IN THE NAME OF ALLAH,vrgs.ju.edu.sa/files_jen/AUMJ-4-2.pdf · IN THE NAME OF ALLAH, THE MOST...

IN THE NAME OF ALLAH,

THE MOST GRACIOUS, THE MOST MERCIFUL

AUMJ Editorial Board and Description

Aljouf University Medical Journal (AUMJ), 2017 June 1; 4(2): i - ii.

2017 2017

AUMJ EDITORIAL BOARD AND DESCRIPTION

EDITORIAL BOARD

AUMJ Editor-in-Chief

Prof. Dr. Saleh Abdul Allah Al-Damegh, Professor of Radiology, General Supervisor for Unaizah Colleges New campus at Qassim University, Founding Dean of Unaizah College of Medicine and Applied Medical Sciences, Qassim University, Qassim, Saudi Arabia.

AUMJ Associate Editor-In-Chief

Prof. Dr. Tarek Hassan El-Metwally, Professor of Medical Biochemistry and Molecular Biology & Consultant Clinical Biochemist, Biochemistry Division, Department of Pathology, CME Coordinator, College of Medicine, Jouf University, Sakaka, Saudi Arabia.

AUMJ DEVELOPMENT HISTORY

Jouf University Medical Journal (AUMJ) was established under the generous patronage of his esteem Prof. Dr. Ismail M. Al-Beshry, the Rector of Jouf University, as an initiative of his esteem Prof. Dr Najm M. AL-Hosainy, The vice-Rector of Jouf University for Graduate Studies and Scientific Research as the General Supervisor of the Journal.

The inaugural issue of AUMJ first appeared September 1, 2014 with Prof. Dr. Saleh A. Al-Damegh, Founding Dean of Unaizah College of Medicine and Applied Medical Sciences and General Supervisor for Unaizah Colleges New campus at Qassim University, Qassim University, Qassim, Saudi Arabia, as the Founding Editor-In-Chief.

AUMJ Editors

Prof. Dr. Parviz M Pour, Professor of Pathology, Department of Pathology and Molecular Biology, UNMC, NE, USA.

Prof. Dr. Ibrahim M. El-Bagory, Professor Pharmaceutical Technology, Department of Pharmaceutics, College of Pharmacy, Jouf University, Sakaka, Saudi Arabia.

Dr. Adel A. Maklad, Associate Professor, Department of Neurobiology & Anatomical Sciences, University of Mississippi Medical Center, MS, USA.

AUMJ DESCRIPTION AND SCOPE

AUMJ (pISSN: 1658-6700) is an online Open-Access and printed General Medical Multidisciplinary Peer-Reviewed International Journal that is published quarterly (every 3 months; March, June, September and

December) by the Deanship for Graduate Studies and Scientific Research as the official medical journal of Jouf University, Sakaka, Saudi Arabia (http://vrgs.ju.edu.sa/jer.aspx).

AUMJ full text articles and their serial code Digital Object Identifier (DOI) address number (according to the International DOI Foundation) are accessible online through searching Journals for Aljouf University Medical Journal at Al-Manhal Platform (https://platform.almanhal.com/Search/Result?q=&sf_21_0_3=Aljouf+University+Medical+Journal&opsf_21_0=1&f_title_type_exact_loc_en=Article&opf_title_type_exact_loc_en=2). The DOI of AUMJ is 10.12816. AUMJ welcomes and publishes innovative original manuscripts encompassing all Basic Biomedical and Clinical Medical Sciences, Allied Health Sciences - Dentistry, Pharmacy, Nursing and Applied Medical Sciences, and biological researches interested in basic and experimental medical investigations. Such research includes both academic researches (basic and translational) and community-based practice researches.

AUMJ AUDIENCE

Physicians, Clinical Chemists, Microbiologists, Pathologists, Hematologists, and Immunologists, Medical Molecular Biologists and Geneticists, Professional Health Specialists and Policymakers, Researchers in the Basic Biomedical, Clinical and Allied Health Sciences, Biological Researchers interested in Experimental Medical Investigations, Educators, and interested members of the public around the world.

AUMJ MISSION

AUMJ is dedicated to expanding, increasing the depth, and spreading of updated internationally competent peer reviewed genuine and significant medical knowledge among the journal target audience all over the world.

AUMJ VISION

To establish AUMJ as an internationally competent journal within the international medical databases in publishing peer reviewed research and editorial manuscripts in medical sciences.

AUMJ OBJECTIVES

1. To evolve AUMJ as a reliable academic reference within the international databases for researchers and professionals in the medical arena.

http://vrgs.ju.edu.sa/jer.aspx

AUMJ Editorial Board and Description

Aljouf University Medical Journal (AUMJ), 2017 June 1; 4(2): i - ii.

2017 2017

2. Providing processing and publication fee-free open-access vehicle for publishing genuine and significant research and editorial manuscripts for local, regional, and international researchers and professionals in medical sciences, along with being a means of education and academic leadership.

3. Expanding, increasing the depth, and spreading of internationally competent and updated medical knowledge among the AUMJ target audiences for the benefit of advancing the medical service to the local and international communities.

4. While insuring integrity and declaration of any conflict of interest, AUMJ is adopting an unbiased, fast, and comprehensively constructive one-month peer review cycle from date of submission to notification of final acceptance.

PUBLICATION FEE & SCHEDULE

AUMJ is processing and publication fee-free as a strategy of Jouf University in support of investigators worldwide. However, subscription to the journal and reprint (black and white or color) requests are placed through Deanship of Library Affairs at Jouf University. AUMJ is a bimonthly journal. Average processing time is 2 months; one month from receipt to issuing the acceptance letter and one month for providing the paginated final PDF file of the manuscript. Abstracts and PDF formatted articles are available to all Online Guests free of charge for all countries of the world. AUMJ is published quarterly (every 3 months) March, June, September and December 1st.

EDITORIAL OFFICE & COMMUNICATION

Aljouf University Medical Journal (AUMJ), Jouf University, POB: 2014 Sakaka, 42421, Aljouf, Saudi Arabia.

Email: [email protected]

Tel: 00966146252271

Fax:00966146247183

SUBSCRIPTION & EXCHANGE

Deanship of Library Affairs, Jouf University, POB: 2014 Sakaka, 42421, Aljouf, Saudi Arabia.

Email: [email protected]

Tel: 00966146242271

Fax: 00966146247183

Price and Shipping Costs of One Issue is 25 SR within KSA and 25 US$ Abroad.

mailto:[email protected]

AUMJ Table of Contents

Aljouf University Medical Journal (AUMJ), 2017 June 1; 4(2): iii.

2017 2017

Table of Contents

Aljouf University Medical Journal (AUMJ), 2017 June 1; 4(2)

Content Pages

Description of AUMJ. i-ii

Table of Contents. iii

Review Article:

Telescreening for diabetic retinopathy to address avoidable visual disabilities in Saudi Arabia – A review. Sultan A. Alzuhairy

Original Articles:

Quality of Life in Patients with Alopecia Areata: A Cross-Sectional Study in Saudi Arabia. Thamer Fahad Mubki, Saad Mohammed

Altelhab, Abdullah Hamad AlHargan, Naief Suliman AlNomair, Abdullah Ibrahim AlKhalifah.

Effect of Physical Activity on Glycemic Control among Type 2 Diabetic Patients: A Study from Qassim Region of Saudi Arabia.

Abdulrhman M. Aldukhayel.

1 – 10

11 – 17

19 - 26

Depressive Symptoms among Students of Jouf University, Sakaka, Saudi Arabia. Abdalkarem F. Alsharari, Ammar M. Aroury,

Abdullah A. AlQahtani, Jazy S. Alotaibi, Hamdan M. Albaqawi.

27 – 36

Case Report:

Complicated Cecal Schistosomiasis: A Case Report. Ali I. Hegy,

Fahad A. Al-Rayyes, Yaser T. Sid-Ahmed, El-Sayed M. Abd-Elwahab, Nasir A-G Mohammed-Nour, Ahmed A. Fayad.

Comprehensive Instructions for Authors and Reviewers.

Manuscript Submission and Copyright Transfer Form.

37 – 40

41 – 54

55

AUMJ Table of Contents

Aljouf University Medical Journal (AUMJ), 2017 June 1; 4(2): iii.

2017 2017

Alzuhairy - Telescreening for diabetic retinopathy to address avoidable visual ...

Aljouf University Medical Journal (AUMJ), 2017 June 1; 4(2): 1 - 10.

2017 2017

Review Article

Telescreening for diabetic retinopathy to address avoidable visual disabilities in Saudi Arabia – A review

Sultan A. Alzuhairy

Department of Ophthalmology, College of Medicine, Qassim University, Burraydah, Qassim, Saudi Arabia.

For Correspondence: [email protected]. [email protected].

Abstract

Background: Diabetes Mellitus (DM) and diabetic retinopathy (DR) represent a significant public health burden in the Arab countries including Saudi Arabia. Changing socioeconomics over the last three years in the Kingdom have necessitated changes to the public health approach for addressing visual disabilities due to diabetes.

Materials and Methods: Hence a critical review of this issue is required to revise strategies for implementation of the National VISION 2030 Initiative. The increase in the elderly population and the increasing magnitude of type II DM has resulted a significant population of patients with DR living for long periods of time with visual disabilities. The resulting visual morbidity presents a major challenge for ophthalmologists. Due to resource constraints, shifting tasks for the early detection of DR could be facilitated by a DR tele-screening model. In this model, ophthalmologists would be the 2

nd level filters for referring sight threatening DR (STDR) cases for timely

management and advanced interventional procedures that could be performed in tertiary eye units with vitreoretinal specialists.

Conclusion: This article reviewed the magnitude of DR in Saudi Arabia and proposed a model for telescreening for DR and the related public health and epidemiological issues to monitor the progression and impact on reducing visual disabilities.

Key Words: Diabetic Retinopathy, Tele-diabetic retinopathy Screening, Tele-medicine, Sight Threatening Diabetic Retinopathy, Saudi Arabia.

Citation: Alzuhairy SA. Telescreening for diabetic retinopathy to address avoidable visual disabilities in Saudi Arabia – A review. AUMJ, June 1, 2017; 4(2): 1 - 10.

Introduction

Global impact of Diabetes Mellitus (DM) and Diabetic Retinopathy (DR)

DM is a metabolic syndrome that is considered a global epidemic

(1). There are

425 million adults with diabetes worldwide

(2). From 1980 to 2014, there

has been a 4-fold increase in people with diabetes worldwide

(3). During the same

period, the global prevalence of DM among adults nearly doubled from 4.7 to 8.5%

(3). By 2045, 629 million adult

individuals are projected to have diabetes

(4). The incidence and prevalence

of DM especially in females and young adolescents in urban areas is increasing

(5).

Type 1 DM (T1DM) is caused by an autoimmune reaction where the body’s immune system attacks the insulin-producing beta cells in the islets of the pancreas gland. A combination of genetic susceptibility and environmental triggers such as viral infection, toxins or some dietary factors have been implicated

(6). In

type 2 DM (T2DM), hyperglycemia is the result of an inadequate production of insulin and inability of the body to respond fully to insulin, defined as insulin resistance

(3). A strong link is noted among

type 2 DM with overweight and obesity and with increasing age as well as with ethnicity and family history. As many as



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90% of people with diabetes globally are have T2DM

(7). Genetic and factors related

to interaction of changes in lifestyle are responsible for T2DM

(8). The genetic

factors are complex and difficult to address. Therefore, lifestyle related factors need to be addressed for the prevention of diabetes and its complications. Obesity, unhealthy diet, sedentary lifestyle, smoking, physical inactivity are the major modifiable risk factors of DM

(9).

DM causes both macro- and microvascular complications resulting in cardiovascular complications, DR, diabetic neuropathy, diabetic foot, erectile dysfunction and depression

(10,11). The

prevalence of DR in T1DM and T2DM is 84.1% and 50.2%, respectively among 40 years and older global diabetic population

(5). In industrialized countries,

eye complications of DM are the leading cause of ocular complications including blindness

(12,13). Poor glycemic control,

longer duration of diabetes, use of insulin in treatment, uncontrolled hypertension, age, pregnancy, nephropathy and smoking are the main risk factors for the occurrence and progression of DR

(14,15).

Myopia protects the eye from the development of DR, whereas cataract surgery accelerates the progression of DR

(15).

Status of DM & DR in KSA

In 2018, population of the kingdom of Saudi Arabia (KSA) is projected to reach 20.8 millions

(16); 50.9% of them are males

and adults aging 20 to 99 years that comprises 61% of the total Saudi population. In view of the rising obesity problem in the Saudi population, projections indicate that the prevalence of diabetes in the Kingdom would be 45.8% in 2030

(17). The exact magnitude of DR in

the Kingdom of Saudi Arabia (KSA) remains unknown. Data from regional studies indicate that it could range from 22.4% in Jezan to 29.7% in Taif among individuals 50 years and older

(18,19).

Progression of DR results in sight threatening diabetic retinopathy (STDR) that requires ophthalmic treatment to reduce visual morbidity. If left untreated, STDR can lead to irreversible blindness. In a survey of individuals over 50 years of

age in Taif, the prevalence of STDR was 17.5% of persons with diabetes and 2% of people with diabetes were bilaterally blind

(19). In another province of KSA,

15.7% of total incidence of low vision was due to complications of DR

(20).

Therefore, a public health approach is crucial for successfully addressing the visual disabilities due to DR in the Kingdom

(21). A national policy to address

DR was proposed in 2012 by the national prevention of blindness committee and other stakeholders

(22). Early detection

through proactive annual DR screening was one of the recommended strategies

(23). Previous studies have

reported the effectiveness of DR screening in Middle Eastern countries

(24).

How does DR occur and progress?

Microvascular changes in the choroid and retina result in decreased perfusion of ocular tissue that causes breakage of blood retinal barrier resulting in micro-aneurysms, hard and soft exudate deposition and neovascularization. The ischemia causes infarcts, retinal tissue damage and edema especially at the macula. The fragile new vessels can bleed, cause fibro-vascular changes at the retinal surface and at the vitreous leading to traction bands and retinal detachment. These stages of DR are well described with a universally accepted American Academy of Ophthalmology (AAO) grading as follows: No DR, non-proliferative DR (NPDR) and proliferative DR (PDR)

(25). Diabetic

macular edema (DME) can occur at any stage due to the accumulation of fluid and thickening of retinal layers. PDR and center involving DME are examples of STDR. Timely intervention helps in reducing visual disabilities. Treatments for DR include pan-retinal photocoagulation (PRP), focal laser treatment and intravitreal injections of anti-vascular endothelial growth factors (AVGF) and steroids

(25-27). Vitreoretinal

surgery is reserved for complicated cases of STDR and screening programs aim to identify cases before they reach this stage.

Resources in Saudi Arabia

The kingdom of Saudi Arabia has undergone socioeconomic changes over the last five years. These changes include



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the decline of the global oil price, conflict in the neighboring countries, adoption of liberal policies and organized planning for the country through the Vision 2030 initiatives. Additionally, 800,000 expatriates left Saudi Arabia over the last 18 months

(28). The GDP per capita

declined from US $ 21,508 in 2015 to US $ 21,395 in 2018

(29). Finding and retaining

skilled ophthalmic staff will be challenging. Hence, optimal utilization of eye care resources is required for providing ophthalmic care to people with diabetes.

In 2017, there were 1,032 ophthalmologists employed in the government sector and 752 ophthalmologists worked in the private sector in Saudi Arabia. Ophthalmologists are responsible for delivering eye care to 3.9 million people with diabetes in the Kingdom

(4,30). Theoretically if all T2DM

patients undergo yearly ophthalmic screening, these ophthalmologists would interact with at least ten diabetic patients per day every working day of the year. Some subspecialty ophthalmologists (e.g., glaucoma, oculoplastic, etc.) are not skilled in managing DR and relying on them for early detection would compromise other eye services. Hence, task shifting is required for screening for DR in KSA. Non-ophthalmologists or mid-level eye care professionals can be trained in DR screening, decreasing the burden of STDR detection on current ophthalmic services

(31).

Technological advances in DR screening

Distance is a barrier to seeking health services among the rural underprivileged population. Technological advances have been able to address this issue. For example, telemedicine is a specialized branch that blends healthcare and modern technological tools for detection, consultation, health promotion and supervised surgical interventions. Diagnosis based on the images transferred from remote areas of a region is widely used in oncology, radiology, dermatology and cardiology

(32-34). Telescreening is very

well suited for ophthalmology with applications in retinopathy of prematurity, DR and glaucoma

(35-38). Barnades et al

(39)

has performed a detailed review of digital

imaging in ophthalmology. Technological advances in ophthalmic services have enabled: 1) capturing retinal images, 2) transferring the retinal images 3), interpreting the images using software, 4) storing and retrieving retinal images for comparison, and, 5) giving feedback to the primary care giver and diabetic patients.

