Friction in orthodontics has been blamed for many orthodontic-related problems in the literature. Much research as well as research and development by numerous companies have attempted to minimize friction in orthodontics. The aim of the present study was to critically review friction in orthodontics and present frictionless mechanics as well as differentiate between segmented arch mechanics (frictionless technique) as compared to sectional arch mechanics. Comparison of the two techniques will be presented and cases treated by either technique are presented and critically reviewed regarding treatment outcome and anchorage preservation/loss.

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Palliative care is a relatively new medical speciality in Saudi Arabia, but it has shown tremendous growth in the last two decades. Nevertheless, there are challenges to this development. The paper reviews these barriers in context of the growing need for palliative care and possible ways to overcome these challenges.

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Achieving and maintaining a stable nursing workforce is an important issue for the well-being of the rapidly growing population of Saudi Arabia. However, high turnover of expatriate staff and low recruitment of Saudi nationals have led to a serious staff shortage in the professions, particularly of well-qualified and experienced nurses. Nursing leaders need to work to improve the image of nurses and facilitate the recruitment of women into the nursing profession. Reduced working hours and part-time contracts with increased salaries and benefits could attract more young women to the profession, as might the provision of facilities such as private transportation and on-site childcare. Furthermore, establishing a national association for nurses would advance the nursing profession and help to ensure that all nurses undertake fully comprehensive training before entering the workforce.

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This paper addresses some of the challenges met when developing widely distributed, broad spectrum, simulation-based education (SBE) for health professionals, such as resource duplication, inconsistent facilities utilization, discipline-specific silos, and the intersection of academic institutions and health services sectors. We examine three primary contributors to successful simulation-based practices - strategic planning, program development, and professional networks. Further, we provide examples of how each of these contributors function at different levels to assure comprehensive, yet sustainable approaches to implementing SBE for greatest impact at national, state, regional, and institutional levels. We draw on the example of Australia and its state and regional government structures, including the challenges in providing health services across a widely variable geography and population distribution. The types of health services and issues relating to health provision and management reflect those found in many western countries. Our hope is that the experiences gained at each level of governance within Australia may inform similar, successful development in other countries. We emphasize the importance of leadership and investment at the national level that serves to inform state, regional, and institutional efforts through a "trickle down" effect. Although evaluation of the strategic planning, program development, and professional networks described in this case study is still ongoing, their preliminary coordination has resulted in significant investment and support at all levels.

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The engineering of insulin analogues illustrates the application of structure-based protein design to clinical medicine. Such design has traditionally been based on structures of wild-type insulin hexamers in an effort to optimize the pharmacokinetic (PK) and pharmacodynamic properties of the hormone. Rapid-acting insulin analogues (in chronological order of their clinical introduction, Humalog ^® [Eli Lilly & Co.], Novolog ^® [Novo-Nordisk], and Apidra ^® [Sanofi-Aventis]) exploit the targeted destabilization of subunit interfaces to facilitate capillary absorption. Conversely, long-acting insulin analogues exploit the stability of the insulin hexamer and its higher-order self-assembly within the subcutaneous depot to enhance basal glycemic control. Current products either operate through isoelectric precipitation (insulin glargine, the active component of Lantus ^® ; Sanofi-Aventis) or employ an albumin-binding acyl tether (insulin detemir, the active component of Levemir ^® ; Novo-Nordisk). Such molecular engineering has often encountered a trade-off between PK goals and product stability. Given the global dimensions of the diabetes pandemic and complexity of an associated cold chain of insulin distribution, we envisage that concurrent engineering of ultra-stable protein analogue formulations would benefit the developing world, especially for patients exposed to high temperatures with inconsistent access to refrigeration. We review the principal mechanisms of insulin degradation above room temperature and novel molecular approaches toward the design of ultra-stable rapid-acting and basal formulations.

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Introduction: The purpose of this article is to provide a general understanding of the concepts of sampling as applied to health-related research. Sample Size Estimation: It is important to select a representative sample in quantitative research in order to be able to generalize the results to the target population. The sample should be of the required sample size and must be selected using an appropriate probability sampling technique. There are many hidden biases which can adversely affect the outcome of the study. Important factors to consider for estimating the sample size include the size of the study population, confidence level, expected proportion of the outcome variable (for categorical variables)/standard deviation of the outcome variable (for numerical variables), and the required precision (margin of accuracy) from the study. The more the precision required, the greater is the required sample size. Sampling Techniques: The probability sampling techniques applied for health related research include simple random sampling, systematic random sampling, stratified random sampling, cluster sampling, and multistage sampling. These are more recommended than the nonprobability sampling techniques, because the results of the study can be generalized to the target population.

