Workforce estimate to treat mental disorders in the Kingdom of Saudi Arabia.

BACKGROUND: Mental, neurological, and substance abuse (MNS) disorders describe a range of conditions that affect the brain and cause distress or functional impairment. In the Middle East and North Africa (MENA), MNS disorders make up 10.88 percent of the burden of disease as measured in disability-adjusted life years. The Kingdom of Saudi Arabia (KSA) is one of the main providers of mental health services and one of the largest contributors to mental health research in the region. Within the past decade, mental health resources and services has increased. METHODS: We employ a needs-based workforce estimate as a planning exercise to arrive at the total number of psychiatrists, nurses, and psychosocial care providers needed to meet the epidemiological need of mental health conditions of the population of KSA. Estimates for a potential mental health workforce gap were calculated using five steps: Step 1-Quantify target population for priority mental health conditions. Step 2-Identify number of expected cases per year. Step 3-Set target service coverage for each condition. Step 4-Estimate cost-effective health care service resource utilization for each condition. Step 5-Estimate service resources needed for each condition. RESULTS: The planning exercise indicates an epidemiologic need for a total of 17,100 full-time-equivalent (FTE) health care providers to treat priority MNS disorders. KSA appears to have a need-based shortage of 10,400 health workers to treat mental disorders. A total of 100 psychiatrists, 5700 nurses, and 4500 psychosocial care providers would be additionally needed (that is, above and beyond current levels) to address the priority mental health conditions. The shortfall is particularly severe for nurses and psychosocial workers who make up 98.9 percent of the shortfall. This shortage is substantial when compared to other high-income countries. Overall, the workforce needed to treat MNS conditions translates to 49.2 health workers per 100,000 population. CONCLUSION: Challenges to addressing the shortfall are Saudi specific which includes awareness of cultural customs and norms in the medical setting. These challenges are compounded by the lack of Saudi nationals in the mental health workforce. Saudi nationals make up 29.5 percent of the physician workforce and 38.8 percent of the nursing workforce. Policymakers and planners supplement this shortfall with non-Saudi providers, who must be mindful of Saudi-specific cultural considerations. Potential solutions to reducing the shortfall of mental health care workers includes nurse task shifting and training of general practitioners to screen for, and treat, a subset of MNS disorders.

The Analysis of Job Satisfaction of Health Practitioners in Saudi Arabia: Determinants and Strategic Recommendations for Health Workforce Planning.

BACKGROUND: Job satisfaction plays an important foundation in the health system to deliver high-quality care services to patients. Job satisfaction describes the inside feeling of workers about their jobs whether they like it or not. Job satisfaction of health practitioners is considered an essential factor that affects their efficiency, well-being, and mental health. AIM: This research study is part of an integrated research aiming to understand the determinants of a revised Workforce Planning Strategy in Saudi Arabia, in close relevance to the demand and supply side in Saudi Arabia. RESULTS: This study showed that males were significantly more satisfied than females in relation to specialty, organization, and overall global score. There is also evidence for a significant association between age groups and job satisfaction. Older health practitioners had a higher level of satisfaction than younger ones. Regarding nationality, we found that Saudi health practitioners were less satisfied in all aspects, while non-Saudi (Arab) healthcare practitioners were the most satisfied in all aspects except city happiness. CONCLUSION: Our study found statistically significant differences that medicine and surgery practitioners are the most satisfied professionals and the least satisfied are dentist practitioners. Health practitioners with more than five years of experience were significantly the most satisfied.

Attitudes and Perceptions of Health Leaders for the Quality Enhancement of Workforce in Saudi Arabia.

BACKGROUND AND AIM: Besides the unique exposure and experience of health leaders in facing challenges and overcoming them, and the relatively fewer articles relating to the perception of health leaders in workforce quality enhancement, health leadership plays a crucial role in redirecting the workforce, increasing job satisfaction, professional development, and burnout prevention. Thus, this study aimed to understand the current healthcare workforce quality and future expectations from the attitudes and perceptions of health leaders. METHODS: A qualitative research was carried out using semi-structured interviews consisting of 24 different questions. Participants of the study were healthcare leaders from different backgrounds and governmental institutions. All interviews were recorded, transcribed, and then analyzed using thematic analysis via the N-Vivo program. RESULTS: Eleven participants were involved in the study, with one female and ten males. A thematic analysis and N-Vivo program yielded 5 main themes: (1) workforce competency, (2) health transformation, (3) leadership, (4) workforce planning, and (5) healthcare quality, with 22 emerging sub-themes. Moreover, participants responded with different attitudes and perceptions. CONCLUSION: Health leaders are satisfied with the current direction of workforce competency and planning, yet fragmentation of the system and poor accessibility may need further enhancement. Furthermore, misutilization of services and the uncertainty of the future and talent pool are potential barriers for capability building. Moreover, with the existing gap in the workforce, health leaders believe that privatization and corporatization may have a positive effect. Aside from that, Saudization with the current plan of having a minimum standard of accepting non-Saudis in certain areas might benefit in maintaining competition and enriching experience. However, catching up with further research in healthcare quality in Saudi Arabia is needed because of the ongoing health transformation.

