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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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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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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Non-communicable diseases (NCDs) are beginning to dominate the global health landscape. Despite numerous calls to action for chronic disease preventive and control, the response to the urgency is insufficient, especially in terms of their prevention efforts. Worldwide, the total number of people dying from NCDs is twice that of the combined total of all infectious diseases (including HIV/AIDS, tuberculosis and malaria), maternal and perinatal conditions and nutritional deficiencies. Cardiovascular disease is the leading cause of death in the world and accounts for about 30% of all deaths. Increased interventions in global NCDs prevention and control programs are needed as a global strategy to improve the current scenario. Specifically, we present this case for the United States to provide leadership in global NCD prevention and control.

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This article describes the importance of selecting the appropriate epidemiological study design for a given study question. It provides an explanation to the different terms used in describing study designs with regards to observational versus interventional and descriptive versus analytical types of study designs. This article focuses on the description of the different types of descriptive study designs, that is, case report, case series, correlational, and cross-sectional study designs. The requirements for selecting these study designs are discussed along with the advantages and disadvantages of each study design. The descriptive studies are similar in the context that they are based on a single sample with no comparative group within the study design. Their basic purpose is to describe the characteristics of the sample with regards to the characteristics that are present and so are useful in generating a hypothesis. The absence of a comparative group is the main limitation of the descriptive studies, and this is the reason they cannot be used to determine an association by testing a hypothesis showing a relationship between a risk factor and disease. The analytical study designs will be discussed in the next article in this series.

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Gestational diabetes mellitus (GDM) is defined as glucose intolerance of variable severity with onset of first recognition during pregnancy. GDM occurs in at least 30% of women with a family history of T2DM/GDM, suggesting that some women are genetically predisposed to develop GDM. Phosphatase and tensin homolog (PTEN) on chromosome 10 is a tumor-suppressor gene. Studies have demonstrated that PTEN dysfunction affects the function of insulin. However, the relationship between GDM and PTEN has not been studied. The aim of the present study was to investigate the relationship between PTEN and GDM in Asian Indian women. The case-control study used PCR-RFLP analysis to assess the PTEN−9C/G polymorphism in 150 GDM cases and 150 controls (non-GDM). No alleles or genotypes were detected at statistically significant frequencies. All subjects were normal, and no variants were detected in any of the pregnant women. In conclusion, PTEN has no role in GDM, consistent with previous studies.

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Emerging infections including those resulting from the bioterrorist use of infectious agents have indicated the need for global health surveillance. This paper reviews multiple surveillance opportunities presented by mass gatherings (MGs) that align with fundamental questions in epidemiology (why, what, who, where, when and how). Some MGs bring together large, diverse population groups coming from countries with high prevalence of communicable diseases and disparate surveillance capacities. MGs have the potential to exacerbate the transmission dynamics of infectious diseases due to various factors including the high population density and rigor of events, increase in number of people with underlying diseases that predisposes them to disease acquisition, mixing of people from countries or regions with and without efficient disease control efforts, and varying endemicity or existence of communicable diseases in home countries. MGs also have the potential to increase the opportunities for mechanical and even heat-related injuries, morbidity or deaths from accidents, alcohol use, deliberate terrorist attacks with biological agents and/or with explosives and from exacerbation of pre-existing conditions. Responding to these wider range of events may require the use of novel bio-surveillance systems designed to collect data from different sources including electronic and non-electronic medical records from emergency departments and hospitalisations, laboratories, medical examiners, emergency call centres, veterinary, food processors, drinking water systems and even other non-traditional sources such as over-the-counter drug sales and crowd photographs. Well-structured, interoperable real-time surveillance and reporting systems should be integral to MG planning. The increase in magnitude of participants exceeding millions and diversity of people attending MGs can be proactively used to conduct active surveillance of communicable and non-communicable diseases or indicators of global and national public health interest during MGs than can collectively complement efforts to enhance global health security.