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Aim: To explore the development of nursing research and provide some examples of research relevant to clinical practice. Background: Nursing research developed in the last century as did nursing theories and models. However, nursing research does not have the same high profile as, for example, medical research and has tended to lag behind medical, and other forms of research, in terms of funding and in the apparent impact it has on clinical practice. Design: Discussion paper. Methods: Using a popular nursing model based on activities of daily living, nursing research that is relevant to these activities of daily living is explored and exemplified using a few key examples. Some of these examples are historical and some are current. Conclusion: Nursing research has developed greatly over the past century and continues to develop in the 21 ^st century. Nursing research is relevant to the needs of patients and has had an impact on clinical practice.

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Introduction: Palliative care is a multidisciplinary approach that aims to improve the quality of life of patients with life-threatening illnesses. It has been recognized as a crucial part of patient care in oncology. Palliative care service was established in the comprehensive cancer center of King Fahad Medical City (KFMC), Riyadh, Saudi Arabia in March 2010. The objective of this study was to determine the interval between the first palliative care consult (PCC1) and death, and explore the possible cause of suggestive short timeframe between PCC1 and death. Patients and Methods: This study included 210 cancer patients who had their PCC1 in KFMC within the period of March 2012 and March 2014. Demographic information, cancer diagnosis, date of cancer diagnosis, reason for referral, all symptoms reported in Palliative Care Unit, and date of death were gathered from the patients' charts. The interval between the PCC1 and death were computed and analyzed. Results: Of the 210 patients, 121 (57.6%) were female, 127 (60.5%) were <60 years old, and 190 (90.5%) had non-haematological tumours. The main reasons for referral were symptom control (62.4%), symptom control and end of life (EOL) care (12.4%), symptom control and transfer of care (11.4%), and EOL care (8.6%). The median interval between PCC1 and death, diagnosis to PCC1, and diagnosis to death intervals were 19, 212, and 360 days, respectively. Patients diagnosed with haematological tumours were referred relatively earlier to palliative care. The difference in the mean (haematology > non-haematology) for the interval between PCC1 and death was 146.2 days (P < 0.001). Conclusions: Late referrals to palliative care services KFMC is the strongest predictor of the short interval between PCC1 to death of advanced stage cancer patients. Identifying the potential cause of the late referrals can lead to developing optimal policies for the timely referral of cancer patients to palliative care upon diagnosis regardless of the stage of their disease. Education and advocacy are needed among the referring oncologists in the cancer center for earlier access to palliative care. Future studies are needed to establish the appropriate timing of the PCC1.

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Introduction: Continuing medical education (CME) is important in developing competencies of medical practitioners with all the different influencing factors that have impact on their opinions and preferences. Despite the broad range of work on CME, very few studies have examined participants' opinions and attitudes towards CME. However, understanding them is critical in improving the practice of CME. Purpose: The purpose of this study was to explore attendees' perception of CME in Saudi Arabia regarding the different aspects of its practices and preferences. Materials and Methods: A survey composed of demographic questions, frequency of reading habits and 24 other related items was developed for CME participants. Participants were asked to indicate the extent to which they agreed or disagreed with each of the 24 items on a 5-point Likert scale. In total, 601 surveys were analysed. Results: The response to each item in the questionnaire was compared on the basis of demographic variables. The results showed that healthcare practitioners acknowledged the importance of CME in improving their knowledge, attitudes, clinical and academic skills, as well as improve their clinical practice outcome. Differences of opinion were categorised by gender, profession, nationality and age. Conclusion: The study showed that opinions related to CME varied among different disciplines and nationalities. Moreover, it raised questions related to the system of sponsoring participants to attend CME events and its consideration for ethical issues. There is a need to embed the concept of lifelong learning into the education of basic health professions. In addition, the policies related to sponsoring and accrediting CME in Saudi Arabia should be improved. We recommend further research into this matter.