Pyeloplasty in children with low differential renal function: Functional recoverability.

INTRODUCTION AND OBJECTIVE: Ureteropelvic junction obstruction (UPJO) is a common pathology in pediatric urology practice. Indications for intervention are well established while the ideal management of children with UPJO in poorly functioning kidneys is still debatable. We aimed in this study to evaluate the outcome of pyeloplasty in patients with UPJO and low DRF ≤20%. STUDY DESIGN: We retrospectively evaluated 218 children with congenital UPJO from two tertiary hospitals between 2008 and 2018. We included only those with primary unilateral UPJO and DRF ≤20% on diuretic renography. Open dismembered pyeloplasty with stenting was carried out in all. Patients with bilateral UPJO, solitary kidney, DRF above 20%, association with other urinary anomalies and patients who underwent previous renal or ureteric surgeries and patients with missed follow-up were excluded. Clinical and radiological outcomes of this subgroup of patients were assessed. RESULTS: A total of 21 patients (12 boys, 9 girls) with a median age at surgery of 2 years were included. Preoperative DRF ranged from 8 to 20% with a mean of 15% ± 3.5%. The median follow-up period was 2.5 years. Renal ultrasound showed improved HN in 16 patients (4 had a complete resolution) and stable in the remaining 5. Most of the improvement was noted in the first postoperative ultrasonography 16/21 (76%). Diuretic renography showed improved DRF by 10-15% in 8 patients (38%) while the remaining patients showed stable DRF with a non-obstructive curve with a mean improvement in DRF of 8 ± 5%. No postoperative complications were encountered and none of our patients required reintervention during follow-up. DISCUSSION: The ideal management of children with UPJO and poorly functioning kidneys is still arguable. In our study we evaluated the outcome of pyeloplasty in patients with a low DRF ≤ 20% aiming to test the patients' variables that can affect the improvement of DRF and HN grade after surgical intervention, however, none of these preoperative variables seemed to be a significant predictor. CONCLUSIONS: Children with unilateral UPJO and DRF ≤ 20% have a favorable outcome after pyeloplasty. Improvement of HN in the first postoperative renal ultrasound is a good indicator for success.

Comparison between internal double J and external pyeloureteral stents in open pediatric pyeloplasty: A multicenter study.

INTRODUCTION AND OBJECTIVE: Anderson-Hynes dismembered pyeloplasty is considered the standard surgical treatment for ureteropelvic junction obstruction (UPJO). After pyeloplasty, stent drainage remains controversial. The commonly used stents are either an internal double-J (DJ) or an externalized pyeloureteral (PU) stents. We evaluated the outcome of using DJ versus PU stents following open pyeloplasty for UPJO in children. STUDY DESIGN: We retrospectively evaluated 175 patients who underwent primary open pyeloplasty in two tertiary hospitals. A total of 110 patients underwent internal DJ stent insertion (63%) while 65 patients (37%) underwent placement of external PU stent. The type of stent used at the time of surgery was according to surgeon preference and experience. Operative time, postoperative hospital stay, overall complications and success rates were compared between the two groups. RESULTS: The mean age was 3.8 years, and the mean follow-up was 4 years. Mean operative time was similar in the two groups (145 min). Mean hospital stay was 3.7 and 4.2 days in DJ and PU stent, respectively (p = 0.003) Summary Table . Postoperative complication developed in 9 out of 110 patients with DJ stent (8%), while complications developed in 6 out of 65 patients with PU stent (9%) (p = 0.81). Success rate of pyeloplasty was 95.5% for DJ group versus 97% for PU group (p = 0.63). DISCUSSION: Dismembered pyeloplasty remains the standard treatment of choice as a surgical management for UPJO. A debate is still there in respect to the method of PU anastomotic stenting and which stent can be used. The major advantage for external PU stents is that it can be removed safely in the outpatient clinic without any sedation preventing the risk of repeated exposure to general anesthesia. Internal DJ stent provides a shorter hospital stay and comparable complication and success rates compared with PU stent. If we manage to overcome the longer DJ stent duration and facilitate early removal by an easy mode, that does not require another anesthesia at that moment we can find the optimal stent for all pyeloplasty cases. CONCLUSIONS: The two types of stents are comparable as regard overall complication and success rates after pyeloplasty. Although internal DJ stent insertion provides a relatively shorter hospital stay, a second operating room visit and anesthesia for removal remains unavoidable.