Stereoscopic digital imaging is routinely performed to capture the retinal changes due to DR. It is debatable if one image, two image or more images in a montage provide adequate viewing of majority of the retina for adequate screening of diabetes. There may be a reduced need for pupillary dilation for DR screening due to the introduction of cameras with 110° to 150° fields of view

(40). In cases of

neovascular changes that affect the iris, pupillary dilation is often difficult or requires considerable time. But it should be noted that often such cases need urgent referral to an ophthalmologist. Iris neovascularization is a sign of serious retinal disease and patient must be referred urgently. Dilation of the pupil in a community health center or at a primary health center is often not possible due to the lack of availability of topical mydriatics at these centers and risk of precipitating acute angle closure glaucoma. The need for pupil dilation for generating high quality retinal images for DR screening remains debatable. In few cases of media opacities pupil dilation is essential for acquiring clear retinal images. Cases of media opacities such as cataract, corneal scar would need referral to an ophthalmologist

(41).

Role of optical coherence tomography (OCT) in DR screening

Newer models of spectral domain optical coherence tomography (OCT) have promising roles for detecting and monitoring DME; a sight threatening complication of DR

(42,43). However, OCTs

are costly which limits their application for mass DR screening initiatives. OCTs are often complimentary to clinical examination/fundus photography and cannot replace them as a method for DR screening.



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In light of employment generation, should digital camera be manually operated or automated?

For DR screening, if trained photographers are available, use of automated digital fundus digital cameras are not encouraged

(44). In countries with a

priority to employ the young educated workforce, automation for the provision of health services should be delayed for the time being in the kingdom. Training non-ophthalmic professionals in fundus photography can improve the quality of images for DR screening

(45). This has

been successfully established in the UK National Health Service (NHS) where a cadre called ‘DR screeners’ is being utilized in national DR screening program.

Image quality assurance, storage and transfer

There are four components of retinal digital images; image color, focus, contrast and illumination. The quality of the image can now be quantified based on indicators of these components

(46,47).

Previous reports have documented that 10 to 15% of images in studies are considered unsuitable for grading. They could be due to hazy media, undilated pupil or poor cooperation of diabetic person. Davis et al

(47) reported that an

algorithm that reviews image quality provided similar results to an ophthalmologist-graded images. Hence, similar algorithms could provide feedback to the photographers. Digital photography is based on simple principle. The flux of photons that forms the final image is divided into small geometrical subunits called pixels. The light intensity in each pixel is stored as a single number

(48).

Changing the objective magnification, the zoom magnification on the control panel, or choosing another coupling tube magnification for the charge-coupled device (CCD) camera will change the size of the area on the object that is represented by one pixel. If a photographer arranges a system in such a way that the smallest feature recorded in image data is at least 4 to 5 pixels wide in each direction, a high quality digital image of minute changes in the retina can be effectively documented and stored

(49).

Selection and application of compression schemes of digital retinal images are crucial for saving and transferring DR image data without losing quality. Wavelet-based image coding with scalable reconstruction quality on a dynamic user-defined region of interest (Rol) is one such scheme

(50).

Reading center and training of image reader

The main objective of a reading center is to provide timely feedback to the healthcare provider and diabetic patient for further action. To facilitate this, manpower, tools and quality control measures must be an integral part of the reading center. Vargo et al

(451) and the

ophthalmic photographers society described the detailed requirements. It is essential to train DR image readers and shift the task of detection of STDR from retina specialists/ophthalmologists to the mid-level care professionals or newly developed group called DR image readers. These groups can be trained at internationally reputed eye care centers such as the Arvind eye care system

(52).

The training includes basic knowledge of diabetes, ocular changes in diabetes, digital photography of retina and use of computer software so that they can receive, store, interpret and send reports of DR images. The trained staff must be supervised for initial period and on approval of supervisor be certified as an independent image grader. Quality assurance measures at reading centers should include practical training of the staff as well as monitoring their activities by an expert.

DR image interpretation and quality control

The interpretation of DR images at reading centers should be action-oriented

(53). The STDR stage should be

detected effectively and referred for prompt management. Patients who do not have DR or those in the early stages of DR should be identified and informed to continue primary prevention of DM. Although automated software is available for interpreting DR images, they should be used judiciously in developing countries as trained manpower is likely to be more cost-effective and efficient.



2017 2017

Horton et al(54)

documented the importance of monitoring DR screening initiatives, especially by non-ophthalmic staff. Using non-ophthalmic personal for digital fundus photography could be an attractive solution for generating employment and resolve constraints of ophthalmologists in developing countries. However, learning curve and supervision of newly trained staff should be integral component of the DR screening system.

Comparison of images with past images

The storage capacity of the computers and servers in a DR reading center should account for bilateral images annually for each patient. These images will be required the following year to determine progression of DR. Most currently available fundus photography software is adequate for displaying the past and present images for comparison. The center should have adequate software to enlarge and compare small lesions to determine progression or regression

(55).

Additional information that is sent with the retinal images

Often digital retinal images are inconclusive and do not fit in systemic progression of risk factors. In these cases, information on risk factors such as glycemic control, duration of diabetes, hyperlipidemia, and hypertension would be useful to the image reader. Information on these factors can help develop a risk score which can predict likelihood of progression of DR to STDR

(56).

Information to be sent back to the PHC or photographer

PHC physicians have reported tardy feedback from the reading centers

(57). This

negatively affects the morale of the referring physician, an inability to improve their skills and not fully participate in comprehensive diabetes care. The feedback should include quality of digital images sent, stage of DR in each eye of the diabetic patient and further action recommended for management of DR and recommendations for DR screening

What information to be given to the diabetic patient and how?

The advent of smartphone should result in rapid and prompt communication from digital image reading centers. Additionally, the smartphone should facilitate easier communication between healthcare centers and diabetic patients. The diabetic patient should be informed of what steps he/she should take for further eye care and for primary prevention. If prompt ophthalmic intervention is required, a retinal specialist should counsel the patient on the findings and explain about the need for prompt intervention

(58,59).

Screening and preparation for the patient load on management unit

In an underprivileged population of people with diabetes, the coverage for routine DR screening was 29%. Proactive efforts will likely increase the rate of coverage

(60). Implementation of

telescreening can address barriers to accessing ophthalmologists and increase the uptake of screening. These benefits will increase the detection of patients with DR, which will warrant enhancing the DR management system. Cases of DME will likely require costly intravitreal injections of anti-vascular growth factors. PRP for cases PDR will required more instruments and skilled manpower to handle the workload. In countries such as KSA that has more than 125,000 registered people with diabetes, telescreening will increase coverage for annual screenings and should be complemented with greater resource allocation towards the system for management of DR

(61).

Automated DR screening reliability; cost effectiveness and current status

Automated software-based interpretation of DR images has been in place for a decade. Their role in DR as well as DME in large-scale DR screening remains debatable

(62,63). The utility of the

automated systems is that they are considered better than human readers in developed countries and are beneficial in remote regions of developing countries. However, the high cost of the software precludes adoption in developing countries as an alternative to human DR graders

(64). Use of artificial intelligence

system to filter normal fundus images in diabetic patients could be helpful in



2017 2017

reducing the workload of reading center and ophthalmologists for cases of early DR where no active ophthalmic intervention is needed

(65). A nationwide

DR screening initiative using telemedicine in Singapore has indicated that automated DR screening is a feasible public health program and cost effective

(66). The image database of

diabetic patients at the reading center could be used for improving the automated DR screening system as well as for testing newer algorithms using artificial intelligence (AI). Written informed consent of patients is essential for future use of their digital images for research purposes and strict patient anonymity should be maintained

(67,68).

Monitoring the tele DR screening initiative

Adoption of telescreening for DR at the national and regional levels will require periodic monitoring of resources and processes. The availability of digital cameras, trained photographers, image transfer and storage facilities, trained DR readers and protocols for referring and providing feedback will need to be standardized. The outcome indicators include coverage of DR screening, quality of captured images, time spent for interpretation and feedback, validity of the DR reader grading of severity of disease. Additional indicators should include feedback of PHC staff, diabetic patients and cost effectiveness of DR screening. Periodic reports of the efficiency of DR screening and improved coverage of DR management and impact in reducing visual morbidity are impact-related monitoring indicators for enhancing the program and expanding it to other regions

(69).

Conclusions

A number of models of DR screening have been attempted in different countries

(70-73). Due to its cost

effectiveness, it has been promoted as a way to address the detection of early stage DR

(74). Different devices are used in

research and as pilot programs for DR screening. Smartphones apps have promising validity and are recommended for achieving VISION 2030 goals

(75,76). A

single image with a 200° field of view of

the retina through an undilated pupil can now be captured with newer cameras

(77).

Addition of OCT can improve detection of macular pathology secondary to DR

(78).

However, the high cost of newer devices and the skills required to operate them limits their use for mass screening initiative. Currently, non-mydriatic fundus photography and tele-transfer of images to a reading center seems to be the most feasible option for DR screening

(79-

82). Introduction of automated grading

software in improving DR screening system is debatable at this stage.

Funding

This study was self-funded.

Conflict of Interest

The author declared no conflict of interests.

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Mubki et al - Quality of Life in Patients with Alopecia Areata: A Cross-Sectional Study.…..


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Original Article

Quality of Life in Patients with Alopecia Areata: A Cross-Sectional Study in Saudi Arabia

Thamer Fahad Mubki1*

, Saad Mohammed Altelhab1, Abdullah Hamad

AlHargan2, Naief Suliman AlNomair

2, Abdullah Ibrahim AlKhalifah

2

1Dermatology Department, College of Medicine, Al Imam Mohammad Ibn Saud

Islamic University (IMSIU), Riyadh, and, 2Dermatology Department, Prince Sultan

Military Medical City, Riyadh, Saudi Arabia.

*Corresponding author: [email protected].

Abstract

Introduction: Alopecia areata (AA) is a common disease. The impact of alopecia areata on patient’s quality of life was studied in only a few populations. There is a paucity of data in this regard from Middle Eastern populations.

Objective: To evaluate the effect of AA on quality of life on Saudi patients considering different variables such as age, gender, and severity of the disease.

Methods: Dermatology Life Quality Index (DLQI) multiple-choice questionnaire was administrated to subjects diagnosed with alopecia areata attending the dermatology clinics at 2 specialized hospitals in Riyadh, Saudi Arabia from August 2016 to May 2017.

Results: Out of 112 subjects with alopecia areata, 100 returned the questioners (response rate 89%). The mean DLQI score was 7.2 ± 6.9 indicating a moderate effect on quality of life. Quality of life was affected very large to extremely large by alopecia areata in 27% of subjects. Patients with AA totalis and universalis had a higher DLQI score (P value = 0.039). Age of onset, education levels, marital status or family history of AA had no significant effect on patient’s quality of life.

Conclusion: AA has a moderate effect on the quality of life of affected patients. The effect is large to extreme in patients with more extensive disease. Physicians should pay more attention toward taking care of this aspect for alopecia areata patients.

Key words: Alopecia areata, Quality of life, Alopecia, Hair loss.

Citation: Mubki T, Altelhab SM, AlHargan AH, AlNomair NS, AlKhalifah AI. Quality of Life in Patients with Alopecia Areata: A Cross-Sectional Study in Saudi Arabia. AUMJ, June 1, 2017; 4(2): 11 - 17.

Introduction

Alopecia areata (AA) is a common immune mediated disease that is affecting 2% of population around the world. Unknown environmental triggers may probably lead to the disease in genetically pre-disposed individuals

(1). AA is a

chronic disease which may affect any hair-bearing region leading to hair loss ranging from patchy to universal involvement of all body hair

(2). AA may

increase the risk of depression and anxiety in both adults and children

(3).

The dermatology life quality index (DLQI) is a dermatology-specific questionnaire that measures the quality of life (QOL) in adults with different dermatological diseases

(3). DLQI was

previously used to evaluate the impact of AA on QOL in a few populations; however, no data is available from Saudi Arab patients

(1,3-6).

Herein, we aimed to evaluate the effect of AA on QOL in the targeted Arabic population of Saudi Arabia and to correlate the DLQI scores to various demographic and clinical variables.



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Patients and Methods

The multiple-choice DLQI questionnaire distributed to all patients, 18 years or older, diagnosed with AA attending dermatology outpatient clinics at 2 hospitals, Prince Sultan Military Hospital and Al-Imam Mohammed ibn Saud Islamic University Medical Center, Riyadh, Saudi Arabia from August 2016 to May 2017. Subjects with a history of mental or psychiatric diseases, seborrheic dermatitis, scalp psoriasis, scalp infections and presence of a concomitant hair loss disease such as androgenetic alopecia were excluded. AA was clinically diagnosed by a qualified dermatologist. We collected both subject’s demography and clinical data for each patient, and the extent of hair loss was categorized according to the AA investigational assessment guidelines

(2).

The study was approved by Prince Sultan Military Hospital Ethics Committee. Each enrolled participant signed written informed study consent.

The DLQI is a validated 10-item measure created to assess QoL in patients with dermatological diseases. There are six domains to be assessed: symptoms and feelings, daily activities, leisure, work or school, personal relationships, and treatment. All questions referred to the preceding 7 days. The interpretation of DLQI scores was as follows: 0–1 = no effect, 2–5 = small effect, 6–10 = moderate effect, 11–20 = very large

effect, and 21–30 = extremely large effect

(7). Arabic version of the DLQI was

used here (Appendices 1 and 2 are the original English and the used Arabic versions of DLQI).

Statistical methods used: management of data was performed using Excel 2013 (Microsoft, Redmond, WA, USA), and all statistical analyses were done using SPSS version 20.0 software (IBM, Armonk, NY, USA). The Mann-Whitney U-test was used to test the equality of distributions of quantitative outcomes. Construct validity was tested by factor analysis. Reliability was assessed as item total correlation and Cronbach’s alpha. A P value <0.05 indicated statistical significance.

Results

Response Rate and Demographics: Out of 112 distributed questionnaires, 100 subjects completed the questionnaires (response rate 89%) and were included in the analysis. A total of 100 subjects (52% men and 48% women) were enrolled. Majority of subjects (65%) were older than 25 years old. Demographics are shown in Table 1.

Disease Characteristics: Disease duration was longer than 1 year in 56% of subjects. Patchy alopecia was the most prevalent type of the disease (73%). 26% of the participating subjects had a 1

st degree

family member affected by AA (Table 1).

Table 1: Demographics and clinical characteristics of Alopecia areata (AA) patients investigated for their quality of life (n = 100). Data shown are frequencies; n (%).

Characteristic n (%)

Gender: Male/Female 52 (52.0) / 48 (48.0)

Age group (years): ≤25/>25 35 (35.0) / 65 (65.0)

Education level: ≤ High school/>High school 42 (42.0) / 58 (58.0)

Marital status: Married/Single/Divorced 65 (65.0) / 33 (33.0) / 2 (2.0)

AA duration (months): ≤ 12/>12 44 (44.0) / 56 (56.0)

AA type: Patchy alopecia / Universalis / Totalis 73 (73.0) / 12 (12.0) / 15 (15.0)

Family history of AA: Yes/NO 26 (26.0) / 74 (74.0)

DLQI scores

In our sample of patients, the mean DLQI score was 7.2 ± 6.9 (range 0 - 30). 49% of AA patients had a moderate to extremely large effect on their QoL (Table 2). The item by item mean scores ranged from 0.24 to 1.24. The most impact on AA

patients was found to be for embarrassment (Questions 2), clothes choices (Question 4), and shopping or housework (Question 3). The lowest impact was for sexual difficulties (Question 9) and sports (Question 6) (Table 3).



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Table 2: DLQI scores for Alopecia areata patients investigated for their quality of life (QoL; n = 100). Data shown are frequencies; n (%).

Range of Scores n (%) Effect on QoL

Grade 1: 0–1 25 (25.0) No effect

Grade 2: 2–5 26 (26.0) Small effect

Grade 3: 6–10 22 (22.0) Moderate effect

Grade 4: 11–20 22 (22.0) Very large effect

Grade 5: 21–30 5 (5.0) Extremely large effect

Table 3: Item by item scores of the DLQI questions used to investigate quality of life among Alopecia areata patients (n = 100). Data shown are frequencies [n (%)] and mean ± SDM.

Question number

Scores n (%) Score, Mean ± SDM

None = 0 A little = 1 A lot = 2 Very much = 3

Q1 63 (63.0) 25 (25.0) 9 (9.0) 3 (3.0) 0.52 ± 0.79

Q2 31 (31.0) 33 (33.0) 17 (17.0) 19 (19.0) 1.24 ± 1.09

Q3 54 (54.0) 18 (18.0) 15 (15.0) 13 (13.0) 0.87 ± 1.11

Q4 53 (53.0) 20 (20.0) 11 (11.0) 16 (16.0) 0.90 ± 1.13

Q5 58 (58.0) 24 (24.0) 7 (7.0) 11 (11.0) 0.71 ± 1.01

Q6 72 (72.0) 14 (14.0) 9 (9.0) 5 (5.0) 0.47 ± 0.89

Q7 60 (60.0) 22 (22.0) 15 (15.0) 3 (3.0) 0.61 ± 0.85

Q8 51 (51.0) 26 (26.0) 14 (14.0) 9 (9.0) 0.81 ± 0.99

Q9 87 (87.0) 5 (5.0) 5 (5.0) 3 (3.0) 0.24 ± 0.68

Q10 67 (67.0) 18 (18.0) 10 (10.0) 5 (5.0) 0.53 ± 0.87

The severity of AA significantly affected quality of patients' QoL. Subjects with AA totalis/universalis had a higher DLQI as compared to patchy type (p = 0.039).