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Context: There is accumulating evidence that the metabolism of several trace elements like Cr, Cu, Pb, Cd, Co, Mn and Zn might have specific roles in the pathogenesis and progress of many diseases like hypertension (HTN) and diabetes mellitus (DM). Objectives: To provide a fast, efficient, sensitive, and reliable analytical procedure for trace element determination in urine samples of HTN and DM patients using inductively coupled plasma optical emission spectrometry (ICP-OES). Setting and Design: The ICP-OES operating conditions were optimised and carefully selected in order to maximise the sensitivity, precision and accuracy. Factors affecting analytical and biological variability of the concentrations under study were discussed and carefully optimised. Materials and Methods: Different digestion procedures with acids and oxidising reagents were tested. The suitable procedure ICP-OES was selected, carefully modified and applied. The validity and accuracy of the different elements were determined by spiking of samples with known amounts of multi-element standard solution. Statistical Analysis: Student t-test and analysis of variance (ANOVA) test were used for analysis. Microsoft Excel was used to assess the significance of the difference between variables. The concentrations obtained were expressed as mean value ± standard deviation (P = 0.05). Results: The results of this study showed that the mean concentrations of Cd, Zn, Pb, Cu, Cr and Mn in urine from both HTN (study group A) and DM (study group B) patients were higher than the corresponding values observed in the control group. However, while the mean value of Co was low as compared to the control group, the differences found were not significant (P = 0.05). Conclusion: The method used had excellent sensitivity, multi-element data could be obtained with very short acquisition time. The elements Cr, Cd, Pb and Zn might have specific roles in the pathogenesis and progress of HTN and DM. Further studies are required to investigate the possible roles of these elements in HTN and DM individuals.

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Context: Nationally, there is no clear scope of practice for nurses working in Saudi Arabia identifying their role legitimacy as the Nursing Board in the Saudi Commission of Health Specialties has not yet formalized a scope of nursing practice. Role legitimacy can be identified either by a supervisory body or by an agreement that may exist among individual groups. Aims: This study aimed to identify nurses' role legitimacy in Saudi Arabia from the view of nurses, doctors, and patients. Settings and Design: A large survey was undertaken in 2008 in 10 hospitals located in the Eastern Province of Saudi Arabia related to three major healthcare sectors (government, military, private). Materials and Methods: A quota sample of nurses (n = 614, RR = 61.4%), doctors (n = 130, RR = 26.0%) and patients (n = 322, RR = 64.4%) was undertaken, utilizing a self-administered questionnaire that drew upon the King's Nurse Performance Scale. Statistical Analysis Used: A descriptive analysis was undertaken, using the Chi-square test to compare the views of the participants. Results: The domains of physical care, professional aspects and care management formed a major focus of the nurses' role, with no evidence of role legitimacy regarding the psychosocial and communication aspects of patient care. Conclusions: There was a traditional view of the nurses' role within acute care delivery which will need to be addressed if nurses are to contribute significantly to promoting the health of people in Saudi Arabia.

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Objective: The objective of this paper was to show the challenges that are faced by the Family Medicine Training Programmes in the Kingdom of Saudi Arabia as well as suggests appropriate and practical solutions. Materials and Methods: This study was conducted from 2010 - 2013 using a semi-structured questionnaire to achieve the objective. The questionnaire was designed and completed by the investigators during their visits to accredit the training centres all over the Kingdom. It consisted of questions concerning the trainers' and trainees' opinions regarding all the aspects of training. Another tool used was the accreditation checklist, which contained a comprehensive list of training structures and processes mandatory for any training centre. The accreditation checklist and questionnaire were reviewed by the investigators after visiting all the training centres. The challenges were then classified manually and solutions were reviewed as well as approved by the members of the Accreditation Committee. Results: Seventy-five training centres were visited and 250 trainees along with 75 trainers participated in this study. Twenty-five challenges were identified and classified under 6 major groups. The practical solutions to these challenges were discussed with participants and then approved by the investigators. Conclusion: This study showed that Family Medicine Training in the Kingdom of Saudi Arabia faces many different challenges. Early identification along with key solutions to these difficulties are extremely important in the efforts to produce a new generation of competent Saudi Family Physicians who can improve the quality of healthcare for the population of Saudi Arabia.

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Intracranial lipomas are rare congenital, non-neoplastic lesions discovered incidentally on computerised tomography (CT) or magnetic resonance imaging (MRI) with an incidence rate of less than 0.1% of all intracranial tumours. Most lipomas are asymptomatic pericallosal lesions sometimes presenting with seizures or headache. Corpus callosum agenesis and defects of midline structures differentiation may be present. Callosal lipomas are of two types: Anterior bulky tubulonodular variety associated with forebrain and rostral callosal anomalies, and posterior ribbon-like curvilinear lipoma generally seen with a normal or near normal corpus callosum. Corpus callosal hypogenesis/agenesis is seen in up to 90% of anterior and 30% of posterior pericallosal lipomas. The association of corpus callosal lipoma with choroid plexus lipoma is variable with its reported incidence rate being 20-50%. A 50-year-old patient was referred to our department for CT scan of brain with history of recent onset of headache and one episode of seizure. We present the imaging findings in this rare case of callosal tubulonodular lipoma having prominent intralesional vessels and extensive calcification with a concomitant intraventricular lipoma in a patient with dysgenetic corpus callosum.