Crossed fused renal ectopia: Diagnosis and prognosis as a single-center experience.

BACKGROUND: Crossed fused renal ectopia (CFRE) is a rare congenital malformation. Renal bladder ultrasound (RBUS) is a good tool for establishing the diagnosis, however, additional imaging with a voiding cystourethrogram (VCUG) and dimercaptosuccinic acid scan (DMSA) might be required. We assessed the need for postnatal evaluation and the long-term consequences in patients with this diagnosis. METHODS: A retrospective review of the records of all patients diagnosed with CFRE between 2004 and 2014 was done. We included all patients who underwent postnatal evaluation with RBUS, DMSA and VCUG. Long-term radiological and functional outcomes were assessed. RESULTS: A total of 29 patients with CFRE were identified. Majority of cases were detected antenatally (79%) and left to right crossed ectopia constituted the majority of cases (65%). RBUS revealed associated hydronephrosis (HN) in 11 patients (38%). DMSA scans confirmed the diagnosis in all patients and showed impaired renal function in 10 ectopic kidneys (34%). Vesicoureteral reflux was detected in 12 patients (41%); one third of them needed surgical intervention. Extra-urinary anomalies were present in 14 patients (48%) mainly of cardiac origin. After a mean follow-up of 4.5 years, 4 patients (14%) with extra-urinary anomalies developed chronic kidney disease and two of them died. CONCLUSIONS: Crossed fused renal ectopia is commonly associated with both urinary and extraurinary malformations. Postnatal RBUS is usually sufficient for diagnosis, however, additional imaging may aid for confirming the diagnosis and detection of associated urinary anomalies. Presence of extra-urinary malformations with crossed fused ectopia carries a higher risk of morbidity. TYPE OF THE STUDY: Retrospective study [diagnostic/prognostic study]. LEVEL OF EVIDENCE: Level IV.

Different managements of horseshoe kidney stones, any difference in the outcome?

PURPOSE: The aim is to assess the outcomes of different approaches for the management of renal stones associated with horseshoe kidneys (HSKs) in our institution over a 12-year period. METHODS: A retrospective review of 144 patients with HSKs who presented from 2000 to 2012 was performed. Twenty-eight patients (19.4%) were found to have renal stones. Demographic data were collected; the method of treatment and the outcomes of stone management were reviewed. We excluded patients with non-functioning moieties and associated genitourinary anomalies, and those with incomplete data. RESULTS: We included 25 patients, of which 16 males (64%) and 9 females (36%), with a mean age of 37 years. Mean serum creatinine level was 66 mmol/L. Eleven patients with a stone size <8 mm were treated expectantly with medical treatment, with only one patient requiring endoscopic intervention. Six patients (24%) with a stone size between 1 cm and ≤2 cm were treated with extracorporeal shock wave lithotripsy (ESWL) with the placement of double J stents, and seven patients (28%) with a stone size of >2 cm were treated with percutaneous nephrolithotomy. One patient with a 10 mm stone was treated using flexible ureteroscopy. No significant perioperative complications were encountered. CONCLUSIONS: Indications, methods of treatment, and outcomes of management of stones associated with HSKs were comparable to those for stones associated with normal kidneys. Tailored approach based on stone size is highly recommended. ESWL accompanied with ureteric stenting is a promising strategy for the management of stones associated with HSKs in selected patients requiring intervention.

Isolated low grade prenatally detected unilateral hydronephrosis: do we need long term follow-up?

ABSTRACT Purpose: To assess the need for postnatal evaluation and the medium term outcome in patients with isolated unilateral low grade prenatally detected hydronephrosis. Materials and Methods: We prospectively selected 424 patients (690 kidney units) with a prenatal diagnosis of urinary tract dilatation between 2010 and 2013. We included only those patients with isolated unilateral low-grade hydronephrosis who underwent at least 2 postnatal ultrasound examinations. The Society for Fetal Urology (SFU) grading system was utilized for assessment of the hydronephrosis. We excluded patients with bilateral dilation or other urological abnormalities. The fate of hydronephrosis including resolution, stability or worsening was documented. Results: A total of 66 infants (44 boys and 22 girls) with antenatally diagnosed unilateral urinary tract dilation (23 right and 43 left) were identified. Ultrasounds showed SFU grade 1 hydronephrosis in 32 patients (48%) and SFU grade 2 hydronephrosis in 34 (52%). After a mean follow-up period of 32 months (range 12 to 60), 37 patients (56%) had complete resolution of hydronephrosis while the remaining 29 were stable (44%). None of our patients developed UTIs during follow-up and none required surgical intervention. Conclusions: Prenatally detected, isolated unilateral low-grade hydronephrosis usually have a favorable prognosis. All cases in our cohort showed either stability or resolution of hydronephrosis without any harmful consequences. Based on our findings on medium-term in this category of patients, long-term follow-up is not warranted.

