Perception and behavior toward neuropsychiatric disorders in Saudi Arabia: A systematic review and quality assessment.

LAY ABSTRACT: In 2010, Saudi Arabia became the first country from the Gulf Cooperation Council states to join the World Mental Health Survey Initiative, which collaborates with Harvard University and has undertaken over 33 countries. The Saudi National Mental Health Survey revealed that 80% of Saudis with severe mental health disorders do not seek treatment. Considering the strong evidence set out in Saudi national study and the recommendations for future research, this systematic literature review was initiated to examine the most studied neurodevelopmental disorders reported in the Kingdom of Saudi Arabia to explore public knowledge, attitudes, and behaviors. Findings have shown that attention deficit hyperactivity disorder and autism spectrum disorder have been the most studied neurodevelopmental disorders in Saudi Arabia since 2010. However, various groups in Saudi society, including healthcare professionals, medical students, and the general public, lacked knowledge about these health conditions, often leading to stigmatized attitudes and behaviors toward people with attention deficit hyperactivity disorder and autism spectrum disorder. However, demographic data showed that most of the studies were carried out in the Central and Western provinces. More research is needed in all regions of the Kingdom of Saudi Arabia to contribute to the knowledge about mental health conditions of attention deficit hyperactivity disorder and autism spectrum disorder children and their parents to increase knowledge about neurodevelopmental disorders and mental health disorders in the Kingdom of Saudi Arabia, thereby enabling people to rethink their attitudes and behavior.

Moyamoya Syndrome in Children With Sickle Cell Disease in Saudi Arabia: A Single-Center Experience.

Background Sickle cell disease (SCD) is relatively common in Saudi Arabia. Its neurologic complications such as stroke and Moyamoya syndrome (MMS) can be severe and devastating. Such complications can be minimized by modern investigative tools such as transcranial Doppler (TCD) ultrasound, which is unavailable in many high-risk places. Our aim is to investigate the prevalence and characteristics of these complications in children with SCD in our center where TCD is not available. Methods We conducted a retrospective record review of children with SCD admitted to the pediatric ward and visited the pediatric hematology outpatient clinic of King Fahad Military Medical Complex, Dhahran, Saudi Arabia, from January 2010 to December 2021. The target population was children aged six months to 14 years with SCD and a history of stroke or transient ischemic attacks (TIAs). Their magnetic resonance imaging/magnetic resonance angiography (MRI/MRA) of the brain radiographic features were reviewed. A descriptive analysis was used to summarize the demographic characteristics and clinical features of patients with and without MMS. Results Twenty-six children (out of 385 with sickle cell anemia, originating mainly from the southwestern and eastern provinces of Saudi Arabia) experienced an overt stroke with an overall prevalence of 6.7%. All patients with stroke were originally from the Southwestern province. Their genotype was SS, and the median age at the onset of the first stroke was six years (IQR: 5.5). The main presenting symptoms were seizures (57.7%), motor weakness (42.3%), headache (15.3%), cranial nerve palsies (11.5%), cognitive deficit (7.6%), and dysphasia (3.8%). The majority of strokes were ischemic (92.3%). MMS was detected in 61.5% and was seen at the onset of the first stroke in all patients with this MRA abnormality. Seven children with moyamoya (43.8%) had recurrent strokes. Conclusion In this study, the prevalence of overt stroke is 9% in children with SCD originating from the southwestern region of Saudi Arabia (26/286), and 61.5% of them (16/26) had MMS. It is absent in the children of Eastern origin (99 children). In places lacking TCD facilities, further studies are required to determine if MRA brain screenings of children with SCD may detect MMS before the onset of stroke and help start protective therapy.

Plasminogen activator inhibitor-2 and impaired fibrinolysis in pregnancy and sickle cell anemia.