Age, gender, level of education, or disease duration had no significant effect on participants' QoL (Table 4).

Table 4: Demographic and clinical factors with potential association with DLQI scores among Alopecia areata (AA) patients (n = 100). Data shown are frequencies [n (%)], mean ± SDM and p value. * = statistically significant at p <0.05

Variable n (%) Score, Mean ± SD

P =

Gender: Female/ Male 52 (52.0)/48 (48.0) 7.1 ± 6.7/7.4 ± 7.1 0.849

Age group (years): ≤25/>25 35 (35.0)/65 (65.0) 8.4 ± 6.4/6.6 ± 7.1 0.061

Education level: ≤High school/>High school

42(42.0)/58(58.0) 8.3 ± 8.3/6.4 ± 5.6 0.492

Marital status: Married 65 (65.0) 7.4 ± 7.3 0.945

Single 33 (33.0) 6.9 ± 6.2

Divorced 2 (2.0) 7.5 ± 6.4

AA duration (months): ≤12/>12 44 (44.0)/56 (56.0) 6.2 ± 5.2/8.1 ± 7.9 0.508

AA type: Patchy /Universalis-Totalis 73(73.0)/27(27.0) 6.1 ± 5.7/10.4 ±8.8

0.039*

Family history of AA: Yes/No 26 (26.0)/74 (74.0) 6.9 ± 5.8/7.4 ± 7.3

0.771

Internal consistency and concurrent validity

Construct validity returned a value of Kaiser-Meyer-Olkin measure (KMO = 0.837) and Bartlett’s test of sphericity

(Chi-Square = 397.15, P <0.001) for factor analysis. From the total variances explained analysis, 2 factors were extracted from the factor solution of the DLQI 10 questions (Table 5).



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Cumulative percentage showed that the two factors accounted for 56.8% of the total variance in DLQI score. The factors loaded were divided into two, Questions 2, 3, 4, 5, 6, 7, 8, and 10 relating to emotional and social affairs were first and then questions 1 and 9 for the physiological effects second. For the scale reliability, Cronbach’s alpha for the DLQI score was 0.865. However, the standardized item alpha was 0.862. The set threshold for internal reliability is 0.70; hence these coefficients (0.865 and 0.862) indicate a high internal reliability. For the inter-item correlations, the mean correlation was 0.385, which passes the 0.20 required mark, therefore, returning good reliability results.

Table 5: Factor loadings using two-factor solution.

DLQI items Factor 1 Factor 2

Q1 0.433 0.530

Q2 0.658 0.356

Q3 0.773 0.131

Q4 0.699 -0.043

Q5 0.827 0.086

Q6 0.653 0.350

Q7 0.716 -0.164

Q8 0.759 -0.275

Q9 0.542 -0.598

Q10 0.609 -0.301

Discussion

Although AA is mostly asymptomatic and has a benign course in most cases, it may affect the emotional and psychosocial status of the diseased patients

(3). A few

studies have been done to evaluate the effect of the disease on QoL in different parts of the world; none of them was done in Saudi Arabia

(1,3-6). In our population,

there was a moderate effect for AA on patient’s QoL (mean DLQI score was 7.2 ± 6.9). Our results are comparable to that found in a recent meta-analysis of all studies done to evaluate the effect of AA on Qol

(6). In the latter, pooled DLQI score

of 1330 AA patients was 6.3 indicating a moderate effect of the disease on QoL. In our study population, 27% reported a very to extremely large impairment of QOL.

This is almost comparable to that reported by Willemse et al in Netherlands (31%)

(8).

In our study, the effect of AA on QoL is also comparable to that reported in acne vulgaris (7.5) and contact dermatitis (7.3). However, AA seems to have a milder effect on QoL as compared to other chronic dermatological diseases, such as psoriasis (10.5), atopic dermatitis (11.2) and pemphigus (12.0)

(9,10). The latter

findings can be attributed to the fact that AA, acne vulgaris and contact dermatitis may have relatively shorter and more benign course as compared to the chronic and relapsing course of psoriasis and atopic dermatitis and are non-life threatening as compared to pemphigus.

In our population, patients with alopecia areata totalis/universalis had a significantly worse QoL as compared to patients with more limited disease (patchy). This was expected, as more extensive disease is more likely to affect patient life and activity. The latter is consistent with results from a previous study

(3). Although not statistically

significant, younger age and females had higher DLQI as compared to older age group and males. The latter is expected as younger individuals tend to show more concern to their appearance while seeking jobs and looking for partners. Similarly, females are generally more conscious about their physical appearance. Lucy et al reported a worse DLQI in AA patients of the older age group as compared to young. In our population, AA had a great impact on clothes selection by affected patients. Similar observation was reported by AA patients in a USA population

(11).

Our group has recently done a similar study, sent for publication, evaluating the effect of androgenetic alopecia (AGA) on QoL in 207 subjects. The mean DLQI in AGA patients was 7.8 ± 5.8. These results are almost similar to our present results of AA patients. QoL was significantly affected more severely in females with AGA as compared to males (Data not shown)

Conclusion

AA moderately affected our patients' QoL. QoL is affected more severely in patients with more extensive disease (AA



2017 2017

totalis/universalis). This study supports previous studies done in other areas of the world which showed a significant psychological impact of the disease. Physicians should pay more attention towards taking care of this aspect managing AA patients.

Limitations of the Study

We believe that there were a few limitations of this study, namely the small sample size compared to the general population and being conducted at 2 hospitals in the same city, despite the fact that we target the capital city. Therefore, the investigated sample may not represent the whole population of Saudi Arabia.

Funding



The authors declared no conflict of interests.

Acknowledgments

DLQI was used after getting the permission from Professor Andrew Finlay. We also thank Dr O. Al-Anazi and Dr Lulwah al Mubarak for their help with

questionnaire collection.

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8. Willemse H, van der Doef M, van Middendorp H. Applying the Common Sense Model to predicting quality of life in alopecia areata: The role of illness perceptions and coping strategies. J Health Psychol. 2018 Jan 1:1359105317752826 (ahead of print).

9. Basra MK, Fenech R, Gatt RM, Salek MS, Finlay AY. The Dermatology Life Quality Index 1994-2007: a comprehensive review of validation data and clinical results. British J. Dermatol., 2008;159(5):997-1035.

10. Rencz F, Gulácsi L, Tamási B, Kárpáti S, Péntek M, Baji P, Brodszky V. Health-related quality of life and its determinants in pemphigus: a systematic review and meta-analysis. British J. Dermatol., 2015;173(4):1076-80.

11. Liu LY, King BA, Craiglow BG. Alopecia areata is associated with impaired health-related quality of life: a survey of affected adults and children, and their families. J Am Acad Dermatol. 2018 Feb 6. S0190-9622(18)30183-X (ahead of print).



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Appendix 1: DLQI English Version.



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Appendix 2: DLQI Arabic Version.



2017 2017

Aldukhayel - Effect of Physical Activity on Glycemic Control among Type 2 Diabetic...


2017 2017

Original Article

Effect of Physical Activity on Glycemic Control among Type 2 Diabetic Patients: A Study from Qassim Region of Saudi

Arabia

Abdulrhman Mohammed Aldukhayel

Department of Family and Community Medicine, College of Medicine, Qassim University, Qassim, Saudi Arabia.

For correspondence: E-mail: [email protected].

Abstract

Background: Physical activity (PA) is recommended for diabetic patients due to its beneficial effects on weight loss, glycemic control, decrease insulin resistance as well as its abilities to retard the progression of other comorbidities in diabetics, such as cardiovascular disease.

Objective: To evaluate the level of PA and its relationship with glycemic control among Saudi diabetic patients from Qassim region.

Patients and Methods: The study sample comprised of type 2 adult diabetic patients living in the study area of Qassim region. A retrospective chart review was performed in 2017. Diabetic patients registered with the primary health center at the National Guard Hospital in Qassim were randomly selected for this study. Data were collected on patient demographics. Data on PA per week was collected using a self-administered International Physical Activity Questionnaire (IPAQ). PA was graded as low, moderate and high based on IPAQ. Calculations of the metabolism equivalent (MET) values for 1 week were used as a proxy indicator for PA. Data on HbA1c levels, hypertension, height, and weight and body mass index (BMI) were also collected. Glycemic control was considered adequate if HbA1c was less than 7%.

Results: A total of 395 diabetic patients were evaluated. The mean HbA1c level of 388 patients was 7.9 ± 1.8%. HbA1c was <7% in 136 patients [34.4% (95% CI, 29.7 – 39.1, P <0.005]. There were 252 (63.8%) patients with HbA1c level >7%. Seventy-five (19%) patients were engaged in moderate PA. None of the patients were engaged in high levels of PA. Three hundred and twenty (81%) patients were engaged in low levels of PA. HbA1c level was 8.0 ± 1.87% among patients who were engaged in low levels of PA. The mean HbA1c was 7.7 ± 1.84% among patients who were engaged in moderate PA. No significant differences were observed between moderate or low PA and HbA1c levels (diff of mean 0.3, 95% CI -0.18 to 0.76; P = 0.23).

Conclusions: Large proportions of the investigated diabetic patients were engaged in low levels of PA that non-significantly improved their poor glycemic control.

Keywords: Glaucoma, Knowledge, Practice, Awareness.

Citation: Aldukhayel AM. Effect of Physical Activity on Glycemic Control among Type 2 Diabetic Patients: A Study from Qassim Region of Saudi Arabia. AUMJ, June 1, 2017; 4(2): 19 - 26.

Introduction

Obesity and diabetes, particularly type 2, are at epidemic proportions in the Arab population

(1). There are 3,852,000

individuals from 20 - 79 years of age with diabetes in Saudi Arabia with an 18.1% prevalence adjusted for the population

(2,3).

Physical activity (PA) is recommended



2017 2017

for preventing obesity and diabetes(4-6)

. Although diabetic patients face intrinsic and external barriers to exercise, PA is recommended as a component of lifestyle changes. Additionally, monitoring PA is recommended to ensure that adequate calories are burned during PA

(7).

Lifestyle changes that aid in glycemic control can prevent diabetes and/or delay and prevent complications associated with the disease. Hence, considerable efforts should be directed at adopting lifestyle changes such as engaging in regular PA, controlling diet and assessing glycemic levels periodically

(8). HbA1c levels

provide information on the fluctuation in glucose levels over the previous 3 months

(9). Jiang et al

(10) noted that a

number of measures of lifestyle changes including exercise have a positive impact on glycemic control. Yoga was also effective at reducing blood glucose levels in patients with type 2 diabetic mellitus (T2DM)

(11). In addition

to exercise, the timing of exercise by diabetic patients also influences blood glucose levels

(12). Hence, prescribing PA

should focus on the level, type and timing of exercises to achieve glycemic control in diabetes.

Recommending PA to diabetic patients in Saudi Arabia remains a significant challenge. Even among general Saudi population, up to 58.5% of adults are not engaged in adequate levels of PA

(13).

Diabetic Saudi patients are likely to have similar or worse levels of PA. Additionally due to negative impact of diabetes such as obesity, depression, etc., improving PA levels would be a significant challenge. A lifestyle alteration program would first require baseline data on the level of PA among diabetic patients and its relationship to glycemic control. The association of PA to glycemic control was evaluated in diabetic patients in Malaysia

(14) and in

Palestine(15)

. However, to the best of our knowledge, a similar study has not been performed in Qassim, Saudi Arabia.

Present study was aimed to evaluate the level of PA among adult T2DM patients and its relationship with glycemic control and risk factors for diabetes in the Qassim region of Saudi Arabia.

Participants and Methods

This cross-sectional study was carried out from January to March 2017 after approval from the Bioethical Research Committee of the Primary Health Center of the National Guards in Qassim (PHC-NG). All adult T2DM patients attending PHC-NG were included in the study. Those with physical disabilities and patients who did not agree to participate in the study were excluded. Written informed consent was obtained from all study participants. There are 212,000 adult T2DM patients in Qassim

(16).

Sample size was calculated from the results of an earlier study conducted by Al Hazzaa et al

(17) that observed that 20% of

diabetic patients had controlled HbA1c. Using 95% confidence interval (CI) and 5% acceptable margin of error with a clustering effect of 1.5, 370 T2DM patients were required in this study. To compensate for patient dropout, the sample was increased by 5% to 390 individuals. During the study period, the first five diabetic cases visiting PHCs in morning and another five diabetic patients attending afternoon clinic were enrolled daily for the present study.

Seven family physicians worked as field staff for this study. They collected participants demographic data such as age, gender, educational level, marital status and occupation. They also reviewed the patient charts to report the last 3 months data on HbA1c and total serum cholesterol levels. Uncontrolled diabetes was defined as an HbA1c levels ≥7% for the last three months. Data were also collected on hypertension, dyslipidemia and medications. Data on height, weight, and systolic and diastolic blood pressure was also collected. The BMI was calculated using a standard formula

(18).

The blood pressure was measured in 3 situations in the setting position using a digital sphygmomanometer and was categorized as hypertension based on previous studies

(18). The BMI was graded

as normal if within 18.5 - 24.5 Kg/M2,

overweight (25 - 29.9 Kg/M2)

, obese (30 -

39.9 Kg/M2)

and extreme obesity was

defined as BMI ≥40 Kg/M2(19)

.

The PA related information was obtained using the short self-administered format



2017 2017

of ‘The International Physical Activity Questionnaires (IPAQ)’. It contained questions on walking, moderate and vigorous exercise included number of hours and minutes per day and the number of days that the patients engaged in these activities in a week

(20,21).

Vigorous exercise was defined as activities that make breathing much harder than normal, e.g. heavy weight lifting, fast bicycling or climbing up stairs. Moderate exercise was defined as activities that make breathing somewhat harder than normal, e.g. carrying light loads, bicycling at a regular pace or doubles tennis. Metabolic Equivalent (MET) values were calculated to categorize the level of PA. The researcher filled the English questionnaire after asking the question to the participants in simple Arabic language. The data were collected on a pretested data collection form. An Excel spreadsheet (Microsoft Corp., Redmond, WA, USA) was used to enter data that automatically calculated the PA grades. PA was graded as low, moderately and highly active; defined as ≤600, 601 - 3000 and ≥3001 MET’s min/week, respectively.

The data were analyzed with the statistical package for the social studies (SPSS-24; IBM Corp., Armonk, NY, USA). Continuous outcome variables were analyzed and presented as the mean and standard deviation. Data that were not normally distributed were presented as median and 25% quartiles. Chi Square test was used to find out any association between categorical variables. Binominal regression analysis was used to study the interaction of known factors of glycemic control and identify the predictors of good glycemic control.

Results

The study sample was comprised of 395 diabetics with mean age 55.1 ± 10.7 years. The demographic data are presented in Table 1. There were more females with diabetes than males in this study.

Table 1: Demographic profile of the Saudi diabetic patients investigated for the relationship between their glycemic control

and physical activity. Data shown are frequencies; n and (%).

Characteristic n (%)

Gender Male Female

159 (40.3) 236 (59.7)

Marital status Married Unmarried

343 (86.8) 52 (13.2)

Literacy Illiterate Literate

205 (51.9) 178 (45.1)

Occupation Employed No job Own business Retired Housewife Missing

51 (12.9) 3 (0.8) 2 (0.2)

106 (26.8) 225 (57.0)

8 (2.0)

BMI (Kg/M2) 18.5 - 24.9 25 - 29.9 30 - 40 >40 Missing

32 (8.1) 99 (25.1) 223 (56.5) 36 (9.1) 5 (1.3)

HbA1c test results were available for 388 patients. The mean HbA1c level was 7.93 ± 1.79%. The HbA1c was <7% in 136 [34.4% (95% CI, 29.7 – 39.1)] patients, and >7% in 252 [63.8% (95% CI, 59.1 – 68.5)] patients.

Eight (2.0%) patients were engaged in vigorous exercise, 42 (10.6%) patients were engaged in moderate exercise and Two hundred and ten (53.2%) patients were walking regularly. Three hundred and twenty (81%) participants were engaged in low levels of PA and 75 (19%) participants were engaged in moderate PA. None of the participants was highly active.

Figure 1 presents the glycemic levels based on the different grades of PA. The trend suggests that increased PA non-significantly improves the glycemic control (Diff of mean 0.3, 95% CI -0.18 to 0.76; P = 0.23). PA did not show any significant variation with known factors related to diabetes (Table 2). Grades of PA were not significantly associated to factors such as gender (P = 0.4), age (P = 0.45), hypertension (P = 0.8) BMI (P = 0.33) and education (P = 0.6). Table 3 presents the correlation of glycemic status to its risk factors. None of the demographic or risk factors of diabetes were significantly correlated to glycemic status (P >0.05; all cases).



2017 2017

Figure 1: Glycemic levels of the Saudi type 2 diabetic participants vs. grades of their physical activity. X-axis shows grades of physical activities (low vs. moderate). Y-axis shows HbA1c level as %. The dots in the HbA1c lines indicate the point estimate and the lines represent the confidence interval.

Table 2: Low (n = 314) vs. moderate (n = 74) physical activity and prognostic factors related to diabetes in the Saudi patients of the study. Data shown are mean ± SDM, frequencies (n (%)] and p values. * = Chi-square test.