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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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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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Objectives: To assess the prevalence of tobacco smoking among health colleges' students at Najran University, and to investigate the students' attitude, practice and knowledge towards smoking and its risks. Settings and Design: A cross-sectional descriptive study was conducted at Najran University during the month of March 2014. Subjects and Methods: A pre-tested validated questionnaire based on the Global Adult Tobacco Survey was answered by 433 students (226 males and 207 females). Results: The prevalence of current cigarettes smokers was 30.1% for males and 0.5% for females (P < 0.001). For males, the prevalence of shisha smoking, snuff and smokeless tobacco usage was 28.3%, 16.8% and 14.6%, respectively. Applied medical sciences college's students had the highest prevalence (72%) of smoking, compared to 4% only at the college of medicine. Females had a better knowledge than males regarding the hazardous effects of smoking on health (87.1% vs. 99.5%; P = 0.007) and as a risk factor of brain thrombosis (67.2% vs. 94.2%; P = 0.001), heart attack (78.3% vs. 95.7%; P = 0.005) and lung cancer (82.3% vs. 99.5%; P = 0.001). Male and female students believed smokeless tobacco and shisha smoking are less harmful (59.7% vs. 30%; P = 0.001 and 38.5% vs. 7.7%; P = 0.001, respectively). Conclusions: Our results highlight the importance of initiating on-campus managed tobacco dependence treatment clinics to provide professional help for students to quit smoking. The results of this study can be used as a basis for the development of tobacco education programmes at Najran University and elsewhere.

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Background and Objectives: Standard isolation precautions (SIPs) are clinical practice policies and guidelines for controlling healthcare associated infections (HCAIs). Healthcare students are frequently exposed to HAIs and their abidance of SIPs is paramount. This study is designated to evaluate healthcare students' knowledge and compliance with SIPs. It also identifies the most frequent sources of their information. Methodology: A cross-sectional survey was conducted from 5^th January to 16^th February 2016 at Prince Sattam Bin Abdulaziz University in Al-Kharj Governorate, Saudi Arabia. A novel self-constructed questionnaire was taken from a literature review and reused. Results: About 353 students, of which 73.4% being males with a mean age of 22.3; 1.53 (mean; standard deviation), were surveyed. Seventy percent had previously attended an infection control course. The overall means of knowledge and compliance with SIPs were included within highest ranges. This means that the study sample agreed with all correct answers of knowledge questions and always complied with all recommended statements of compliance. The most frequent source of information was self-learning while the current curriculum was the least frequent. Females were found to have higher mean scores in knowledge and compliance, with statistically significant differences (P < 0.05). According to the results of one-way analysis of variance, there were statistically significant differences in mean scores of knowledge and compliance between different specialities and academic levels. Conclusion: Despite the relatively weak role played by the current curriculum, this sample showed above average overall means of knowledge and compliance with SIPs.

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Background: Herbal medicine use has become a popular treatment among patients with chronic diseases worldwide. Many patients with chronic illnesses use herbal medicine without consulting their healthcare professionals. Therefore, the primary aim of this study was to determine the frequency and correlates of herbal medicine use in Saudi patients with chronic diseases. The secondary aim was to explore how frequent patients with chronic illnesses consult their healthcare professionals for concomitant use of conventional treatment and herbal medicine. Materials and Method: A cross-sectional study conducted from December 2014 to January 2015 at King Abdullah General Hospital in Bisha. Adults aged > 18 years with chronic illnesses were enrolled in the study. The survey data form included demographic data and types of herbal medicines. Multivariate logistic regression was used to explore the effect of different factors promoting the use of herbal medicine. Results: Of the 235 patients who completed the data form, the prevalence of herbal medicine users was (67.65%), with Trigonella foenum-graecum (32.7%), Pimpinella anisum (19.49%), Nigella sativa (17.61%), Green tea (13.83%) and Peganum (5.66%) as the most frequently used. Nearly 88.67% of herb users did not consult their healthcare professionals. Almost 90.56% of healthcare professionals did not respond to herbs users' questions about herbal medicine. Patients with increased age and living in the urban area are likely to use herbal medicine with odds ratio (OR): 4.12, 95% confidence interval (CI): 1.94–8.74 and OR: 109.20, 95% CI: 31.88–374.02, respectively. Conclusion: This study revealed a high prevalence of herbal medicine use among patients with chronic diseases. More awareness and education about risks and complications of herbal medicine use are needed for both patients and healthcare professionals.