PURPOSE: This is the first study that aimed to determine antigen levels in plasma and genotypes of PAI-2 in pregnant and non-pregnant homozygous sickle cell anemia (SCA) patients. METHODS: The study subjects were all Bahraini females in the reproductive age group. The study population included 31 pregnant homozygous SS (SCA) patients. Three control groups were also studied to evaluate the effect of pregnancy and SCA on PAI-2 levels and fibrinolysis: (1) 31 healthy non-pregnant volunteers; (2) 31 cases of normal pregnancy; and (3) 20 non-pregnant SCA patients. Pregnancies were screened in the second (TM2) and third (TM3) trimesters. Global coagulation, fibrinolysis rate (euglobulin clot lysis time, ECLT), PAI-2 antigen (ELISA), and PAI-2 Ser(413)/Cys polymorphism (restriction fragment length polymorphism analysis) were determined. RESULTS: Feto-maternal complications were documented in both pregnancy groups. PAI-2 antigen levels were undetectable in the non-pregnant groups, but was quantifiable in both pregnant groups. Impaired fibrinolysis rate and rising PAI-2 levels with progression of pregnancy were observed in both healthy and SCA subjects. These changes were more prominent in SCA, although the rise in ECLT was less steep and PAI-2 antigen levels were not significantly different compared to normal pregnancy in the third trimester. No correlation was observed between PAI-2 genotypes and plasma antigen levels. Also, no significant difference in feto-maternal complications was found in normal (n = 25) versus SCA pregnant patients (n = 30). CONCLUSIONS: These observations suggest that with progression of pregnancy, increasing PAI-2 levels contribute to the hypercoagulable state, particularly in SCA patients.

Knowledge, Attitude, and Behavior Toward Organ Donation and Transplantation Among Medical Students in the Eastern Province of Saudi Arabia.

BACKGROUND: Organ donation is an integral part of medical ethics worldwide, including Saudi Arabia. Although the Saudi community has a positive attitude toward the concept of organ donation and transplantation, several factors prevent people from agreeing to donate organs and tissues. This study aimed to explore and evaluate the knowledge and attitudes medical students in the Eastern Province of Saudi Arabia have toward organ donation and transplantation. METHODS: A cross-sectional study among 722 medical students in the Eastern Province. The questionnaire consisted of 3 parts: sociodemographic questions, organ donation and transplantation knowledge questions, and questions on attitudes toward organ donation and reasons for consenting or refusing to donate. RESULTS: Both men and women had positive attitudes toward organ donation. The level of knowledge of organ donation and related procedures did not differ significantly among men (13.07%) and women (13.60%) (P < .027). The motives for donation were the desire to help others (88.8%) (P = .02) and sympathy (59.8%). The main source of information on organ donation for respondents was television, followed by the internet and relatives and/or friends. CONCLUSIONS: While medical students are generally supportive of organ donation and transplantation, they may lack basic knowledge on organ donation. Due to lack of basic knowledge, they become hesitant to make the decision to donate. It is recommended that additional organ donation modules be included in the student curriculum to increase the knowledge of future health care providers. Most of the participants would not change their attitudes toward organ donation based on the Saudi government initiatives to register for the Saudi Center for Organ Transplantation organ donation program.

Current state of ethical challenges reported in Saudi Arabia: a systematic review & bibliometric analysis from 2010 to 2021.