Quantitative variable Moderate Low P value

Age 54.8 ± 9.9 55.2 ± 10.9 0.7 (95% CI = 2.2 - 3.1)

BMI, Kg/M2 31.9 ± 5.6 32.3 ± 6.1 0.7 (95% CI = 1.1 -1.8)

HbA1c, % 7.7 ± 1.84 8.0 ± 1.77 0.2 (95% CI = 0.18 - 0.76)

Serum Cholesterol, mM/L 4.6 ± 0.91 4.4 ± 1.1 0.08 (95% CI = -0.46 - 0.03)

Qualitative variable n (%) n (%) P value*

Hypertension Yes

No

39 (53.4)

34 (46.6)

165 (51.7)

154 (48.3)

P = 0.8

Gender Male

Female

27 (36.0)

48 (64.0)

132 (41.2)

188 (58.8)

P = 0.4

Education School

Higher education

52 (73.2)

19 (26.8)

238 (76.3)

74 (23.7)

P = 0.6

Discussion

The profile of T2DM diabetic patients in the currents study, is fairly similar to previous studies from Saudi Arabia

(22).

The level of physical activity was low and glycemic control was poor in a large proportion of diabetic patients. The glycemic control was not significantly correlated to grades of the patients' PA. Risk factors such as obesity, hypertension, hyperlipidemia, age, gender and education level were correlated to the grades of MET but not to the glycemic

status. This is perhaps the first study to present a lack of correlation of glycemic control and PA among diabetic patients from Saudi Arabia. This may be due to the low grade of PA performed with low impact on the glycemic control. The high prevalence of both poor glycemic control and low levels of PA among these warrants urgent attention. Additionally, healthcare providers need to regularly monitor both PA and glycemic levels and change medications to control diabetes.



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Table 3: Results of the correlation analysis between glycemic status [HbA1c <7% (n = 136) vs. ≥7% (n = 252)] and diabetic risk factors among the Saudi patients of the study. Data shown are mean ± SDM, frequencies (n (%)] and p values. * = Chi-square test.

Quantitative variable HbA1c <7% HbA1c ≥7% P value

Age 56 ± 10.3 54.6 ± 10.8 P = 0.2

BMI (Kg/M2) 32.1 ± 5.9 32.3 ± 6.0 P = 0.88

Metabolic Equivalent 5.6 ± 3.4 5.2 ± 3.2 P = 0.29

Serum Cholesterol, mM/L 4.4 ± 0.93 4.4 ± 1.1 P = 0.78

Qualitative variable n (%) n (%) P value*

Hypertension Yes

No

68 (50)

68 (50)

134 (53.2)

118 (46.8)

P = 0.55

Gender Male

Female

55 (40.4)

81 (59.6)

100 (39.7)

152 (60.3)

P = 0.88

Education School

Higher education

80 (58.8)

56 (41.2)

157 (62.3)

86 (34.1)

P = 0.27

The present results indirectly agree with an Italian study showing a strong correlation of physical inactivity to high glycemic levels

(23). A Japanese study

reported a decline in HbA1c following exercise among diabetic patients

(4). The

Italian study was based on supervised exercise and its impact while the Japanese study recruited diabetic patients with cirrhosis. A community-based Chinese study suggested that home-based walking exercises might have a greater influence than vigorous physical activities on glycemic levels

(25). The differing

outcomes of these studies is likely due to varying data collection methods and differences in the study population. Marked correlations of glycemic level and PA have been reported among adolescents and children who had T1DM

(26). The

average age of patients in the current study is 55 years. Perhaps the glycemic levels are more strongly correlated to PA in T1DM diabetic patients managed by insulin.

Physical inactivity is one of the most important risk factors for developing chronic diseases and increasing morbidity and mortality among diabetic patients

(27).

In Saudi Arabia, a number of barriers to PA have been reported including; obesity, the culture and the hot climate

(28).

Therefore, this study assessed the magnitude of obesity in the investigated population and its effect on PA and glycemic control. BMI was correlated to PA but not to glycemic levels. The high

level of physical inactivity among diabetic patients and obese patients is noteworthy. Both these health issues warrant attention for primary prevention of non-communicable diseases including diabetes. All member countries of United Nations including Saudi Arabia have committed to decrease the prevalence of obesity and improve PA

(29).

The current study was cross-sectional in nature, hence, a causal association between PA and glycemic control cannot be established. Further studies are recommended to evaluate an association between PA and glycemic control. A study comparing two areas of Japan with longer life spans and shorter life spans noted that exercise capacity was significantly correlated to the plasma adiponectin levels and adiponectin levels were significantly correlated to HbA1c

(30).

Adiponectin is an anti-inflammatory protein found at low levels in T2DM and is influenced by exercise

(31). Thus, the

effect of PA on glycemic control could be indirect through its effect on the adiponectin and metabolic pathways - along with the many metabolically beneficial myokines released upon exercise. The lack of correlation in the present study requires further evaluation by estimating the levels of these biomarkers to assess the biofunctionality of the alleged PA.

In the present study, gender did not show effect on the relationship between PA and glycemic control. Females respond less to



2017 2017

weight loss compared to male diabetic patients

(32). Future studies should assess

other risk factors related to obesity and poor glycemic control. This study may explain the non-differential gender influence on HbA1c levels and PA.

Conclusion

The diabetic population is facing numerous challenges in adopting a healthy lifestyle. Their management is usually dependent on glycemic levels. In this study, there was no significant correlation between PA and the glycemic level. 75% of T2DM patients were obese and hence PA was limited, and the disease was overwhelmingly poorly controlled. Although known risk factors for T2DM correlated with glycemic control, they did not affect the relationship of PA and glycemic control. PA levels and poor glycemic control reported in this study could highlights the values of promoting PA and adjust the disease management strategies for better control.


Limitation of our study is that information collected on the unsupervised PA was based on a questionnaire and could be a less powerful tool compared to the measurement of calories burnt during a week using electronic tools and apps

(33,34).

The cross-sectional nature of this study means that causal associations of PA and glycemic level cannot be established.

Funding

This study was personally funded.


The author declared no conflict of interests.

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Alsharari et al - Depressive Symptoms among Students of Jouf University, …………


2017 2017

Original Article

Depressive Symptoms among Students of Jouf University, Saudi Arabia

1*Abdalkarem F. Alsharari,

1Ammar M. Aroury,

2Abdullah A. AlQahtani,

3Jazi S. Alotaibi,

4Hamdan M. Albaqawi

1Nursing Department, College of Applied Medical Sciences, Jouf University, Sakaka,

2Assir Health Region, Ministry of Health, Assir,

3Nursing Department, Majmaah

University, Majmaah, and, 4Nursing Department, University of Hail, Hail, Saudi

Arabia.

*Corresponding Author: [email protected].

Abstract

Background: The educational process in higher education system is reportedly associated with higher depression levels among student population, resulting from various challenges such as academic requirements and other external demographic and socioeconomic factors.

Objective: The aim of this study was to assess the prevalence of depression and detect potential predictors that are associated with depression among Jouf University's students.

Participants and Methods: A total of 568 undergraduate students, Jouf University, north of Saudi Arabia, were recruited and surveyed utilizing the Beck’s Depression Inventory II (BDI-II).

Results: 35.5% (CI: 31.6 – 39.5%) of students scored high depression level on the BDI-II (17 or more). Socio-demographic variables that are significantly associated with depression in the bivariate analysis included gender, income, academic performance and college type. Multivariate logistic regression analysis revealed that those socio-demographic variables were jointly predictive of increased depression rate, with female as gender variable being the strongest risk factor.

Conclusions: Gender, income, academic performance and college type were jointly predictive of increased depression rate, with female gender the strongest. University students are perceptible to depression and in order to lower depression levels among them, academic and family-based strategies should be initiated and implemented targeting female students and the foundation year.

Key Words: University students, Depression, Gender, Socio-demographic variables, Depressive Symptoms, Beck Depression Inventory.

Citataion: Alsharari AF, Aroury AM, AlQahtani AA, Alotaibi JS, Albaqawi HM. Depressive Symptoms among Students of Jouf University, Sakaka, Saudi Arabia. AUMJ, 2017; 4 (2): 27 – 36.

Introduction

The pedagogical system in universities may cause stress and depression for students, resulting from a variety of internal and external sources such as academic requirements, family expectations, socio-demographic factors and financial strain

(1). Depression is an

emotional state manifested by sadness, low self-esteem, discouragement and

decreased concentration and attention span

(2). It is one of the most common

mental health disorders affecting, with variation in prevalence rate, all age groups globally

(3), which negatively

influences one's performance in study or at work

(4-6). The World Health

Organization (WHO) estimated the global prevalence of depression at 4.4% in 2015

(3) and that varies across different



2017 2017

countries(3,7)

. Early detection is extremely important to prevent complications of untreated depression, which may include substance abuse and/or suicidal attempts

(2,4,5,8).

Several studies have revealed that depression and depressive symptoms are prevalent among university students worldwide. A systematic review of 24 papers concerning depression among higher education students stated that 30.6% of university students experience depression, and that was significantly higher than depression level found in general population

(9). In China, the

average prevalence of depression among 32,694 Chinese university students was 23.8% as reported in 39 studies conducted between 1997 and 2015

(10). In Iran, a

meta-analysis of 35 studies estimated the prevalence of depression at 33% among 9743 Iranian students

(11).

Furthermore, a comparative study conducted among four European universities, two from Eastern Europe (Poland and Bulgaria) and two from Western Europe (Germany and Denmark) suggests that depression symptoms were more prevalent among Eastern European students

(7). In addition, the same study

highlights that female students as a cohort have significantly higher level of depression, which corroborate with WHO estimates

(3) and earlier studies

(5,8,12,13). On

the contrary, a number of published papers revealed no significant differences between female and male students in depression level or depressive symptoms

(11,14-16).

It is thought that depressive symptoms are prevalent among medical students

(16-18). In

a systematic review of 40 articles published between 1980 and 2005 among United States (US) and Canadian medical students, to assess depression and anxiety, indicates a high level of depression

(19).

However, a study in the United Kingdom (UK) states that non-medical students have a higher degree of moderate to severe depressive symptoms compared to medical students, although medical students reported more scores in mild symptoms

(20).

In Saudi Arabia (SA), there has been little literature published on prevalence of

depression; especially among university students. One study conducted depression screening using 21-item Beck Depression Inventory II (BDI-II) scale in a large shopping mall in Riyadh city in 2012, which shows high rates of moderate and severe depression among the general population. More depression levels were reported among female participants in particular, but not significantly associated to marital status or age

(21). A cross

sectional study at Qassim University assessed anxiety and depression among 288 medical students using Aga Khan University Anxiety and Depression Scale (AKUADS) revealed overall depression prevalence of 66.6% and 44.4% among female and male students, respectively. The study also reported that students on their first year had the highest prevalence of depression

(22). Another cross-sectional

study in Riyadh surveyed 1,500 students from colleges of Medicine, Dentistry, Nursing, and Applied Medical Sciences (AMS) at King Saud University during the academic year of 2012–2013. The study adapted the BDI-II and the results shows 47.0% overall prevalence of depressive symptoms among all students. With the highest levels among Dentistry students (51.6%), followed by Medicine (46.2%), AMS (45.7%) and was the least among Nursing students (44.2%). In addition, females, Dentistry students, the third year students in all colleges and the fifth year students in Medicine and Dentistry were significantly associated with higher rates of depressive symptoms

(12). In contrast, another Saudi

study conducted at Umm Al-Qura University at Mecca compared medical and two non-medical colleges and showed opposing results. Male students were reported to have higher depression levels (31.2%) compared to females (26.4%) among the three participating colleges. Moreover, the level of depression among male students was relatively similar in colleges of Medicine (36.6%) and Engineering (34.8%), but significantly lower (22.7%) among the college of Islamic study students

(18).

The current study aimed to identify and quantify the level of depression and associated symptoms among students at



2017 2017

Jouf University. The study also sought to assess levels of depression among different colleges and campuses within the university. Furthermore, the comparison gives insight as to whether academic workload affects depression level among college students as predicted in earlier studies. In addition, Jouf University students were also compared within different colleges and campuses focusing in particular to gender differences and other social and academic variables. The research questions were as follow; 1) What is the prevalence of depression among the students of Jouf University? 2) Are there any significant differences between students' gender in the level of depression? And; 3) How do students from different colleges and campuses of Jouf University differ in relation to depression level?

Participants and Methods

Research Design: A cross-sectional analytic study design was used. A non-probability sample (convenient) was taken from Jouf University students, including 13 colleges in seven university campuses. BDI-II, which was developed by Beck et al in 1961, was selected to assess depression in the current study

(23). Since it

was developed, the tool has been reviewed several times and modified to 21-items (BDI-II) in 1996. The Arabic version of BDI-II scale developed by Ghareeb in 2000 and tested by Alansary in 2006 with 9,168 students from 18 Arab countries for internal consistency. The coefficient alphas range between 0.82 and 0.93 showing it is useable by literate participants in Arab countries without the need of any phrasing modifications

(24).

Ethical approval was granted from Jouf University local bioethical committee (approval no 5-1-7-38).

Upon survey distribution, a statement of purpose and the phone contact number of the primary author was provided to participants to inform them about the purpose of research and assure them about privacy and confidentiality of their identity. No personal data were collected. Completion and electronic submission of the survey implies consent to participate

(25).

Participants Sampling: The study covered all campuses of Jouf University in four major cities in Jouf region. The total population of students at the university was estimated at 27000 students. The vast majority of students are undergraduate Saudi students

(26). The study therefore

included undergraduate Saudi students only. The university students were recruited using personal mobile phone and email invitations with link to the electronic survey

(27). Students were

encouraged to pass on invitations to peers through personal contact and social media groups, which are common among classmates, to maximize participation. Qualtrics platform was utilized to collect and manage data, which included a feature to prevent multiple participations from the same participant

(28). No personal

identifying data were collected from students. A sample size of 379 students was calculated to be sufficient for precise data analysis of the present study based on the population size, confidence level of 95% and a confidence interval of 5

(29).

Upon completion of data collection and cleaning process, the total number of undergraduate Saudi students who participated in the study was 586.

Data collection period extended from December 2016 till February 2017. The survey included the following colleges: Foundation year (the first year for all medical & engineering students), AMS, Pharmacy, Medicine, Engineering, Dentistry, Computer and Information Sciences, Education, Law, Science, Administrative Sciences and Humanity, Arts and Sciences (Qurayat), Arts and Sciences (Tabarjel). The survey was made available to all university students and to further encourage participation from all campuses and levels an Arabic translated electronic format of the survey

(24) was

distributed using students' social media groups and university email to maximize response rate.

Statistical Analysis: Continuous data are expressed as mean ± standard deviation and categorical data as number/%. Comparisons between non-depressed vs. depressed students (BDI-II ≥17) were done using independent two sample t-test and Pearson Chi-square test for



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continuous and categorical variables, respectively. Chi-square analysis was performed to examine the association between depression and categorical variables; while, t-test was used for continuous variables. Multivariate Logistic models were built using stepwise selection method. The final model was used to quantify the association between statistically significant variables (the chi-square and t-test analysis) and depression. The results were given as Odds ratios (OR) with their corresponding 95% CIs and P values to determine the strength of association of these potential variables with depression. All analyses were done using SAS 9.4 (SAS Institute, Inc., Cary, North Carolina)

and conclusions made at

a significance level of 5%.

Results

Students represented 13 colleges from different Jouf University campuses. The total number of students who completed the questionnaire during the study was 586; 371 (63.3%) were male while 215 (36.7%) were female. The age of 243 (41.5%) was 21 - 23 years old. The majority of respondents were single (~70%), and 73.7% of students were living with their families at home. The overall depression prevalence among the studied students was 35.5% (95% CI: 31.6

- 39.5%). The prevalence was lower in males, 31.8% (27.1 - 36.5%), compared to females 41.9% (35.3 - 48.5%). The mean score of BDI-II was higher in the depressed students (BDI-II scored 17 or more) than in the non-depressed students (24.5 ± 6.4 vs. 8.7 ± 4.5, p <0.001). Results from bivariate analyses confirmed significant association between depression and four demographic variables including gender, income, academic performance measured using students Grade Point Average (GPA) and College of student (p-values <0.05). Age, address, marital status, living condition and study level did not show any individual significant association with depression (Table1).

Building multivariate logistic models with all variables with p-value <0.10 using stepwise method (SLE = 0.10, SLS = 0.10), five variables (gender, living condition, income, GPA and college type) jointly predicted depression in the university's students. Among these variables in the model, only four (gender, living condition, GPA and college type) were jointly associated with depression (all with p-values <0.05). The respective strength of associations was quantified in terms of Odds Ratio (OR) (95% CI) as presented in Table 2.

Table1: Association of socioeconomic, academic and demographic variables with depression

among the study Jouf University students. Data shown are mean ± SDM, frequencies [n (%)] and

p value. P value <0.05 considered significant.