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Nurses constitute the greatest number of healthcare workers in the United States and globally. Increasingly, the role they play in meeting societal demands for safe, evidence-informed, quality care is being recognized. However, how they are educated around the world varies greatly. The purpose of the paper is provide a brief review of the evolution of nursing education in the United States and globally, describe the current and projected state of nursing education, and discuss some pressing challenges educators face as they strive to meet the charge to prepare nurses to care for more complex patients situated in ever-changing health-care systems.

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Objectives: Gastroenteritis is a leading cause of childhood morbidity and mortality in developing countries. Our aim was to determine the prevalence of bacterial, viral and parasitic aetiology of gastroenteritis in children aged < 5 years in the Najran region, south-western Saudi Arabia, to determine the contribution of these enteropathogens in childhood diarrhoeal diseases and to put forward effective preventive measures for controlling the disease in the future. Design and Setting: A descriptive study conducted at Najran Maternity and Children's Hospital and the Microbiology Department of the Najran University College of Applied Medical Sciences from October 2011 to June 2012. Patients and Methods: Stool samples were collected from 326 children aged ≤ 5 years with diarrhoea and examined for bacterial, viral and parasitic enteropathogens. Results: Seventy-two (22.1%) samples were positive for viral pathogens, including 56 (17.2%), 12 (3.7%) and 4 (1.2%) samples for rotavirus, adenovirus and astrovirus, respectively. Thirty-five (10.7%) samples were positive for bacterial pathogens, including 28 (8.6%) and 7 (2.1%) samples for Salmonella and Shigella spp. isolates, respectively. Pathogenic parasites were detected in only 4 (1.2%) samples, including 3 (0.9%) Giardia lamblia and 1 (0.3%) Entamoeba histolytica isolates. Conclusions: Rotavirus is the most common pathogen in paediatric acute gastroenteritis in the Najran region. This fact, in combination with the severity of the infections, warrants consideration of a rotavirus vaccine in the childhood immunization program in Saudi Arabia. On the basis of clinical and laboratory parameters, it appears possible to distinguish between the different causative agents of acute gastroenteritis.

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Aims: The Saudi Commission for Health Specialties' question banks for licensing international medical graduates and certifying Saudi trained residents are currently being upgraded. The process is briefly explained with the justification for the developments made to all the banks over the last 3 years. A process of quality assurance has been introduced to ensure the banks are maintained at the highest standards and procedures that are fit for purpose introduced for the management of test results. Results: An analysis of 16 undergraduate exams shows a sigmoid relationship between mean test scores (MTS) and numbers of functioning distractors. Sixteen computer-based Saudi Licencing Exam (SLE) banks were also analyzed to determine the mean MTS for all, 52.3 ± 7.88, which justifies the use of four option items and also validates the quality of the exams with a majority of items falling within the desired range of medium difficulty to obtain the highest reliability. Conclusion: The Saudi Commission believes that it is achieving increased quality in all aspects of test measurement and would hope that over the next 3 - 5 years achieve levels of excellence for all aspects of it licensing and certifying assessments.

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In the past few decades, surgery has advanced greatly because of an improved understanding of perioperative pathophysiology, development of minimally invasive operative techniques and advanced anaesthetic techniques. Fewer operations are requiring extended periods of hospital stay and a growing number of procedures are performed on an ambulatory basis. The pressure on medical systems is continuously growing as a result of economic constraints, increasing numbers of patients undergoing surgical procedures and greater patient autonomy. Patient awareness is steadily increasing along with their participation in their own care, leading to expectations of a higher standard of care. This has led to the development of a new concept of fast-track surgery.

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Pruritus or itch is an uncommon symptom observed in palliative care, even more uncommon in cancer patients. However, if a patient experiences pruritus, the 'itch-scratch' cycle can damage the skin integrity and can increase the susceptibility of patients to infection owing to their frail immune system. The outcome can be very distressing, dramatically impacting the quality-of-life of the patient. Moreover, since severe pruritus seen in patients with advanced disease can be associated with failure of different organ systems, pruritus must be assessed based on the underlying organ systems and the pathophysiology involved. Regardless of the cause of pruritus, general skin care is important. Depending on the origin of pruritus, specific approach and medications must be considered. Caution must be taken during management of pruritus since most cancer patients take pain medications that interact with some antipruritic medications. In addition to the complex and unclear nature of cutaneous and central pathogenesis of pruritus, treatment of pruritus is challenging.