BACKGROUND: Over the past few years, five domains of importance about the current state of bioethics in Saudi Arabia have shaped the perspective of most research: doctor-patient relationship, informed consent, do-not-resuscitate, organ donation, and transplantation, medical students' knowledge and attitudes about medical ethics curriculum. This systematic review aimed to systematically identify, compile, describe and discuss ethical arguments and concepts in the best-studied domains of bioethics in Saudi Arabia and to present cultural, social, educational, and humane perspectives. METHODS: Six databases were searched using Boolean operators (PubMed, Embase, Web of Science, Scopus, CINAHL, Google Scholar) from December 2020-June 2021. The search and report process followed the statement and flowchart of preferred reporting items for systematic reviews and meta-analyses (PRISMA). RESUTLS: The search resulted in 1651 articles, of which 82 studies were selected for a final review and assessment. There is a gradual increase in research, whereby a substantial increase was observed from 2017. Most of the published articles focused on 'Organ Donation & Transplantation' with 33 articles, followed by 'Doctor-Patient Relations' with 18 publications. Most of the published articles were from Central Province (33), followed by Western Province (16). The authorship pattern showed a collaborative approach among researchers. The thematic analysis of keywords analysis showed that 'Saudi Arabia,' 'attitude PHC,' 'organ donation,' 'knowledge and education,' and 'donation' have been used the most commonly. CONCLUSION: This systematic quantitative synthesis is expected to guide researchers, stakeholders, and policymakers about the strengths and gaps in knowledge and attitudes regarding medical ethics in Saudi Arabia, both among the general public and health professionals.

Detection of Left Ventricular Thrombi on Cardiac Magnetic Resonance Viability Studies.

OBJECTIVE: To highlight detection of left ventricular thrombi on cardiac magnetic resonance (CMR) viability studies. METHOD: This retrospective observational study was conducted in the Radiology Department at our Hospital in Dhahran, from April 2015-2019. All recently re-perfused (post-percutaneous coronary intervention/PCI) patients with ST-segment elevation myocardial infarctions (STEMI), having low ejection fractions (<40%), impaired LV functions or abnormal wall motions on transthoracic echocardiographies (TTEs), who underwent cardiac magnetic resonance (CMR) imaging viability studies were included. Patients with incomplete or limited studies (due to artifacts), previous coronary artery bypass graft (CABG), those who lost follow-ups, and those who were contraindicated or unfit for MRIs were excluded. An area of low signal intensity with no late gadolinium enhancement (LGE) was defined as thrombus on MR imaging, and two radiologists reached consensus report for the diagnoses. Patients with anterior or non-anterior wall MI were documented, and their ejection fractions were recorded. Percentage estimation of LV thrombi as detected on CMR studies was made. Any complications (like MI, stroke or death) that occurred within one year of diagnoses were documented. A Chi-square was used to determine association. RESULTS: Of the 125 patients, most were men (71.2%) with a mean age of 56.78 years. Eleven patients had left ventricular thrombi (8.8%), and most of these were anterior wall infarctions with low ejection fractions (<40%). Three out of 11 patients with LV thrombi developed complications versus 3 out of 114 without LV thrombi (P- value, .0005). CONCLUSION: Left ventricular thrombi can be detected on cardiac viability studies in recently re-perfused STEMI patients and may possibly predict the risk of complications.

Magnetic resonance imaging findings in patients with initial manifestations of perianal fistulas.

BACKGROUND: Crohn's disease (CD) is a serious cause of perianal disease and the incidence is increasing in Saudi Arabia. MR imaging may document specific features that may help to foresee Crohn's disease in patients making an initial presentation. OBJECTIVE: Present MR imaging findings of perianal fistulas in patients making an initial presentation. DESIGN: Retrospective, observational. SETTING: Radiology clinic in in Dhahran. PATIENTS AND METHODS: All previously undiagnosed and untreated patients who presented for the first time to the outpatient clinics from September 2015-2018 with perianal fistulas were retrospectively evaluated. Previously diagnosed CD patients, post-surgical or intervention cases were excluded. Fistulas were categorized as low or high anal, simple or complex, and were graded per St. James University Hospital Classification. Imaging was interpreted by two experienced readers based on the Van Assche score. MAIN OUTCOME MEASURES: Fistula features on MR imaging and diagnosis of CD. SAMPLE SIZE: 171 patients. RESULTS: Of 171 patients, 139 (81.3%) were males with mean age of 37.2 (12.7) years; the 32 females had a mean age of 35.8 (10.6) years. Twenty-one patients (12.3%) had CD. Fourteen (40.4%) patients with complex fistulas had CD in comparison to only 5 (4.8%) simple fistula patients ( P=.0005). More than half of patients with complex and high anal fistulas had CD ( P=.0005). Females were more affected than males ( P=.0005). CONCLUSION: Complex or high anal fistula on MR imaging may be the initial presentation of CD and warrant further work up to establish the diagnosis. LIMITATIONS: Retrospective, small sample, single center, and short duration study. CONFLICT OF INTEREST: None.