Characteristics n = 586

Non-depressed

(n = 378)

Depressed

(n = 208) P value

BDI-II score 14.3 ± 9.2 8.7 ± 4.5 24.5 ± 6.4 <0.001

Age (Years) n (%) n (%) n (%) 0.051

18-20 117 (20) 78 (13.3) 39 (6.7)

21-23 243 (41.5) 149 (25.4) 94 (16)

24-26 85 (14.5) 52 (8.9) 33 (5.6)

27-29 55 (9.4) 32 (5.5) 23 (3.9)

30+ 86 (14.7) 67 (11.4) 19 (3.2)

Gender 0.014

Male 371 (63.3) 253 (43.2) 118 (20.1)

Female 215 (36.7) 125 (21.3) 90 (15.4)

Address 0.273

Jouf 350 (59.7) 232 (39.6) 118 (20.1)

Outside Jouf 236 (40.3) 146 (24.9) 90 (15.4)

Marital status 0.296



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Married 182 (31.1) 123 (21) 59 (10.1)

Single 404 (68.9) 255 (43.5) 149 (25.4)

Income 0.007

Low 110 (18.8) 57 (9.7) 53 (9.0)

Average 447 (76.3) 300 (51.2) 147 (25.1)

High 29 (5.0) 21 (3.6) 8 (1.4)

GPA <0.001

Fail 19 (3.2) 7 (1.2) 12 (2.0)

Average 62 (10.6) 31 (5.3) 31 (5.3)

Good 215 (36.7) 132 (22.5) 83 (14.2)

Very Good 197 (33.6) 133 (22.7) 64 (10.9)

Excellent 93 (15.9) 75 (12.8) 18 (3.1)

Staying (living) with 0.067

Family 432 (73.7) 288 (49.2) 144 (24.6)

Friends 154 (26.3) 90 (15.4) 64 (10.9)

Study level 0.121

Level 1 18 (3.1) 11 (1.9) 7 (1.2)

Level 2 62 (10.6) 32 (5.5) 30 (5.1)

Level 3 59 (10.1) 41 (7) 18 (3.1)

Level 4 106 (18.1) 72 (12.3) 34 (5.8)

Level 5 49 (8.4) 29(5.0) 20 (3.4)

Level 6 88 (15) 50(8.5) 38 (6.5)

Level 7 64 (10.9) 45(7.7) 19 (3.2)

Level 8 140 (23.9) 98(16.7) 42 (7.2)

College 0.002

Foundation year 30 (5.1) 15 (2.6) 15 (2.6)

Medicine 52 (8.9) 43 (7.3) 9 (1.5)

Dentistry 15 (2.6) 10 (1.7) 5 (0.9)

Pharmacy 41 (7) 15 (2.6) 26 (4.4)

Applied Medical Sciences 165 (28.2) 107 (18.3) 58 (9.9)

Science 34 (5.8) 22 (3.8) 12 (2)

Engineering 25 (4.3) 21 (3.6) 4 (0.7)

Computer Sciences 37 (6.3) 22 (3.8) 15 (2.6)

Sharia and Law 61 (10.4) 36 (6.1) 25 (4.3)

Education 35 (6) 24 (4.1) 11 (1.9)

Humanitarian & Administration 44 (7.5) 29 (5) 15 (2.5)

Science and Arts Qurayat 37 (6.3) 27 (4.6) 10 (1.7)

Science and ArtsTabarjal 10 (1.7) 7 (1.2) 3 (0.5)

Discussion

Results from this research showed that 35.5% of the students who took part in the survey were depressed, which corroborate with previous studies

(9-11,18,22) that

reported prevailing depression and depressive symptoms among university

students. In the current investigation female student, students living within a shared accommodation with friends, those with low or high income, students with low academic performance and students at the foundation year were the high-risk groups who are more likely to be depressed. In particular, female students were more likely to be depressed



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compared to male students, 43.2% and 21.3%, respectively (P = 0.014). Two earlier studies conducted in SA at Qassim and King Saud Universities revealed similar findings that female students were at greater risk of depression as compared to male students

(12,22). In contrast, one

study at Umm Al-Qura University

reported that male students were more susceptible to depression than females

(18).

It is possible that Saudi women are at higher risk for depression than Saudi men due to sociocultural factors and family commitments that affect their feelings and thoughts.

Table 2: Logistic models showing the Odds Ratio (OR) and 95% CI of Jouf University students' socioeconomic, academic and demographic variables association with depression. * = Significant association, r = reference group.

Characteristic Univariate Analysis Multivariate Analysis

OR 95% CI P value OR 95% CI P value

Gender 0.0145 <0.0001

Female 1.54 1.1 - 2.2 2.50 1.6 - 3.9

Male (r)

Staying with 0.0676 0.031

Friends 1.42 1.0 - 2.1 1.66 1.05 - 2.62

Family (r)

Income

0.0080 0.088

Average 0.53 0.3 - 0.8*

0.59 0.4 - 1.0

High 0.41 0.2 - 1.0

0.47 0.2 - 1.3

Low (r)

GPA

0.0001 0.001

Average 0.58 0.2 - 1.7

0.91 0.3 - 2.9

Good 0.37 0.1 - 1.0 0.54 0.2 - 1.6

Very good 0.28 0.1 - 0.7* 0.40 0.1 - 1.2

Excellent 0.14 0.1 - 0.4* 0.20 0.1 - 0.6*

Fail (r)

College 0.0044 0.002

Medicine 0.21 0.1- 0.6* 0.37 0.1 - 1.1

Dentistry 0.50 0.1- 1.8 0.56 0.1 - 2.3

Pharmacy 1.73 0.7 - 4.5 2.44 0.9 - 6.8

Applied Medical Sciences 0.54 0.2 - 1.2 0.82 0.3 - 1.9

Science 0.55 0.2 - 1.5 0.49 0.2 - 1.4

Engineering 0.19 0.1 - 0.7* 0.20 0.1 - 0.8*

Computer Sciences 0.68 0.3 - 1.8 0.57 0.2 - 1.6

Sharia and Law 0.69 0.3 - 1.7 0.84 0.3 - 2.2

Education 0.46 0.2 - 1.3 0.40 0.1 - 1.2

Humanitarian & Administration 0.52 0.2 - 1.3 0.42 0.2 - 1.2

Science and Arts Qurayat 0.37 0.1 - 1.0 0.34 0.1 - 1.0

Science and Arts Tabarjal 0.43 0.1 - 2.0 0.37 0.1 - 1.8

Foundation year (r) - - - - - -

In addition, Jouf University students who were staying with their families have less chance of being depressed compared to those who lived with their friends in a

shared facility. It is believed that being surrounded with family members and beloved ones could have decreased the incidence of depression among students by offering support during hard times and



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promoting resilience(30)

. Jouf University students with average income are less depressed compared to each of those with low or high income - without significant difference between the last two categories. Some experts negatively associate financial status with depression levels among university students

(1,7,15). On

the other hand, a UK-based study reported no significant relationship between financial burden and students with depression

(20).

Unsurprisingly, Jouf University students with higher academic performance are less depressed compared to those who had fair or failed GPA, which is generally consistent with previous investigations

(6,13,15). It is believed that

depression as a mental disorder affects one's mode, thought process, motivation and concentration

(8) that consequently

reduces the performance of academic study, which in turn become an additional burden that frustrates students. Furthermore, coping mechanism with stressful situations are of great importance to depressed university students. It is argued that adaptive coping strategies could significantly enhance management and promote effective behavior

(31). It has

been confirmed that cognitive therapy and relaxation technique in combination could be effective in managing depression of students and consequently improving their academic performance

(6).

The average depression level among the studied students across Jouf University colleges is (35.5%) that was significantly highest at the college of Pharmacy (65%) followed by the Foundation year (50%). The Foundation year is the first year at the university for medical and engineering students to experience after completion of secondary school. During this transition, students are exposed to a new system of education with greater academic challenges that determines their career path. Likewise, the Foundation year students at Qassim University reported the highest rate of depression

(22).

However, some studies revealed that medical students have higher depression scores than other colleges, including first-year students

(10,16-18). Whereas, Bayram

and Bilgel reported that social and

political sciences students have higher depression scores than students who study basic sciences, engineering and medicine

(14). This inconsistency may be

due to different educational systems and socio-economic factors from country to country. For instance, in SA male and female students have separate campuses and Saudi students get free higher education in public universities. Other socio-economic factors can also vary such as job opportunities after graduation and family expectations.

Conclusion

The strongest association with depression was recorded in this study for Jouf University female students, followed by academic performance (GPA), specific college type and students' living condition. Current findings could help improve further studies to detect factors that are causally related to student's depression. In order to lower depression to a manageable level among universities' students, focus should be on enhancing living conditions by establishing housing units within the university campus that can offer recreational facilities and counseling office. Although income level was not strongly associated with depression, financial assistance to low-income students could help circumvent the depressive symptoms. It is also recommended for academic advisers and university management in SA to pay special attention to female campuses and the Foundation year.


Some students might had not been able to receive email invitations as their official university emails were not updated and/or clogged with junk social media materials.

There were not enough students' participations from some colleges (Dentistry and Science and Art in Tabarjal), which may affect the generalization of results to those colleges.

Funding




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Hegy et al - Complicated Cecal Schistosomiasis: A Case Report


2017 2017

Case Report

Complicated Cecal Schistosomiasis: A Case Report

Ali Ibrahim Hegy1*

, Fahad Ayed Al-Rayyes1, Yaser Taha Sid-Ahmed

1,

El-Sayed Mahmoud Abd-Elwahab2, Nasir Abdel Gadir Mohammed-Nour

3,

Ahmed Abdullah Fayad4

1Department of General Surgery, Prince Moteeb ibn Abd Al-Aziz Hospital, Ministry of

Health, Sakaka, 2Departments of Surgery, College of Medicine for Girls, Al-Azhar

University, Egypt and College of Medicine, Jouf University, Sakaka, 3Histopathology

Department, and, 4Department of Radiology, Prince Moteeb ibn Abd Al-Aziz Hospital,

Ministry of Health, Sakaka, Saudi Arabia.

*Corresponding Author: [email protected]

Abstract

Background: Schistosomiasis is endemic in many countries including Egypt. Schistosomiasis can affect the colon leading to chronic active granulomatous colitis mainly on the rectum and left side of the colon. Also, it affects the cecum and very rarely it leads to perforation.

Case Description: We present a 39-years-old male patient from Nile Delta in Egypt, a resident in Sakaka, Saudi Arabia, who was presented to the ER department of Prince Moteeb ibn Abd Al-Aziz Hospital, Ministry of Health, Sakaka, Al-Jouf, Saudi Arabia. He underwent an abdominal exploration for a perforated inflammatory cecal mass. Emergency right hemicolectomy was done for him and the postoperative biopsy revealed cecal schistosomiasis with perforation which is a rare entity.

Conclusion: Intestinal schistosomiasis may be a rare cause of inflammatory cecal masses, particularly in patients inhabiting infested areas. Right hemicolectomy may be the option when the surgeon is in doubt about the etiology of the mass.

Key Words: Schistosomiasis, Cecal perforation, Emergency right hemicolectomy, Case report.

Citation: Hegy AI, Al-Rayyes FA, Sid-Ahmed YT, Abd-Elwahab EM, Mohammed-Nour NA, Fayad AA. Complicated Cecal Schistosomiasis: A Case Report. AUMJ, 2017 June 1; 4(2): 37 - 40.

Introduction

Human schistosomiasis is reported to be endemic in 77 countries in tropical and subtropical regions and it is estimated that about 250 million individuals worldwide are affected

(1). The colorectum is one of

the primary targets for schistosomiasis (S. mansoni and S. intercalatum). The adult worms live in the portal vein and its tributaries and travel further towards the distal colon and rectum to lay their eggs seeking freedom. Egg deposition in the submucosa leads to granuloma formation, congestion, edema, polyp formation and ulceration

(2). Although most inflammatory

cecal masses found during exploration of a patient with suspected acute appendicitis are benign in origin and

iliocecal resection is enough, right hemicolectomy may be indicated if the surgeon is in doubt and malignancy cannot be excluded. Common inflammatory cecal masses which may be found during exploration for suspected acute appendicitis are appendicular phlegmon, perforated cecal diverticulitis, tuberculosis of the cecum, appendiceal and cecal rupture, malignant mesenchymal neoplasm, non-specific granuloma and appendicular endometriosis

(3).

We are presenting a patient with perforated inflammatory cecal mass to whom we performed right hemicolectomy because we could not exclude malignancy based on the gross appearance, but the




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postoperative biopsy revealed Schistosomiasis to be the cause of the perforated mass which is extremely rare.

Case Description

A 39-years-old male patient from Nile Delta in Egypt, a resident in Sakaka, Saudi Arabia, was presented to the ER department of Prince Moteeb ibn Abd Al-Aziz Hospital, Ministry of Health, Sakaka, Al-Jouf, Saudi Arabia on May 1, 2017. He was complaining of abdominal pain, maximum at the right lower abdomen associated with anorexia and nausea but normal bowel habits and no vomiting. No other symptoms and no past medical or surgical history.

On examination, patient appeared ill and in pain. No pallor, jaundice or cyanosis. Patient was afebrile, and his pulse rate was 100/min. He was lying still at the bed trying not to do any movement. There was restricted abdominal movement with respiration and no visible scars. There was significant tenderness and rebound tenderness maximum at the right lower abdomen with sluggish intestinal movements.

Random blood sample laboratory results revealed WBC 12.0 x 10

3/μL, platelets

273 x 103/μL, RBC 5.93 x 10

6/μL, Hb

14.9 g/dL. Sodium 139 mmol/L, potassium 4.2 mmol/L, total bilirubin 0.8 mg/L, glucose 134 mg/dL and creatinine 0.97 mg/dL with normal liver enzymes and normal lipase and amylase. Abdominal X ray erect was done for the patient and it showed no air under diaphragm and no air fluid levels. Abdominal ultrasonography was done, and it showed enlarged bright liver with enlarged spleen and an inflammatory process at the right iliac fossa related to the cecum. Other organs were sonographically free.

IV contrast CT study of the abdomen (Figure 1A and B) revealed moderate mural thickening, involving the cecum (more at its lateral side) as well as adjoining part of the ascending colon and the terminal ileum with small hyperdense foci at the cecal wall; likely representing micro-bleeding. Associated stranding of the peri-colic mesenteric fat planes with minimal right paracolic collection and

thickening of the anterior perinephric fascia were noted. Few enlarged peri-colic and mesenteric lymph nodes were also seen, the largest measured about 1.3 cm. The appendix was seen tortuous but of average caliber showing few air foci within (non-obstructed) with rather clear surrounding fat planes. Patient was evaluated by diagnostic laparoscopy which revealed apparently normal appendix with a patch of necrosis and a possible perforation of the cecum. The decision was taken for laparotomy.

Laparotomy was done through a midline incision. The cecum had thickened wall especially the lateral and posterior walls giving a mass effect with an area of perforation and palpable mesenteric lymph nodes. It was difficult to determine by the gross appearance whether the mass is benign or malignant. Right hemicolectomy was performed. We did not take an operative photo because we thought that the cecal mass is malignant and hence we did not plan for the case report publication. The surprising histopathology report encouraged us for reporting the rare case of schistosomiasis-induced perforated inflammatory cecal mass which is a rare entity. The patient had overnight observation at the ICU then shifted to the ward. He had transient post-operative hepatic decompensation; serum total bilirubin of 3.5 mg/dL and albumin of 2.5 g/dL. All returned to normal values within 4 days. Patient was discharged at post-operative day 9 while tolerating regular diet and passing motion at normal frequency. He was pain free and the wound was clean.

Histopathology report (Figure 2A, B and C) described the specimen as being 42 cm in length and composed of a small intestinal segment 10 cm and a large intestinal segment measures 30 cm. The area of perforation (Figure 2A) measured 3 mm and was surrounded by inflammatory response and was located at the cecum. The appendix was 10x1 cm and looked inflamed. Microscopic examination of the cecum revealed extensive mucosal ulceration covered by neutrophilic scale and crust and transmural neutrophilic infiltration reaching up to the outer fatty layer with



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focal gangrenous area exhibiting complete mural necrosis. Transmural neutrophilic, eosinophilic and lymphoplasmacytic infiltration reaching up to the serosa and the periappendiclar fatty tissue was also noted. Transmural presence of schistosoma-like eggs surrounded by few chronic inflammatory cells, macrophages

and foreign body multinucleated giant cells was also noted (Figure 2B and C). No malignancy was seen. Histopathology diagnosis was chronic active Schistosomiasis-associated granulomatous colitis/appendicitis with perforation.

Figure 1: IV contrast CT study of the abdomen (Axial view, A, and, coronal view, B).

Figure 2: Histopathological findings of the biopsy (H&E; A and B x100, and C x400). A) Area of perforation, B) Schistosomiasis-associated inflammation near the perforation, and, C) Schistosoma eggs (short arrow) and inflammation (long arrow).

Discussion

Schistosomiasis affects more than 200 million people worldwide in Africa, Asia and South America

(4). Egypt has a long

history with Schistosomiasis known in Egypt as Bilharziasis, after the discoverer of the parasite, Theodore Bilharz, at Kasr El-Aini Hospital in Cairo in 1852. However, the story did not begin at that time. The use of immunoassays led to the diagnosis of the earliest case of human schistosomiasis which occurred more than 5000 years ago in an Egyptian mummy

(5).

In Egypt, the incidence of schistosomiasis dropped from 60 - 85% at1937

(6) to 1.5%

at 2006(7)

, and, this is the time to set the agenda for schistosomiasis elimination

(8).