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Adenocarcinoma (AC) of the oesophagus is an important disease in western communities in terms of its unprecedented recent increase in incidence and its relatively poor outcomes despite today's variety of treatment options. The increasing incidence of this deadly disease is probably related to the changing lifestyle patterns within affluent societies, in terms of diet and sedentary practices, obesity and the prevalence of gastro-oesophageal reflux disease. Barrett's oesophagus has been identified as a major risk factor and surveillance strategies for at-risk groups are being proposed, together with endoscopic management strategies for those with high-grade dysplasia or early and localised AC. It is recognised that the disease is better treated in high-volume centres under the guidance of a multidisciplinary team. Increasing availability and accuracy of sophisticated staging tools such as endoscopic ultrasound, endoscopic mucosal resection and positron-emission tomography (PET) have helped define treatment strategies. Endoscopic tools can identify patients who might be suitable for some form of local ablative therapy and PET scanning will often pick up metastatic disease missed with other imaging investigations. Refinement of the pathological staging system has also helped define treatment modalities. Although surgery may still be seen as the mainstay of treatment, its use is now more in context with adjuvant therapies. With the unwavering epidemic of obesity, it is likely that AC of the oesophagus is going to remain an important disease confronting healthcare and this paper deals with some of the current issues.

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Research about the selection of students into health care practitioner programs, principally medical programs, and into specialty training has become a worldwide phenomenon. Set against a rapid expansion of healthcare professional students, there have been calls to make national policy considerations and provide guidance for an evidence-based selection process. This article considers the implications of the international research base underpinning current selection processes, and makes recommendations for policy makers, health educators, and institutional leaders to consider. We recommend that selection procedures into health professional education and specialty training becomes part of an international conversation that takes account of the complexities of local context, the evidence base into what works and what does not, and the efficient and effective use of resources.

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Background: Given significant regional differences globally in healthcare systems, policies, and culture, we examined rates of pharmaceutical utilization among four developed nations using antidepressant drugs as a case example. Materials and Methods: We conducted a population-based cross-sectional time series analysis of antidepressant utilization in Canada, the United States, Greece, and Ireland from January 2007 to September 2011 using data from IMS Healthcare Inc., which tracks over 80% of global prescription sales of over 1.3 million products. We studied 23 antidepressants from five drug classes, namely, 1) serotonin-specific reuptake inhibitors (SSRIs), 2) serotonin-norepinephrine reuptake inhibitors (SNRIs), 3) tricyclic antidepressants (TCAs), 4) monoamine oxidase inhibitors (MAOIs), and 5) 'other' antidepressants. We used time series analysis to examine trends in utilization patterns. Results: Overall antidepressant utilization increased steadily over time for all study regions, although regions differed considerably in the magnitude of antidepressant utilization and the rates of increase. While overall antidepressant utilization rates were similar between Canada (2,876 units per 1,000 population per month) and the United States (2,815 units per 1,000 population per month), these rates were approximately 83% higher than in Greece (1,558 units per 1,000 population per month) and approximately 50% higher than in Ireland (1,898 units per 1,000 population per month). Although the use of SSRIs, SNRIs, and other antidepressants generally increased over time, the use of TCAs and MAOIs generally decreased over time. Utilization of specific drug classes varied widely between regions, ranging from an 80% relative difference in SSRI utilization between the United States and Greece to a nearly 700% difference in the utilization of MAOIs between Canada and the United States. Conclusions: The findings of our study, using antidepressants as the case example, are consistent with previous studies demonstrating significant variation in drug utilization levels internationally. Future studies are needed to document regional variation in light of appropriateness of drug therapies to determine optimal utilization levels for maximal societal benefit.

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Congenital epiglottic cysts are a rare cause of respiratory tract obstruction in neonates and infants with an incidence of 1.82 per 100,000 live births. The majority arise from the vallecula, aryepiglottic fold, and from the saccule of the ventricle and rarely from the epiglottis. This uncommon entity requires prompt diagnosis and treatment. Traditionally, such cysts are treated surgically via endoscopic excision or marsupialization. Recurrence occurs if excision incomplete and multiple procedures may be necessary. Some authors favour an open surgical approach for more extensive cysts. The patient presented here underwent endoscopic excision and was discharged 3 days later

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