusion of sagittal sutures. The infant had airway obstruction. Features of hydrocephalus, papilledema and optic atrophy were not evident. We chose to manage the symptoms and prevent complications, and the surgery was deferred for later, depending on the degree of malformation and psychological needs. Diagnosis of this rare condition at an early stage can help in preventing the development of complications. A careful follow-up and appropriate surgical intervention can improve the prognosis of this condition, which carries the risk of respiratory complications, poor vision and, in some cases, mental retardation as the age advances.

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Background: Medical students are prone to burnout, and several stressors have been associated with it. From the literature, it is yet unclear if type of curricula in medical schools plays a role in burnout among students. Aims: To assess the prevalence of burnout and its associated stressors in medical students in problem-based learning and traditional curricula at Imam Abdulrahman Bin Faisal University. Subjects and Methods: The analytical, cross-sectional study was conducted between February and May 2017 and included all third- to sixth-year medical students of Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia. In the 2016–2017 academic year, third- and fourth-year students were in problem-based learning, whereas fifth- and sixth-year students were in traditional learning. All eligible students were verbally invited to complete a 56-item questionnaire comprising three sections eliciting sociodemographic information, level of burnout (using a modified Copenhagen Burnout Inventory with personal, medical school- and faculty-related subsections) and stressors associated with burnout. Burnout was measured using a Likert-type scale, and scores of >50 were considered as high burnout. Chi-square and logistic regression analysis were used for statistical analysis. Results: Of 947 eligible students, 593 (62.6%) completed the questionnaire: 317 (53.5%) were in problem-based learning and 276 (46.5%) in traditional learning. Of these, 329 (55.5%) had high burnout, with no difference between type of curricula (problem-based learning = 178 [56.2%]; traditional = 151 [54.7%]; P = 0.73). All measured stressors were significantly associated with high burnout, including lack of sleep (odds ratio [OR] = 2.139, P = 0.005) and perceiving teaching staff as inflexible and unsupportive (OR = 2.995,P < 0.001). Conclusions: This study found high prevalence of burnout among medical students in a university from Saudi Arabia, but no significant difference between students in problem-based learning and traditional curricula. A longitudinal study is recommended to better understand the long-term effect of type of curricula on burnout.

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Background: Despite its importance, no study from the Middle East has assessed the neonatal pain knowledge of health-care providers in neonatal intensive care units (NICUs). Objectives: To evaluate the knowledge and attitudes of pediatricians and nurses in Saudi Arabia toward procedural pain assessment and its management in neonates. Materials and Methods: This questionnaire-based, cross-sectional study was conducted between March and June 2015 at three NICUs in the Eastern Province of Saudi Arabia, namely, King Fahd Hospital of the University, Al Khobar; Security Forces Hospital, Dammam; and King Fahd Medical Military Complex, Dhahran. All pediatricians/neonatologists and nurses in these units were included, and a previously validated questionnaire was distributed and collected by an assigned clinician. The questionnaire elicited pain-related knowledge of seven procedures using a 10-point Likert scale. Results: A total of 150 questionnaires were distributed, from which 107 complete responses were obtained (nurses: 81 [75.7%]; doctors: 26 [24.3%]). The overall knowledge scores were high (mean ± standard deviation = 77.3% ±11.6%). The mean pain rankings of doctors (7.2) were higher than those of nurses (6.5) for all procedures. Nurses reported more frequent use of analgesia than doctors (15.4% vs. 11.5%). Doctors often did not use comfort measures for any procedures, except during procedures on term to 28-day-old neonates. The use of pain tools was reported by only 12 (11%) clinicians. Conclusion: This study found that despite adequate knowledge about pain perception by neonates, the use of analgesia for procedural pain relief is low among doctors in the NICUs of the Eastern Province of Saudi Arabia. In addition, there is underutilization of pain assessment tools, thereby indicating the need to address this knowledge–practice gap.

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Amyloid goiter is a very rare manifestation of amyloidosis. Here, we describe the case of a 40-year-old male, who presented with upper airway obstructive symptoms including hoarseness and breathing difficulty, to highlight the clinical and pathological features of secondary amyloidosis of the thyroid gland and the difficulties in making a preoperative diagnosis. The patient had previously been wounded in the war in Bosnia, which resulted in the right kidney being surgically removed. Further, he had undergone two surgical interventions on both hips due to osteomyelitis and was on a chronic dialysis program due to a progressively poor left kidney function that had eventually resulted in complete loss of renal function. Thyroid function tests were normal, and the patient clinically was euthyroid; biochemical investigations were within normal limits. Results from sonography, computed tomography scan of the neck, scintigraphy and fine-needle aspiration cytology were nondiagnostic. Therefore, a thyroid biopsy was carried out, and amyloid deposits were found. After preoperative work-up, total thyroidectomy was performed with no complications. We conclude that amyloid goiter may have no major impact on thyroid function even when a substantial amount of amyloid has replaced the normal thyroid parenchyma, as was the case in our patient. Amyloid goiter should be suspected in all patients with a progressive, rapidly growing bilateral thyroid enlargement with concomitant inflammatory processes or in patients undergoing hemodialysis treatment.

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Pyonephrosis is a rare condition in both adult and pediatric population. Here, the author presents a rare case of pyonephrosis induced by extended-spectrum beta-lactamase-producing Klebsiella pneumoniae in a 12-month-old girl presenting with a picture of urosepsis. The patient presented with febrile urinary tract infection and was unresponsive to intravenous meropenem. Physical examination revealed huge, firm and irregular right renal swelling. Ultrasound and computed tomography imaging revealed severely hydronephrotic right kidney, and laboratory investigations showed elevated C-reactive protein level (22.9 mg/dl). Emergency percutaneous nephrostomy tube was inserted, pus was drained (20 ml) and intravenous vancomycin and amikacin were started. Her general condition improved, and urine culture was negative. Functional assessment with dimercaptosuccinic acid renal scan revealed that the split renal function was 5% on the right and 95% on the left side, and the bladder outline was smooth with no reflux in voiding cystourethrogram. A right nephrectomy was done a week later using the anterior subcostal approach. The postoperative course was smooth. Histopathological examination was diagnostic for xanthogranulomatous pyelonephritis. No adverse events were reported in the follow-up over 12 months. It can be concluded that a high degree of suspicion, rapid initiation of appropriate antibiotics and drainage of pus are crucial in the management of pyonephrosis.

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