Schistosomiasis can affect the colon. All segments may be affected, yet the rectum, sigmoid and descending colon which are drained by the inferior mesenteric vein, are the main site of pathology in over 90% of cases

(9). Egg deposition in the

submucosa leads to granuloma formation, congestion, edema, polyp formation and

ulceration(10)

. When the submucosa becomes densely thickened by fibrous tissue containing immense numbers of calcified eggs, sandy patches develop. The overlying mucosa becomes atrophic and acquires a granular dirty yellowish appearance

(11). The eggs elicit a cell

mediated inflammatory response in the submucosa with granuloma formation and necrosis

(12). In acute schistosomal colitis,

the mucosa is usually edematous and congested with petechial hemorrhage. In the chronic colitis form, the mucosa reveals confused vascular net with flat or elevated yellow nodules, polyps and intestinal stricture. Both types could be observed in colon segments of chronic active schistosomal colitis. Similar to those of pseudomembranous enterocolitis, the grayish yellow or yellowish white schistosomal nodules is the most characteristic finding

(9).

The patient in this case report is Egyptian from the Delta valley. The histopathology findings in our case were the same as



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previous reports, with two differences. The first is that in our case, necrosis progressed to gangrene and perforation that made the patient presented with acute abdominal pain. The second is that in our case the cecum is the part of the colon affected in addition to the appendix in contrary to the left side in the majority. When we found a perforated cecal mass, we were not able to exclude malignancy. Therefore, we did right hemicolectomy and the diagnosis of schistosomiasis being the cause was established from the postoperative histopathological examination of the biopsy since intra-operative frozen section histopathology was not available.

Chronic liver disease is one of the most feared complications of schistosomiasis. Accordingly, after the diagnosis had been established, we revised the data to evaluate the liver condition. Preoperative liver function tests were within normal values. Imaging modalities we used described the liver as being enlarged and bright (fatty liver). During exploration, we inspected and palpated the liver searching for hepatic masses. We were thinking that the cecal mass is malignant and we were searching for hepatic metastasis. However, the liver was soft with no cirrhosis of fibrosis. The patient had transient hepatic decompensation which was not clear to be anesthesia-related or was related to the chronic schistosomiasis infestation. Fortunately, the liver functions returned to normal within 4 days.

Hakan Guven et al reviewed 48 patients who underwent emergency iliocecal resection or right hemicolectomy for complicated inflammatory cecal messes. They concluded that iliocecal resection is enough as most inflammatory cecal masses are benign. They did not mention about schistosomiasis as a cause of perforated cecal masses

(3). Right

hemicolectomy is indicated when malignancy cannot be excluded.

Conclusion

Intestinal schistosomiasis may be a rare cause of inflammatory cecal masses, particularly in patients inhabiting infested areas. Right hemicolectomy may be the

option when the surgeon is in doubt about the etiology of the mass.



Reference

1. Hotez PJ, Savioli L, Fenwick A. Neglected tropical diseases of the Middle East and North Africa: review of their prevalence, distribution and opportunities of control. PLoS Negl Trop Dis., 2012;6:e1475-82; 1-8.

2. Barsoum RS, Esmat G, El-Baz T. Human Schistosomiasis: Clinical Perspective, Review. J. Advanced Research, 2013;4:433-4.

3. Guven H, Koc B, Saglam F, Bayram IA, Adas G. Emergency right hemicolectomy for inflammatory cecal masses mimicking acute appendicitis. World J. Emergency Surgery, 2014; 9:7; 1-5.

4. Gryseels B, Polman K, Clerinx J, Kesteri L. Human Schistosomiasis. Lancet, 2006;368:1106-18.

5. Deelder A, Miller N, De Longe M, Krijker F. Detection of schistosome antigen in mummies. Lancet, 1990;335:724-5.

6. Scott J. The incidence and distribution of the human schistosomiasis in Egypt. Am J Hyg., 1937;25:566-614.

7. World Health Organization. EMRO report of an inter-country meeting on strategies to eliminate schistosomiasis from the Eastern Mediterranean Region, Muscat, Oman, 6 - 8 November, 2007 (https://zdoc.site/report-inter-country-meeting-on-strategies-to-eliminate-worl.html) (Last accessed May 10, 2017).

8. Rollinson, D. Time to set the agenda for schistosomiasis elimination. Acta Trop., 2013;128:423-40.

9. Cao J, Liu WJ, Xu XY, Zou XP. Endoscopic findings and clinic-pathologic characteristics of colonic schistosomiasis: a report of 46 cases. World J Gastroenterol., 2010;16(6):723-7.

10. Palmer PES, Reeder MM (Editors). The imaging of tropical diseases, 2nded., 1981, vol. 1, p: 155. The Williams & Wilkins Company, Baltimore, USA.

11. Strickland GT. Leading article: tropical infections of the gastrointestinal tract and liver series. Gastrointestinal manifestations of schistosomiasis. Gut, 1994;35:1334-7.

12. Mostafa I. Schistosomal colonic polyposis. Gastrointest. Endosc., 1997;46:584-7.

AUMJ Comprehensive Instructions for Authors and Reviewers

Aljouf University Medical Journal (AUMJ), 2017 June 1; 4(2): 41 – 56.

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AUMJ Comprehensive Instructions

For Authors and Reviewers

INTRODUCTION

Types of submission and criteria

Original Research Communications may be offered as Full Papers, as Short Communications or as Short research Paper. The latter format is recommended for presenting technical evaluations and short clinical notes, comprising up to 1,500 words of text, 15 references, and two illustrative items (Tables and/or Figures).

Clinical Trials and Case Reports will be accepted only where they provide novel insight into disease mechanisms, management, or diagnostic applications.

Reviews and Minireviews will be welcome but prospective authors are strongly advised to seek authorization from the Editor-in-Chief to avoid conflict with scheduled reviews invited by the Editorial Board. They should address new topics or trends in basic biomedical, clinical, and allied health sciences – Dentistry, Pharmacy, Nursing and Applied Medical Sciences.

Policy Papers, Study Protocols and Pre-Protocols and Method Articles.

Medical educational articles, Commentaries (on the clinical, scientific, social, political, and economic factors affecting health), Opinion, Meeting Summary and Book review articles. Please contact the Editor-in-Chief for consideration.

BEFORE YOU BEGIN: THE JOURNAL PLAGIARISM POLICY

AUMJ employs software for plagiarism screening to verify the originality of content submitted before reviewing. We strongly oppose the practice of duplicate publication or any type of plagiarism. Plagiarized manuscripts would not be considered for publication. If plagiarism is found in any published paper after internal investigation, a letter would be immediately sent to all the authors, their affiliated institutes and funding agency, if applicable and subsequently the paper will be retracted.

AUMJ Editorial Board trusts that authors understand why the Journal's integrity must be protected through preventing plagiarism. The manuscript must be free from plagiarism according to our iThenticate® plagiarism detection software - defined as ≤1% similarity or "Text overlap" from any source including your published works (self-plagiarism).

iThenticate® checks for plagiarism from world-wide databases, including internet web sites. Even less than that rate in the results section - case-dependently - may not be accepted. Manuscripts with the minor plagiarism scientific misconduct of ≥2% similarity rate per source with multiple references will not be processed for publication till corrected.

On initial submission, the manuscript will be tested for similarity with iThenticate®. The iThenticate® report of your manuscript is color-coded such that each "source" has a unique color that is used for each instance of copied text (words, sentences, paragraphs) from the source. We limit the iThenticate® software check to Abstract, Introduction, Results, Discussion, Table Titles and contents and Figure contents and legends, and, it excludes Title page (including authors names, communication and affiliations), Methods section, Acknowledgment section, and Literature Cited section - since similarities in these sections is expected to be high. However, how high the accepted similarity rates in those sections is case-dependent and should be as low as possible.

AUMJ encourages authors to use the Similarity Report to write original text for the words, phrases, sentences and/or paragraphs that have similarity of ≥2% with the identified source published works. We understand the importance of keeping specific key words and phrases (molecules, models, drugs, species, equipment, assay technique, etc). In cases with similarity of ≥2%, the author(s) will have One of Two Options; either withdraw the submission, or, resubmit the manuscript after removing the indicated plagiarism so as to have ≤1% similarity rate per source as determined by iThenticate®.

Dedicated to protecting the integrity of research to contribute to a decline of scientific misconduct, AUMJ takes strict measures. When incidents occur involving scientific misconduct, such measures include alerting the agency funding the work as well as the university provost.

Plagiarism policy of this journal is mainly inspired from the plagiarism policy of The Nature (http://www.nature.com/authors/policies/plagiarism.html) and is summarized as described below:



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1. Plagiarism is when an author attempts to pass off someone else's work as his or her own. This journal also adopted IEEE definition of plagiarism to deal such cases. It defines plagiarism as "the reuse of someone else’s prior ideas, processes, results, or words without explicitly acknowledging the original author and source.”

2. Plagiarism can be said to have clearly occurred when large chunks of text have been cut-and-pasted. Such manuscripts would not be considered for publication in the journal. Papers with confirmed plagiarisms are rejected immediately.

3. But minor plagiarism without dishonest intent is relatively frequent, for example, when an author reuses parts of an introduction from an earlier paper.

4. Duplicate publication, sometimes called self-plagiarism, occurs when an author reuses substantial parts of his or her own published work without providing the appropriate references. This can range from getting an identical paper published in multiple journals, to 'salami-slicing', where authors add small amounts of new data to a previous paper. Self-plagiarism, also referred to as ‘text recycling’, is a topical issue and is currently generating much discussion among editors. Opinions are divided as to how much text overlap with an author’s own previous publications is acceptable. We normally follow the guidelines given in COPE website. Editors, reviewers and authors are also requested to strictly follow this excellent guideline (Reference: Text Recycling Guidelines: http://publicationethics.org/text-recycling-guidelines).

5. In case of “suspected minor plagiarism”, authors are contacted for clarification. Depending on all these reports, reviewers and editors decide final fate of the manuscript.

6. Use of automated software is helpful to detect the 'copy-paste' problem. All submitted manuscripts are checked by the help of different databases, eTBLAST, Plagiarism Detection tools, etc. At the same time scientific implication of the case ('suspected minor plagiarism'), also judged by reviewers and editors. Plagiarism Detection tools are useful, but they should to be used in tandem with human judgment and discretion for the final conclusion. Therefore, suspected cases of plagiarisms are judged by editors on 'case-to-case basis'.

7. Editors have the final decision power for these cases.

Ethics in publishing

Policy and ethics

The work described in your article must have been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans (http://www.wma.net); Uniform Requirements for manuscripts submitted to Biomedical journals (http://www.icmje.org) published by the International Committee of Medical Journal Editors. An official local authorized body should review the research project before its beginning and a document acknowledging the ethical clearance of the research could be requested from prospective authors. This must be stated at an appropriate point in the article (Material and Methods). Research papers based on animal studies should get a similar ethical clearance from an official committee for the animal welfare.

Cover letter

A cover letter is required to accompany the manuscript submission along with the Manuscript Submission/Copyright Transfer Form. It should include information about the following points relevant to the specific type of your article:

Why should AUMJ publish your manuscript?

Relevance to AUMJ publication policy. Potential competing interests. Approval of the manuscript by all authors. Adherence to Simultaneous and Duplicate

Publication Policy.

Conflict of interest

All authors are requested to disclose any actual or potential conflict of interest including any financial, supplements, personal or other relationships with other people or organizations within three years of beginning the submitted work that could inappropriately influence, or be perceived to influence, their work.

Submission declaration and verification

Submission of an article implies that the work described has not been published previously (except in the form of an abstract or as part of a published lecture or academic thesis or as an electronic preprint), that it is not under consideration for publication elsewhere, that its publication is approved by all authors and by the responsible authorities where the work was carried out, and that, if accepted, it will

http://www.wma.net/

http://www.icmje.org/



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not be published elsewhere in the same form, in English or in any other language, including electronically without the written consent of the copyright-holder. To verify originality, your article may be checked by an appropriate originality detection service.

Authorship

All authors should have made substantial contributions to all of the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted.

Changes to authorship

This policy concerns the addition, deletion, or rearrangement of author names in the authorship of accepted manuscripts before the accepted manuscript is published in an online and/or printed issue.

Requests to add or remove an author, or to rearrange the author names, must be sent to the Journal Manager from the corresponding author of the accepted manuscript and must include: (a) the reason the name should be added or removed, or the author names rearranged and (b) written confirmation (e-mail, fax, letter) from all authors that they agree with the addition, removal or rearrangement.

In the case of addition or removal of authors, this includes confirmation from the author being added or removed.

Requests that are not sent by the corresponding author will be forwarded by the Journal Manager to the corresponding author, who must follow the procedure as described above.

Journal Deputy Editor will inform the Journal Editor-in-Chief of any such requests and publication of the accepted manuscript in an online issue is suspended until authorship has been agreed.

After the accepted manuscript is published in an online and/or printed issue: Any requests to add, delete, or rearrange author names in an article published in an online issue will follow the same policies as noted above and result in a corrigendum.

Role of the funding source

You are requested to identify who provided financial support for the conduct of the research and/or preparation of the article and to briefly describe the role of the sponsor(s), if any, in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article

for publication. If the funding source(s) had no such involvement then this should be stated.

Open access

Once AUMJ is launched as an open access journal, articles are freely available to both subscribers and the wider public with permitted reuse. No Open Access publication fee. All articles published Open Access will be immediately and permanently free for everyone to read, download, distribute and copy the article, and to include in a collective work (such as an anthology), as long as they credit the author(s) and provided they do not alter or modify the article.

The processing and publication fee

No processing or publication fee is required.

Language (usage and editing services)

Please write your text in good English (American or British usage is accepted, but not a mixture of these). Authors who feel their English language manuscript may require editing to eliminate possible grammatical or spelling errors and to conform to correct scientific English may wish to use any English Language Editing service available. The abstract content will be translated into Arabic to accompany the published manuscript as an Arabic Abstract. In case the author's mother language is not Arabic, the Journal will help preparing it.

Submission

Manuscript submission and follow up to this journal proceeds totally online through email communications ([email protected]). Complete manuscript with tables and figures inserted within the text at their final place should be submitted as a single file in the two; word and PDF formats. The submission and copyright transfer form is available on request and is mandatory to hand fill, sign and date by all authors before any processing of the submitted material. The form is provided at the last page of every issue of AUMJ. Authors are encouraged to print and fill the form and submit alongside with the manuscript.

Referees

A minimum of six suitable potential reviewers (please provide their name, email addresses, title, institutional affiliation, and, ORCID or Scopus ID). When compiling this list of potential reviewers please consider the following important criteria: They must be knowledgeable about the manuscript subject area; must not be from your own institution; at least two of the suggested reviewers should be from another country than the authors'; and



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they should not have recent (less than four years) joint publications with any of the authors. However, the final choice of reviewers is at the editors' discretion. Excluding peer reviewers: During submission you may enter details of anyone who you would prefer not to review your manuscript.

Types of submission and criteria

Original Research Communications may be offered as Full Papers or as Short Communications. The latter format is recommended for presenting technical evaluations and short clinical notes, comprising up to 1,500 words of text, 15 references, and two illustrative items (Tables and/or Figures).

Case Reports will be accepted only where they provide novel insight into disease mechanisms, diagnostic, and management applications.

Critical Reviews will be welcome but prospective authors are strongly advised to seek authorization from the Editor-in-Chief to avoid conflict with scheduled reviews invited by the Editorial Board. They should address new topics or trends in fields of the Journal Scope.

Editorial and opinion pieces Please contact the Editor-in-Chief for consideration.

PREPARATION

NEW SUBMISSIONS

Submit your manuscript as a single PDF file and a single Word document file, in any format or layout that can be used by referees to evaluate your manuscript. It should contain high enough quality figures for refereeing.

References

There are no strict requirements on reference formatting at submission. References can be in any style or format as long as the style is consistent. Where applicable, author(s) name(s), chapter title/article title, journal title/book title, year of publication, volume number-issue number/book chapter and the pagination must be present. Use of DOI is highly encouraged. The reference style used by the journal will be applied to the accepted article at the proof stage. Note that missing data will be highlighted at proof stage for the author to correct.

Formatting requirements

On initial submission, there are no strict formatting requirements but all manuscripts must contain the essential elements needed to convey your manuscript message; Title, Abstract, Keywords, Introduction, Materials/Patients and Methods, Results with

Artwork, Figures and Tables with legends and titles (below the figure and on top of the table, respectively), Discussion, Limitations of the study and Future directions, Gain of Knowledge, Conclusions, Conflict of Interest, Acknowledgement (if any), and References. Upon final acceptance, the author(s) will be instructed to reformat their manuscript according to AUMJ format detailed below.

If your article includes any Videos and/or other Supplementary material, this should be included in your initial submission for peer review purposes.

Divide the article into clearly defined sections with title, subtitles and sub-subtitles on separate lines whenever applicable.

Figures and tables embedded in text. Please ensure the figures and the tables included in the single file are placed next to the relevant text in the manuscript.

All standard and non-standard abbreviations should be define in full at the fist mention in the text and should be consistent throughout the paper.

In the initial submission, it is advisable to have references in names (e.g., Smith et al, 2014) within the text rather than numbering them. Revision and correction frequently necessitate dropping or inserting text with their references. Numbering references in that stage will create the problem of renumbering them is the text and list.