Isolated low grade prenatally detected unilateral hydronephrosis: do we need long term follow-up?

PURPOSE: To assess the need for postnatal evaluation and the medium term outcome in patients with isolated unilateral low grade prenatally detected hydronephrosis. MATERIALS AND METHODS: We prospectively selected 424 patients (690 kidney units) with a prenatal diagnosis of urinary tract dilatation between 2010 and 2013. We included only those patients with isolated unilateral low-grade hydronephrosis who underwent at least 2 postnatal ultrasound examinations. The Society for Fetal Urology (SFU) grading system was utilized for assessment of the hydronephrosis. We excluded patients with bilateral dilation or other urological abnormalities. The fate of hydronephrosis including resolution, stability or worsening was documented. RESULTS: A total of 66 infants (44 boys and 22 girls) with antenatally diagnosed unilateral urinary tract dilation (23 right and 43 left) were identified. Ultrasounds showed SFU grade 1 hydronephrosis in 32 patients (48%) and SFU grade 2 hydronephrosis in 34 (52%). After a mean follow-up period of 32 months (range 12 to 60), 37 patients (56%) had complete resolution of hydronephrosis while the remaining 29 were stable (44%). None of our patients developed UTIs during follow-up and none required surgical intervention. CONCLUSIONS: Prenatally detected, isolated unilateral low-grade hydronephrosis usually have a favorable prognosis. All cases in our cohort showed either stability or resolution of hydronephrosis without any harmful consequences. Based on our findings on medium-term in this category of patients, long-term follow-up is not warranted.

Prenatally detected, unilateral, high-grade hydronephrosis: Can we predict the natural history?

INTRODUCTION: Fetal hydronephrosis (HN) occurs in approximately 5% of pregnancies and its prognosis depends mainly on the grade of the dilation. We attempted to determine the fate of isolated, unilateral, high-grade HN in children with antenatal diagnosis, emphasizing the risk factors for progression. METHODS: We retrospectively evaluated 424 children (690 kidney units) with antenatal HN in the period between 2010 and 2014. We included only those patients with isolated high-grade HN (Society for Fetal Urology [SFU] Grade 3 or 4). Patients with bilateral HN or unilateral HN associated with dilated ureter or reflux and patients with missed followup were excluded. The prognosis of HN (whether improved, stabilized, or progressed) and the need for surgical intervention in this subset of patients was evaluated. RESULTS: A total of 44 children (34 boys and 10 girls) were identified. Ultrasounds showed SFU Grade 3 HN in 24 (54%) and SFU Grade 4 HN in 20 (46%). After a mean followup of three years (range 1-5), 10 children (23%) needed surgical intervention; four Grade 3 HN (16%) and six Grade 4 HN (30%). The majority of children with differential renal function (DRF) ≥40% (69.5%) were stable or improved. Five girls (50%) and five boys (17%) progressed and required surgical intervention. No patient with a renal pelvis anteroposterior diameter (APD) <1.5 cm needed surgical intervention. CONCLUSIONS: Infants with isolated, unilateral, high-grade HN might be managed conservatively. Male gender, DRF ≥40%, SFU Grade 3 HN, and APD <1.5 cm were favourable prognostic factors.

Unilateral Renal Agenesis: Necessity of Postnatal Evaluation in a Contemporary Series.