Breast cancers missed during screening in a tertiary-care hospital mammography facility.

BACKGROUND: Breast cancer is the most common cancer in females worldwide. Screening with mammography for early breast cancer detection is standard community practice in many countries. OBJECTIVE: Identify causes of missed breast cancers during screening. DESIGN: Retrospective, observational. SETTING: Department of radiology at a tertiary-care hospital mammographic screening facility. PATIENTS AND METHODS: All women who came with initial negative screens from July 2015 to July 2018 were retrospectively reviewed and followed-up for their second or subsequent mammographic screening. Missed breast cancer was defined as a cancer that was detected on a subsequent mammogram with an initial negative screen. Mammograms were interpreted by two radiologists as per BIRADS (Breast Imaging Reporting and Data System) lexicon. Causes of missed breast cancers were categorized as imaging acquisition (IA), imaging feature (IF) and imaging interpretation (II). True (occult) incident breast cancers were also documented. Percentage estimations for these causes were calculated. MAIN OUTCOME MEASURES: Breast cancer detection on follow-up screening. SAMPLE SIZE: 943 women. RESULTS: Of 15 (1.6%) screening-detected breast cancers, 7 cases (46.6%) were missed on the initial screen; 3 (43%) of these were II related, 2 (28.5%) of each were IA and IF. The remaining true (occult) cases were detected on either the second (5 cases) or third screens (3 cases). CONCLUSION: Improved screening facilities, quality mammographic acquisition and interpretation, double reading, and implementation of an organized screening program may help to avoid missed breast cancers. LIMITATIONS: Retrospective, small sample, single center, and short duration study. CONFLICT OF INTEREST: None.

Patterns of injury detected by pan-computed tomography after road traffic accidents: retrospective review from a trauma center in Saudi Arabia.

BACKGROUND: Pan-scan (whole-body) computed tomography (CT) has a paramount role in the diagnosis of injuries in road traffic accidents (RTA). OBJECTIVE: Identify patterns of injuries on pan-CT scans. DESIGN: Retrospective medical record review. SETTING: Tertiary care center. PATIENTS AND METHODS: The records of all RTA patients who presented to the radiology department at King Fahad Military Medical Complex (KFMMC) in Dhahran for the 3-year period from July 2014 to July 2017 and underwent pan-CT were retrospectively reviewed. Drivers and front-seat passengers with complete clinical information on seating, safety and mechanism of injury were selected. Children under 5 years of age, pregnant women and back-seat passengers were excluded. Patterns of injuries were categorized as 'no abnormality detected' (NAD), isolated or combined head, face and neck (H), isolated or combined chest, abdomen and pelvis (C) or both regions of the body (B). MAIN OUTCOME MEASURES: Injury patterns on pan-CT scans. SAMPLE SIZE: 305 RESULTS: Most patients were males (n=287, 94.1%). The median age was 26 years for males (IQR, 22-33 years) and 30 years for females (IQR, 28-39). More than two-thirds were drivers (all males); the remainder were front-seat passengers. Young males were most often involved. The most common type of accident was a roll-over. Of those who sustained injuries, 273 (89.5%) were not wearing a seat belt (unrestrained). The patterns of injuries were NAD (87, 28%), H (27, 9%), C (93, 30.5%), B (98, 32%). CONCLUSION: When abnormalities were detected, most high-speed vehicular injuries affected the torso. Unrestrained young male drivers are most often involved in RTAs in Saudi Arabia. LIMITATIONS: Retrospective study with a small sample size. Types and severity of injuries on pan-CT were not documented. CONFLICT OF INTEREST: None.