ORIGINAL RESEARCH PAPER WRITING TEMPLATE

Papers include original empirical data that have not been published anywhere earlier or is not under consideration for publication elsewhere (except as an abstract, conference presentation, or as part of a published lecture or academic thesis), and after accepted for publication it will not be submitted for publication anywhere else, in English. Null/negative findings and replication/refutation findings are also welcome. If a submitted study replicates or is very similar to previous work; authors must provide a sound scientific rationale for the submitted work and clearly reference and discuss the existing literature. Submissions that replicate or are derivative of existing work will likely be rejected if authors do not provide adequate justification. Studies, which are carried out to reconfirm/replicate the results of any previously published paper on new samples/subjects (particularly with different environmental and/or ethnic and genetic background) that produces new data-set, may be considered for publication. But these types



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of studies should have a ‘clear declaration’ of this matter. The English language in submitted articles must be clear, correct, and unambiguous. No limits for the total number of words for articles of this type.

Title page information

Page 1 of the typescript should be reserved for the title, authors and their affiliation and addresses.

Title. Concise, informative and reflects the study content. Titles are often used in information-retrieval systems. Avoid abbreviations and formulae where possible.

Running Title: A shorter running title of no more than 55 letters including spaces should be provided.

Author names and affiliations. Where the family name may be ambiguous (e.g., a double name), please indicate this clearly. Present the authors' affiliation addresses (where the actual work was done) below the names. Indicate all affiliations with a superscript Arabic number immediately after the author's name and in front of the appropriate address. Provide the full postal address of each affiliation, including the country name and the e-mail address and phone number (with country and area code) of each author.

Corresponding author. The corresponding author should be indicated in addition with a superscript asterisk * immediately after his/her affiliation superscript Arabic number. The corresponding author will handle correspondence at all stages of refereeing, publication, and post-publication. Contact details must be kept up to date by the corresponding author.

Present/permanent address. If an author has moved since the work described in the article was done, or was visiting at the time, a 'Present address' (or 'Permanent address') may be indicated as a footnote to that author's name. The address at which the author actually did the work must be retained as the main, affiliation address. Superscript lower-case letters are used for such footnotes.

Abstract

Page 2 of the typescript should be reserved for the abstract which should be presented in a structured format and should not exceed 350 words. The following headings should be included for research articles followed by a colon: a) Background, b) Hypothesis/Objectives: c) Materials/Patients and Methods: d) Results: e) Conclusions (should be data justified). Suitable headings could be used for other types of publications (Case reports, Review articles, etc).

A concise and factual abstract is required. The abstract should state briefly the purpose of the research, the principal results and major conclusions. An abstract is often presented separately from the article, so it must be able to stand alone. For this reason, References should be avoided. Non-standard or uncommon abbreviations should be avoided, but if essential they must be defined at their first mention in the abstract itself.

Keywords

Immediately after the abstract, provide a maximum of 10 keywords for full papers, or 5 keywords for Short Communications, using American spelling and avoiding general and plural terms and multiple concepts (avoid, for example, "and", "of"). Please use terms from the most current issue of medical subject headings of Index Medicus. The key words should cover precisely the contents of the submitted paper and should give readers sufficient information as to the relevance of the paper to his/her particular field. Be sparing with abbreviations: only abbreviations firmly established in the field may be eligible. These keywords will be used for indexing purposes.

Introduction

Provide adequate background that highlights the importance and gap information of your research point in relation to previous studies, but avoiding a detailed literature survey. State the hypothesis or rationale and objectives of the work and a brief description of how you planned to approach them.

Materials or Patients and Methods

Provide sufficient detail to allow the work to be reproduced, with details of supplier and catalogue number when appropriate. Methods already published should be indicated by a reference: only relevant modifications should be described.

Patients and Normal Subjects

If human participants were used in the experiment please make a statement to the effect that this study has been approved by your Institution Ethics Review Board for human studies (the number of the approval should be stated in the methods section and AUMJ may ask for submission of the original ethical approval with the manuscript), and, that patients or their custodians have signed an informed consent that also states right of withdrawal without any consequences. Sample sized should be appropriately calculated. The manuscript should describe how the size of the experiment was planned. If a sample size calculation was performed this should be reported in detail, including the expected



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difference between groups, the expected variance, the planned analysis method, the desired statistical power and the sample size thus calculated. For parametric data, variance should be reported as 95% confidence limits or standard deviations rather than as the standard error of the mean. Normal participants and patients criteria, inclusion and exclusion criteria should be stated. Name and address where the work was done and when it was done (time period, from …. to …..) should be clearly stated, too.

Experimental animals

When animals were used in the experiments, a local Institutional Ethics Review Board for animal studies should review and approve the experiment and that all animal procedures were in accordance with the standards set forth in guidelines for the care and use of experimental animals by Committee for Purpose of Supervision of Experiments on Animals (CPCSEA) and according to National Institute of Health (NIH) protocol. The precise species, strain, sub-strain and source of animals used should be stated. Where applicable (for instance in studies with genetically modified animals) the generation should also be given, as well as the details of the wild-type control group (for instance littermate, back cross etc). The manuscript should describe the method by which animals were allocated (randomized) to experimental groups, particularly for comparisons between groups of genetically modified animals (transgenic, knockout etc), the method of allocation to for instance sham operation or focal ischemia should be described.

Experimental

Provide sufficient detail to allow the work to be reproduced. Methods already published should be indicated by a reference: only relevant modifications should be described. Where and when the study was conducted should be stated.

Results

Results should be clear and concise. Data should be presented in an appropriately organized tables, figures and/or artworks. The statistical analysis used should be suitable for the objectives of the study and type of data analyzed. Prospective authors are highly advised to consult a biostatician.

Footnotes

Footnotes should be used sparingly. For table footnotes, indicate each footnote in a table with a superscript lowercase letter or add them into the title.

Graphical abstract

A Graphical abstract is optional and should summarize the contents of the article in a concise, pictorial form designed to capture the attention of a wide readership online. Authors must provide images that clearly represent the work described in the article. Please provide an image with a minimum of 531 × 1328 pixels (h × w) or proportionally more. The image should be readable at a size of 5 × 13 cm using a regular screen resolution of 96 dpi. It is preferable to be inserted at its normal place to the relevant text or otherwise be submitted as a separate TIFF, EPS, PDF or MS Office files.

Discussion

This should explore the significance, interpretation and reasoning of the results of the work vs. other studies. Do not repeat describing the results in this section. A combined Results and Discussion section is acceptable. Avoid extensive citations and discussion of published literature. In the same time, avoid speculations without a supporting literature. Avoid discussion based on "Data not Shown" or "Personal Communications".

Limitations and Future Prospective

The authors may wish to pinpoint the limitations of the study and their reason and foresee the next step to go from their study. This may be presented in a short Limitations and Future Prospective section standing alone or as a separate paragraph in the Discussion or Results/Discussion section.

Conclusions

The main conclusions of the study may be presented in a short Conclusions section standing alone or as a separate paragraph at the end of the Discussion or Results/Discussion section. Conclusions should not be biased and should be based on the data, presented and discussed inside the manuscript only.

Gain of Knowledge

Following the conclusion section, it is mandatory for manuscripts submitted for final publication in AUMJ to have a Gain of Knowledge section that is consisted of 2 - 5 bullet points (maximum 90 characters, including spaces, per bullet point) that convey the core findings of the article.

Acknowledgements and Funding

Collate acknowledgements in a separate section at the end of the article before the references. List individuals or organizations that provided help during the research (e.g., providing language help, writing assistance or proof reading the article, etc.). Whoever would



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be acknowledged should be informed and a verification for that could be requested by AUMJ Editor. If funded, the source of funding should be mentioned.

Appendices

If there is more than one appendix, they should be identified as A, B, etc. Formulae and equations in appendices should be given separate numbering: Eq. (A.1), Eq. (A.2), etc.; in a subsequent appendix, Eq. (B.1) and so on. Similarly for tables and figures: Table A.1; Fig. A.1, etc.

CASE REPORT WRITING TEMPLATE

Title. Include the words “case report” in the title. Describe the phenomenon of greatest interest (e.g., symptom, diagnosis, diagnostic test, intervention, and outcome).

Abstract. Summarize the following information if relevant: 1) Rationale for this case report, 2) Presenting concerns (e.g., chief complaints or symptoms, diagnoses), 3) Interventions (e.g., diagnostic, preventive, prognostic, therapeutic exchange), 4) Outcomes, and 5) Main lesson(s) from this case report.

Key Words. Provide 3 - 8 key words that will help potential readers search for and find this case report.

Introduction. Briefly summarize the background and context of this case report.

Presenting Concerns. Describe the patient characteristics (e.g., relevant demographics - age, gender, ethnicity, occupation) and their presenting concern(s) with relevant details of related past interventions.

Clinical Findings. Describe: 1) the medical, family, and psychosocial history including lifestyle and genetic information; 2) pertinent co-morbidities and relevant interventions (e.g., self-care, other therapies); and 3) the physical examination (PE) focused on the pertinent findings including results from testing.

Timeline. Create a timeline that includes specific dates and times (table, figure, or graphic).

Diagnostic Focus and Assessment. Provide an assessment of the; 1) diagnostic methods (e.g., PE, laboratory testing, imaging, questionnaires, referral), 2) diagnostic challenges (e.g., financial, patient availability, cultural), 3) diagnostic reasoning including other diagnoses considered, and, 4) prognostic characteristics (e.g., staging) where applicable.

Therapeutic Focus and Assessment. Describe: 1) the type(s) of intervention (e.g., preventive, pharmacologic, surgical, lifestyle, self-care) and 2) the administration and intensity of the

intervention (e.g., dosage, strength, duration, frequency.

Follow-up and Outcomes. Describe the clinical course of this case including all follow-up visits as well as 1) intervention modification, interruption, or discontinuation, and the reasons; 2) adherence to the intervention and how this was assessed; and 3) adverse effects or unanticipated events. In addition, describe: 1) patient-reported outcomes, 2) clinician-assessed and ‐reported outcomes, and 3) important positive and negative test results.

Discussion. Please describe: 1) the strengths and limitations of this case report including case management, 2) the literature relevant to this case report (the scientific and clinical context), 3) the rationale for your conclusions (e.g., potential causal links and generalizability), and 4) the main findings of this case report: What are the take-away messages?

Patient Perspective. The patient should share his or her experience pr perspective of the care in a narrative that accompanies the case report whenever appropriate.

Informed Consent. Did the patient or their custodian give the author of this case report informed consent? Provide if requested .

Case Report Submission Requirements: 1) Competing interests, are there any competing interests?, 2) Ethics Approval, Did an ethics committee or institutional review board review give approval? If yes, please provide if requested, 3) De‐Identification, Has all patient's related data been de-indentified?

RANDOMIZED CLINICAL TRIALS WRITING TEMPLATE

In this particular type of original study, individuals are randomly allocated to receive or not receive a preventive, therapeutic, or diagnostic intervention and then followed up to determine the effect of the intervention. All randomized clinical trials should include a flow diagram and authors should provide a completed randomized trial checklist (see CONSORT Flow Diagram and Checklist; http://www.consort-statement.org) and a trial protocol.

Authors of randomized controlled trials are encouraged to submit trial protocols along with their manuscripts.

All clinical trials must be registered (before recruitment of the first participant) at an appropriate online public that must be independent of for-profit interest, e.g.:

http://www.clinicaltrials.gov; http://www.anzctr.org.au;

http://www.clinicaltrials.gov/

http://www.anzctr.org.au/



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http://www.umin.ac.jp/ctr; http://isrctn.org; http://www.trialregister.nl/trialreg/index.as

p).

Each manuscript should clearly state an objective or hypothesis; the design and methods (including the study setting and dates, patients or participants with inclusion and exclusion criteria, or data sources, and how these were selected for the study); the essential features of any interventions; the main outcome measures; the main results of the study; a comment section placing the results in context with the published literature and addressing study limitations; and the conclusions.

Data included in research reports must be original. A structured abstract not exceeding 300 words is required. Clinical trials are limited to 2700 words (not including abstract, tables, figures, and references), 40 references, and no more than 5 tables and figures.

REVIEW, MINIREVIEW AND META-ANALYSIS PAPERS

These papers will not have empirical data acquired by the authors but will include historical perspectives, analysis and discussion of papers published and data acquired in a specific area.

Systematic reviews and meta-analyses are a particular type of original articles that perform systematic, critical assessment of literature and data sources pertaining to clinical topics, emphasizing factors such as cause, diagnosis, prognosis, therapy, or prevention. All articles or data sources should be searched for and selected systematically for inclusion and critically evaluated, and the search and selection process should be described in detail in the manuscript. The specific type of study or analysis, population, intervention, exposure, and tests or outcomes should be described for each article or data source. A structured abstract of less than 300 words is required. The text is limited to 3500 words (not including abstract, tables, figures, and references); about 4 tables (a flow diagram that depicts search and selection processes as well as evidence tables should be included) - and no reference limit.

Minireview is a brief historical perspective, or summaries of developments in fast-moving areas covered within the scope of the journal. They must be based on published articles; they are not outlets for unpublished data. They may address any subject within the scope of the journal. The goal of the minireview is to provide a concise very up-to-date summary of

a particular field in a manner understandable to all readers.

SHORT COMMUNICATION AND SHORT RESEARCH ARTICLE

Short Communications are urgent communications of important preliminary results that are very original, of high interest and likely to have a significant impact on the subject area of the journal. A Short Communication needs only to demonstrate a ‘proof of principle’. Authors are encouraged to submit an Original Research Paper to the journal following their Short Communication. There is no strict page limit for a Short Communication; however, a length of 2500-3500 words, plus 2-3 figures and/or tables, and 15-20 key references is advisable. Short Research Article may be smaller single-result findings as a brief summary that include enough information, particularly in the methods and results sections, that a reader could understand what was done.

POLICY PAPER

The purpose of the policy paper is to provide a comprehensive and persuasive argument justifying the policy recommendations presented in the paper, and therefore to act as a decision-making tool and a call to action for the target audience.

COMMENTARIES/OPINION ARTICLES

An opinion-based article on a topical issue of broad interest, which is intended to engender discussion.

STUDY PROTOCOLS AND PRE-PROTOCOLS

AUMJ welcomes publishing protocols for any study design, including observational studies and systematic reviews. All protocols for randomized clinical trials must be registered and follow the CONSORT guidelines; ethical approval for the study must have been already granted. Study pre-protocols (i.e., discussing provisional study designs) may also be submitted and will be clearly labeled as such when published. Study protocols for pilot and feasibility studies may also be considered.

METHOD ARTICLES

These articles describe a new experimental or computational method, test or procedure, and should have been well tested. This includes new study methods, substantive modifications to existing methods or innovative applications of existing methods to new models or scientific questions. We also welcome new technical tools that facilitate the design or performance of experiments or operations and

http://www.umin.ac.jp/ctr

http://isrctn.org/

http://www.trialregister.nl/trialreg/index.asp

http://www.trialregister.nl/trialreg/index.asp



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data analysis such as software and laboratory and surgical devices, or of new technologies to assist medical diagnosis and treatment such as drug delivery devices.

Maximum length of submissions

Full length original research articles should not exceed 10000 words (maximum 60 references), and up to 6 tables and/or figures.

Short communications comprising up to 1800 words of text, maximum 15 references, and two illustrative items (Tables and/or Figures).

Letters and Case Reports (provide novel insight into disease mechanisms, diagnostic and management applications). Clinical Laboratory Notes (technical evaluation or important insight into analytical methodology), or Letters to the Editor (focused on a specific article that has appeared in Aljouf Medical Journal within 4 weeks of print issue date of article). For all 3 types of letters listed above, the text should not exceed 600 words, with no abstract, a maximum of 1 table or figure and up to 5 references.

Review Articles, Surveys, Essays, and Special Reports may exceed the word and reference limit for Full-length articles as per the comprehensive nature of these articles. However, both of these articles (Reviews and Special Reports) will still require an abstract (unstructured, 350 word maximum).

Editorials, Meeting summary, Commentaries, Book review and Opinion pieces will not require an abstract and will be limited to 2000 words and up to 20 references. A book review is a brief critical and unbiased evaluation of a current book determined to be of interest to the journal audience. Publication of a submitted book review is at the discretion of the editor.

Artwork

General points

Make sure you use uniform lettering and sizing of your original artwork. Preferred fonts: Arial (or Helvetica), Times New Roman (or Times), Symbol, Courier. Number the illustrations according to their sequence in the text. Use a logical naming convention for your artwork files. Indicate per figure if it is a single, 1.5 or 2-column fitting image. For Word submissions only, you may still provide figures and their captions, and tables within a single file at the revision stage.

Formats

Regardless of the application used, when your electronic artwork is finalized, please 'save as' or convert the images to one of the following formats (note the resolution requirements for line drawings, halftones, and line/halftone

combinations given below). Please do not supply files that are optimized for screen use (e.g., GIF, BMP, PICT, WPG); the resolution is too low, supply files that are too low in resolution, and, submit graphics that are disproportionately large for the content.

EPS (or PDF): Vector drawings. Embed the font or save the text as 'graphics'.

TIFF (or JPG): Color or grayscale photographs (halftones): always use a minimum of 300 dpi.