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The professions of nursing and midwifery currently face many challenges, such as an increasing number of patients with communicable and non-communicable diseases, which strains resources and requires nurses and midwives to develop their knowledge and skills to a higher level. This is also true in the Middle East, including the Mediterranean East and North African regions, which means it is vitally important that nurses and midwives have access to and use current research to inform their practice, with research targeting the most relevant issues, including complex humanitarian emergency situations that increase health issues and challenge health infrastructure. For this to be achieved, a scoping review of the indexed clinical nursing and midwifery literature in the Middle East was performed to identify gaps in clinical nursing and midwifery research and areas requiring focus. A search of PubMed, CINAHL/EBSCO, EMBASE, the Jordanian Database for Nursing Research resulted in 210/1398 articles which met the inclusion criteria: (1) original research, (2) conducted in Middle Eastern countries as defined by the World Health Organization, (3) had at least one nurse or midwife author (but not limited to nurses in Middle Eastern countries), (4) published in an indexed, peer-reviewed journal between January 1, 2000, and December 31, 2015, (5) included patient outcomes in the results, (6) written in English or Arabic and (7) included an abstract. Studies were found from 10 of the 22 countries; the majority (n = 199; 94.76%) was conducted in three countries: Jordan, Iran and Lebanon. Most studies (n = 158, 75.24%) used quantitative designs, primarily cross-sectional, descriptive studies (n = 106) and the most frequently researched topics were related to maternal child health and women's health (n = 95, 48.5%). Strategies are needed to encourage collaboration between nursing and midwifery faculty members including clinicians to assure that clinical research is disseminated and used to improve patient care.

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Filariasis is a common health problem in India. Lymphatic filariasis is mostly caused by Wuchereria bancrofti and Brugia malayi. Microfilariae are often found in cytology smears from swelling at various sites and it is rarely associated with neoplasms. However, filarial breast nodule is a very rare finding even in an endemic region. Here, we present a rare case of filarial breast lump diagnosed by fine needle aspiration cytology.

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Background: Saudi Commission for Health Specialties (SCFHS) has adopted CanMEDS competency framework for developing curriculum for postgraduate training programmes. Purpose: The purpose of this paper is to share the process of developing postgraduate curricula under SCFHS's patronage and to identify potential barriers to implement newly developed curricula and suggest strategies to overcome the barriers. Methods: The process of consensus building started with one-one interview with key stakeholders, review of literature, and comparison of various curricular models. A prototype curriculum was developed with inputs from international advisors. The proposal for the curriculum development and outcomes was reviewed amongst SCHS education committee members and approved. Two medical education experts have been involved in coordinating the process of curriculum development. Results: Over the last two years, SCFHS has been working with several residency and fellowship programmes to develop formal curricula. The goal is to complete formal curriculum for all residency and fellowship programmes using CanMEDS competency frameworks.

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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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Objectives: This study investigates the relationship between the presence of non-functioning distractors (NFDs) and the difficulty index of multiple choice questions (MCQs). Materials and Methods: The number of NFDs and difficulty index were correlated for each MCQ of Family Medicine Examination, College of Medicine, King Saud University (KSU) in three consecutive years (2010, 2011 and 2012). Results: The MCQs with more NFDs showed high difficulty index as compared to MCQs having less NFDs. The pattern of increasing difficulty index was 1NFD < 2NFD < 3NFD. However, the MCQs with a lesser number of NFDs would not necessarily be always difficult. Conclusion: MCQs with a higher number of NFDs are easier than those with lower number of NFDs.

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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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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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Background: The advantages of involving students in scientific research have been well-documented. Many educational organisations and universities have placed emphasis on integrating scientific research into the undergraduate curriculum. Aims: The objective of this paper is to elaborate on the importance of integrating scientific research into the undergraduate curriculum and to propose a model on how to integrate it into the current curriculums. Methods: In this proposed model, students would be exposed to research in each academic year from the 1^st year up to the 5^th year. In the 1^st year, students would attend lectures introducing them to scientific research. In the 2^nd year, students would be distributed among the faculty members and would be exposed to a more detailed research science by having lectures that explain research problems, and the objectives of the study. In the 3^rd year, students would have detailed lectures about study designs and how to write one. In the 4^th year, students would have lectures about biostatistics, in addition to, lectures that explain how to write the 'Results' section of their study in a manuscript format; then they would be trained to conduct the study and collect pertaining data. In the 5^th year, students would have lectures on the components of the 'Discussion' and 'Conclusion' sections as well as how to write them appropriately in a manuscript format. Finally, they would be taught on how to finalize editing of their research manuscript in preparation for publication. In the internship programme, they would be obligated to conduct another study independently, in order to evaluate their understanding. Conclusion: The undergraduate research is a cumulative learning experience which requires the support of the institute and faculty. Establishing a dental student research journal would encourage students to conduct and publish their research.

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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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