OBJECTIVE: To assess the need for postnatal evaluation and the long-term consequences in patients with prenatal diagnosis of unilateral renal agenesis (URA). MATERIALS AND METHODS: A retrospective review of the records of all patients with prenatal diagnosis of URA between 2004 and 2013 was done. We included all patients who underwent postnatal evaluation with renal bladder ultrasound (RBUS), dimercaptosuccinic acid scan, and a voiding cystourethrogram. Long-term follow-up included physical examination and assessment of contralateral renal growth. RESULTS: A total of 46 children (24 boys and 22 girls) with URA were identified. Ultrasounds showed associated hydronephrosis in 9 patients (19%). Dimercaptosuccinic acid scans confirmed the diagnosis of URA in all patients and showed renal scars in 2 solitary kidneys (4%). Vesicoureteral reflux was diagnosed in 4 patients (12%); all were of low grade and managed conservatively. After a mean follow up of 4 years, RBUS showed compensatory hypertrophy in 31 patients (67%), 3 patients (6%) developed chronic kidney disease, and 2 patients (4%) developed hypertension. CONCLUSION: Prenatally detected cases of URA should be promptly evaluated. RBUS is found to be sufficient for diagnosis. However, additional imaging may be indicated for confirming the diagnosis and detection of other associated urinary anomalies. Serial assessment of the contralateral solitary kidney growth and serum creatinine measurement will be helpful to assess kidney function on the long term.

Uroprotective effect of oleuropein in a rat model of hemorrhagic cystitis.

Hemorrhagic cystitis is one of the devastating complications seen after receiving cyclophosphamide chemotherapy. Oleuropein is the most important phenolic compound of olive leaves that mediates most of its beneficial pharmacological properties. Herein, we investigated the possible uroprotective effect of oleuropein against cyclophosphamide induced hemorrhagic cystitis in a rat model. For this purpose, we measured bladder nitric oxide, reduced glutathione, catalase, tumor necrosis factor-alpha and vascular endothelial growth factor levels in addition to the bladder gene expression of intercellular adhesion molecule-1 after induction of hemorrhagic cystitis in the presence or absence of oleuropein. Histopathological examination of bladder tissues was also performed. After cyclophosphamide injection, we demonstrated a significant decrease in bladder reduced glutathione (39%) and catalase (55.4%) levels and a significant increase of nitric oxide (5.6 folds), tumor necrosis factor-alpha (3.3 folds), vascular endothelial growth factor (2 folds) and intercellular adhesion molecule-1 (8 folds) bladder contents when compared to those in normal control rats. Administration of oleuropein induced a marked elevation in bladder reduced glutathione (37.8%), catalase (100.4%) with a prominent reduction of bladder nitric oxide (40%), tumor necrosis factor-alpha (35.9%) and vascular endothelial growth factor (56.2%) levels along with downregulation of intercellular adhesion molecule-1 bladder expression (73.1%) in comparison to cyclophosphamide treated rats levels. Our data demonstrated that oleuropein counteracts the harmful effects of cyclophosphamide on the bladder through its antioxidant and anti-inflammatory activities. Oleuropein exerts a definite uroprotective effect against cyclophosphamide induced hemorrhagic cystitis in rats.

Prune belly syndrome with urethral hypoplasia and vesico-cutaneous fistula: A case report and review of literature.

Association between Prune belly syndrome (PBS) and urethral hypoplasia is an unusual condition. It is usually fatal unless there is a communication between the fetal bladder and the amniotic sac. We report a case of PBS with urethral hypoplasia and congenital vesico-cutaneous fistula in a male neonate. Patient underwent cutaneous vesicostomy and was discharged for close follow up of his renal function and for future reconstruction.

Did antenatal diagnosis protect against chronic kidney disease in patients with posterior urethral valves? A multicenter study.

OBJECTIVE: To evaluate the prognostic role of antenatal diagnosis of posterior urethral valves (PUVs) on ultimate renal function. METHODS: Between 1990 and 2010, 315 patients with PUVs were diagnosed and treated at 2 separate tertiary centers. Primary valve ablation was performed in all patients except 18, who underwent initial vesicostomy. Patients were divided into two groups: group 1 included 144 patients who were diagnosed antenatally, and group 2 included 171 patients with a postnatal diagnosis. Long-term functional and radiologic outcomes were assessed. RESULTS: Follow-up was a median 5.5 years (range, 2-15 years). Mean age at ablation was 2.5 years (range, 1 day-15 years). Chronic kidney disease developed at the end of follow-up in 96 patients (30%): 27 (19%) in group 1 and 69 (40%) in group 2 (P <.05). The mean nadir serum creatinine was 0.6 and 0.8 mg/dL in groups 1 and 2, respectively, and the mean final serum creatinine was 0.9 and 1.7 mg/dL, respectively (P <.05). Persistent upper tract dilatation was noted in 43% of group 1 patients and in 69% of group 2 patients (P <.05). CONCLUSION: The potential for recovering renal function is believed to be significant in patients in whom early detection of PUVs and, hence, early intervention was performed. Antenatal screening and detection of these patients might play a significant role in protecting the upper tract and reducing the incidence of chronic kidney disease.