TIFF (or JPG): Bitmapped line drawings: use a minimum of 1000 dpi.

TIFF (or JPG): Combinations bitmapped line/half-tone (color or grayscale): a minimum of 500 dpi is required.

Color artwork

Please make sure that artwork files are in an acceptable format (TIFF (or JPEG), EPS (or PDF), or MS Office files) and with the correct resolution. If, together with your accepted article, you submit usable color figures the Journal will ensure that these figures will appear in color on the Web regardless of whether or not these illustrations are reproduced in color in the printed version. Because of technical complications which can arise by converting color figures to 'gray scale' please submit in addition usable black and white versions of all the color illustrations.

Figure captions

Ensure that each illustration has a caption (Legend). A caption should comprise a brief title below the figure that describes its content and not to be general. Keep text in the illustrations themselves to a minimum but explain all symbols and abbreviations used in the legend. Figure caption should stand for itself (self-explanatory) without the need for consulting the text.

Tables

Number tables consecutively in accordance with their appearance in the text. Place footnotes to tables below the table body and indicate them with superscript lowercase letters within the table. If necessary, such footnotes could be placed at the end of the table title. Avoid vertical rules. Be sparing in the use of tables and ensure that the data presented in tables do not duplicate results described elsewhere in the article (Figures or text). The table caption (Title) should be brief but describes its content and not to be general. Explain all symbols and abbreviations used in the table in the footnote. Table title should stand for itself (self-explanatory) without the need for consulting the text. The table structure should be scientifically organized



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(columns and rows) and its message should be easily comprehendible.

The Editor-in-Chief, on accepting a manuscript, may recommend that additional tables and/or graphs containing important backup data, too extensive to be published in the article, may be published as supplementary material. In that event, an appropriate statement will be added to the text. However, the author should submit such material for consideration with the manuscript.

References

References cited should be relevant, up-to-date and adequately cover the field without ignoring any supportive or conflicting publications. Please ensure that every reference cited in the text is also present in the reference list (and vice versa). If present, unpublished results and personal communications may be mentioned in the text and not in the reference list. Citation of a reference as 'in press' implies that the item has been accepted for publication, and shows up on PubMed literature search or a copy of the title page of the relevant article must be submitted. DOI of the references - whenever applicable should be presented. Authors are encouraged to cite primary literature rather than review articles in order to give credit to those who have done the original work.

Reference management software

This journal has standard templates available in key reference management packages EndNote (http://www.endnote.com/support/enstyles.asp) and Reference Manager (http://refman.com/support/rmstyles.asp). Using plug-ins to word processing packages, authors only need to select the appropriate journal template when preparing their article and the list of references and citations to these will be formatted according to the journal style, which is described below.

Reference formatting

There are no strict requirements on reference formatting at submission but should be consistent, complete and up-to-date. Where applicable, author(s) name(s), chapter title/article title, journal title/book title, year of publication, volume number-issue number/book chapter and the pagination must be present. For the book reference, the edition number, editors (if they are not the authors), publisher and its main address (City and Country) should be added as described below in the example. The reference style used by the journal should be applied to the accepted article at the proof stage. Note that missing

data will be highlighted at proof stage for the author to correct. Use peer-reviewed references only except for national and international organizational reporting and registers. If you do wish to format the references yourself they should be arranged according to the following examples:

Reference style

Indicate references by number(s) in curved brackets as a bolded superscript at the end of the cited text(s) before the full stop, e.g., ………. shorter hospital stay and lower cost(20). The actual authors can be referred to, but the reference number(s) must always be given. Number the references in the list in the order in which they appear in the text. The authors list should not be shortened, all authors’ names should be mentioned up to 10 authors and end longer list by et al. For further details you are referred to 'Uniform Requirements for Manuscripts submitted to Biomedical Journals' (J Am Med Assoc 1997; 277: 927-34) (see also http://www.nlm.nih.gov/bsd/uniform_requirements.html).

Examples:

Reference to a journal publication: Format your journal publications according to the following examples depending on whether; 1) It is already published with specific page numbers, 2 and 3) It is already published with article ID number and pages from 1 to …, or 4) It is published put ahead of print.

1. Van der Geer J, Hanraads JAJ, Lupton RA. The art of writing a scientific article. J. Sci. Commun., 2010;163(1):51-9.

2. Leta S, Dao TH, Mesele F, Alemayehu G. Visceral Leishmaniasis in Ethiopia: An Evolving Disease. PLoS Negl Trop Dis., 2014; 8(9):e3131;1-7.

3. Arjmand MH, Ahmad Shah F, Saleh Moghadam M, Tara F, Jalili A, Mosavi Bazaz M, Hamidi Alamdari D. Prooxidant-antioxidant balance in umbilical cord blood of infants with meconium stained of amniotic fluid. Biochem Res Int., 2013;2013:ID270545;1-4.

4. Teferra RA, Grant BJ, Mindel JW, Siddiqi TA, Iftikhar IH, Ajaz F, Aliling JP, Khan MS, Hoffmann SP, Magalang UJ. Cost minimization using an artificial neural network sleep apnea prediction tool for sleep studies. Ann Am Thorac Soc., 2018 Jul 28 (ahead of print).

Reference to a book: Strunk Jr W, White EB (Editors). The elements of style, 4th Edition, Longman, New York; 2000, pp. 210-9.

http://www.nlm.nih.gov/bsd/uniform_requirements.html

http://www.nlm.nih.gov/bsd/uniform_requirements.html



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Reference to a chapter in an edited book: Mettam GR, Adams LB. How to prepare an electronic version of your article. In: Jones BS, Smith RZ (Editors), Introduction to the electronic age, 1st Edition, E-Publishing Inc., New York, 2009, Chapter 2: pp. 281-304.

Reference to a homepage: It is acceptable to refer to an Organizational Guidelines, Reports, Forms, Data sheets, Questionnaires, etc. It should follow the following format. World Health Organization. Non-communicable Diseases (NCD) Country Profile, 2014 (http://www.who.int/globalcoordinationmechanism/publications/ncds-country-profiles-eng.pdf; last accessed March, 1, 2017).

Journal abbreviations source

Journal names should be abbreviated according to the List of Title Word Abbreviations: http://www.issn.org/services/online-services/access-to-the-ltwa/.

Abbreviations and units

Standard abbreviations as listed in the Council of Biology Editors Style Manual may be used without definition. Use non-standard abbreviations sparingly, preceding their first use in the text with the corresponding full designation. Use units in conformity with the standard International System (SI) of units.

Video data

The journal accepts video material and animation sequences to support and enhance your scientific research. Authors who have video or animation files that they wish to submit with their article are strongly encouraged to include links to these within the body of the article. This can be done in the same way as a figure or table by referring to the video or animation content and noting in the body text where it should be placed. All submitted files should be properly labeled so that they directly relate to the video file's content. In order to ensure that your video or animation material is directly usable, please provide the files in one of our recommended file formats with a preferred maximum size of 50 MB. Video and animation files supplied will be published online in the electronic version of your article. Since video and animation cannot be embedded in the print version of the journal, please provide text for both the electronic and the print version for the portions of the article that refer to this content.

Audio Slides

AUMJ encourages authors to create an Audio Slides presentation with their published article as supplementary material. This gives authors

the opportunity to summarize their research in their own words and to help readers understand what the paper is about. Authors of this journal will automatically receive an invitation e-mail to create an Audio Slides presentation after acceptance of their paper.

Supplementary data

AUMJ accepts electronic supplementary material to support and enhance your scientific research. Supplementary files offer the author additional possibilities to publish supporting applications, high-resolution images, background datasets, sound clips and more. Supplementary files supplied will be published online alongside the electronic version of your article. In order to ensure that your submitted material is directly usable, please provide the data in one of our recommended file formats. Authors should submit the material in electronic format together with the article and supply a concise and descriptive caption for each file.

Supplementary material captions

Each supplementary material file should have a short caption which will be placed at the bottom of the article, where it can assist the reader and also be used by search engines.

THE COPYRIGHTS

The copyrights of all papers published in this journal are retained by the respective authors as per the 'Creative Commons Attribution License' (http://creativecommons.org/licenses/by/3.0/). The author(s) should be the sole author(s) of the article and should have full authority to enter into agreement and in granting rights to the journal, which are not in breach of any other obligation. The author(s) should ensure the integrity of the paper and related works. Authors should mandatorily ensure that submission of manuscript to AUMJ would result into no breach of contract or of confidence or of commitment given to secrecy.

Submission checklist

The following list will be useful during the final checking of an article prior to sending it to the journal for review. Please consult this Guide for Authors for further details of any item.

To avoid unnecessary errors you are strongly advised to use the 'spell-check' and 'grammar-check' functions of your word processor.

Ensure that the following items are present:

One author has been designated as the corresponding author with contact details for all authors:



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E-mail address. Full postal address. Telephone.

All necessary files have been uploaded, and contain:

Keywords. All figures and their captions. All tables (including title, description,

footnotes).

Further considerations:

Manuscript has been 'spell-checked' and 'grammar-checked'.

All references mentioned in the Reference list are cited in the text, and vice versa.

Permission has been obtained for use of copyrighted material from other sources (including the Web).

Color figures are clearly marked as being intended for color reproduction on and in print, or to be reproduced in color electronically and in black-and-white in print.

PEER REVIEW PROCESS

High quality manuscripts are peer-reviewed by minimum of two peers of the same field along with a biostatician in the case the study requires. Pre-reviewing advice and help will be provided by the Editor-In-Chief on first submission for initial improvements to meeting the minimum criteria of peer-reviewing. The journal follows strict double blind fold constructive review policy to ensure neutral evaluation. During this review process identity of both the authors and reviewers are kept hidden to ensure unbiased evaluation. A cycle of one-month reviewing process is the target of the journal from submission to final acceptance. For meeting this goal, the Editor-In-Chief is expecting strict compliance from author hastening corrections and replying editorial requests. Continuous post-publication open peer reviewing is highly encouraged through submitting comments to the Editor on any of the published article that will show up with author reply in the subsequent issue to the journal.

The reviewers’ comments are sent to authors once received. With the help of the reviewers’ comments, FINAL decision (accepted or accepted with minor revision or accepted with major revision or rejected) will be sent to the corresponding author. Reviewers are asked if they would like to review a revised version of the manuscript. The editorial office may request a re-review regardless of a reviewer's response in order to ensure a thorough and fair evaluation.

In order to maintain this journal’s mission of one-month publication cycle, authors are encouraged to submit the revised manuscript within one week of receipt of reviewer’s comment (in case of minor corrections). However, revised manuscript submission should not go beyond 2 weeks (only for the cases of major revision which involves additional experiment, analysis etc.). Along with corrected manuscript authors will be requested to submit filled a point-by-point answers to the reviewers' comments and any rebuttal to any point raised. The Editor-In-Chief of the journal will have exclusive power to take final decision for acceptance or rejection during any dispute.

Under special circumstance, if the review process takes more time, author(s) will be informed accordingly. The editorial board or referees may re-review manuscripts that are accepted pending revision. Manuscripts with latest and significant findings will be handled with the highest priority so that it could be published within a very short time. The journal is determined to promote integrity in research publication. In case of any suspected misconduct, the journal management reserves the right to re-review any manuscript at any stages before final publication.

Our massage to AUMJ potential reviewers says “Although the Manuscript General Evaluation Form is attached, we like to instigate a policy of constructive reviewing and to do our best to make the submitted manuscripts publishable - provided that it is genuine and contain no major frauds of republication, duplicate use of self data or plagiarism of intellectual properties of the others. Please, make your changes and insert your corrections, comments and suggestions directly into the manuscript text but in a different color. Please also make sure that the author(s) presented an inclusive and updated list of genuine references, applied proper statistics and extracted justified conclusions”.

PATIENT CONSENT FORM

Date: ………………...

Place: ……………….

Title of the article

Name of the Author(s)

Patient’s name:

I give my consent for this material to be published in Aljouf University Medical Journal and associated publications without limit on the duration of publication.

I understand that the material will be published in Aljouf University Medical Journal will be



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included in any reprints of the published article. I understand that my name will not be included in the published article, and that every effort will be made to keep my identity anonymous in the text and in any images. However, I understand that complete anonymity and control of all uses cannot be guaranteed.

Signed: ………………

Full name of the relative: ……..........

Relation: ……………….

Patient’s Name and Contact Address

Corresponding Author’s Name and Contact Address

Alternative:

I have been offered the opportunity to preview the material in the format it will eventually appear and I am satisfied with it.

Signed: …..…………..

Full Name of the Patient: ……..……….

Manuscript General Revision Form

The Manuscript Assigned Number and Title: ……..

Although the following manuscript general evaluation form is sent to reviewers, AUMJ asks the reviewer for further meticulous one-word-at-a-time revision, please. Please insert corrections, changes, suggestions, questions, comments and points of deficiency directly into the manuscript text but in a different color. Also, please do not worry much for the formatting.

The Manuscript Evaluation Score: Please, score the manuscript from 0 to 4 (highest) for each of the following items, and sum the total score. Please, also check if the statistics of the results require revision.

Items Scores 0 1 2 3 4 Item Score

The Study is a Priority Problem

Originality

Significance of the Work

Research Design

Quality and Clarity of the English Writing

Standard and Reproducible Methodology

Results Presentation and Appropriate Statistics

Relevant Discussion and Justified Conclusions

Tables/ Illustrations/ Figures

References: Inclusive and Updated

Total score

Requires Statistical Revision (Mark Please)

Yes No

Justification for Decision & Feedback for the Author (REQUIRED): AUMJ recommends the reviewer to introduce such justifications and feedback into the text at the appropriate places within the manuscript (Specific and Comprehensive Revision).

Note to the Editor (WELCOMED): AUMJ welcomes reviewer writing a note to the Editor including conflict of interest that will not be disclosed to the Author(s).

The Decision: Should AUMJ publish the manuscript? Please, check the appropriate box.

Yes, without any revision:

Accepted

Yes, with minor revision and alterations:

Accepted with revision

Yes, with major revision and alterations:

Re-Evaluation after substantial

revision

No, this manuscript should be denied publication:

Denied

AFTER ACCEPTANCE

Online proof correction

Corresponding authors will receive an e-mail with annotation for correction of MS format proofs and resend the corrected version. All instructions for proofing will be given in the e-mail we send to authors. We will do everything possible to get your article published quickly and accurately - please upload all of your corrections within 48 hours. It is important to ensure that all corrections are sent back to us in one communication. Please



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check carefully before replying, as inclusion of any subsequent corrections cannot be guaranteed. Proofreading is solely your responsibility.

Offprints

The corresponding author, at no cost, will be provided with a PDF file of the article via email (the PDF file is a watermarked version of the published article and includes a cover sheet with the journal cover image and a disclaimer outlining the terms and conditions of use). For an extra charge, paper offprints can be ordered at any time via the offprint order form, which is sent once the article is accepted for publication.

AUTHOR INQUIRIES

For inquiries relating to the submission and follow up of review and proof correction of an article, please email us.

ABSTRACTING and INDIXENG

It is in processing since membership in such Data Bases and organizations requires precedential publication of a few issues of the journal.

Aljouf University Medical Journal (AUMJ)

Manuscript Submission and Copyright Transfer Form Newly submitted manuscript should be accompanied with this form. The form must be fully and accurately completed and signed by all authors before final acceptance. Scan the form and send it as an email attachment to [email protected].

By signing this form, I/We accept and/or certify of the following information:

1. I/We reviewed and approved the version submitted as a valid work. 2. I/We acknowledged all related direct and indirect source of grant, financial and material

supports and got appropriate written permission for data used in the manuscript. 3. I/We certify that the manuscript had not been previously published or is currently under

consideration for publication elsewhere. 4. I/We attest that, upon Editor's request, I/We will provide the data/information on which the

manuscript is bases for examination by the Editor or his assignees. 5. I/We have participated sufficiently in the work to take public responsibility for all or part of

the content. My intellectual contribution was in the form of (please, put author number beside the suitable activity):

a. Concept and design. b. Acquisition of data. c. Analysis of data. d. Drafting the article. e. Critically revising the article.

6. I/We agree that the authors mentioned are my/our coauthors in the sequence presented and that the named corresponding author shall be the sole correspondent with the Editorial Office in all matters related to this submission including review and correction of the final proof after which no substantial changes will be allowed.

7. To the best of my knowledge, I/We have specified the nature of all potential conflicts of interest. For authors that have nothing to declare, they should state it explicitly.

8. I/We hereby transfer all copyright ownership (preprinting, reprinting, republishing and translating in whole or in part in any format) to the Journal, in event that such work is published by the Journal, and I/We authorize the corresponding author to make the changes as per request of the Journal as the guarantor for the manuscript and to execute the Journal Publishing Agreement on our behalf.

9. If I am named as the corresponding author, I additionally certify that: a. All individuals who meet the criteria for authorship are included as authors. b. The version submitted is the version that all authors have approved. c. Written permission has been received by all individuals named in Acknowledgment

section.

Manuscript Assigned Number & Title: …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….………………………………………

Author(s) List (in order; Please encircle the Corresponding Author):

# Name: Signature: # Name: Signature:

1 6

2 7

3 8

4 9

5 10

Date: Attached another blank paper for signature if necessary.


Aljouf University Medical Journal (AUMJ)

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