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Purpose: Despite the surge of melatonin supplement consumption in recent years, data on the prevalence and patterns of melatonin usage in Saudi Arabia is lacking. The aim of this study was to assess the prevalence and pattern of sleep-related melatonin usage among adults in Saudi Arabia. Methods: This was a cross-sectional, web-based, self-administered survey study conducted across all regions of Saudi Arabia. Participants were recruited from the general population (≥18 years). The survey was distributed between February and April 2023. Chi-squared tests and t-tests were performed for comparative bivariate analyses where binary logistic regression was performed to derive the main predictors of melatonin consumption. Results: Out of 5,606 participants, 536 (10 %) were consumers of melatonin. Older age (Adjusted OR = 1.01, 95 % CI = 1.01-1.02, p = 0.002), being a male (Adjusted OR = 1.76, 95 % CI = 1.46-2.14, p = 0.001), individuals with a doctorate degree or an equivalent (adjusted OR 2.37 95 % CI = 1.35-4.17, p = 0.003), perceived poor sleep quality (Adjusted OR = 1.52, 95 % CI = 1.10-2.11, p = 0.01), and being diagnosed with a sleep disorder (Adjusted OR = 2.55, 95 % CI = 2.04-3.18, p = 0.001) were all associated with increased likelihood of sleep-related melatonin usage. 35 % of consumers self-reported taking ≥1 tablet per day, while 26 % of them were uncertain about the dosage they consume. Conclusion: With a notable prevalence of 10% among the general population in Saudi Arabia, melatonin usage was more common in older adults, males, and those with higher education.

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Background: There are few direct comparisons of service utilization and patient-reported outcomes in patients attending medical consultations in person or virtually. This was a prospective, cross-sectional study of adults engaging with a healthcare practitioner via virtual or in-person consultations. Methods: Participants were recruited in person by convenience sampling between November 2023 and January 2024 across Saudi Arabia, and data were gathered on (i) basic demographic and consultation information and (ii) convenience, quality of interaction, and satisfaction with their consultations. Results: Of 3196 individuals who completed the survey, 28.7% had attended their most recent healthcare interaction virtually and 71.3% had attended in person. Participants attending virtual consultations were more likely to live rurally (69.0% vs. 21.9% for in-person consultations; p < 0.001). Virtual appointments were more common for primary care and diabetes/endocrinology but not surgical specialties (p < 0.001), and private apps and hospitals more frequently provided virtual appointments. Conclusions: Overall, patients found virtual consultations to be significantly more convenient, prompt, private, and well communicated than in-person appointments, translating into extremely high satisfaction (97.4% overall vs. 84.0% for in-person consultations; p < 0.001). This study provides population-level data on the current prevalence of telehealth use in Saudi Arabia. Further prospective research demonstrating the clinical noninferiority of telemedicine could help promote further uptake in specialties such as surgery.

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This Thoracic Society of Australia and New Zealand Guideline on the provision of home oxygen therapy in adults updates a previous Guideline from 2015. The Guideline is based upon a systematic review and meta-analysis of literature to September 2022 and the strength of recommendations is based on GRADE methodology. Long-term oxygen therapy (LTOT) is recommended for its mortality benefit for patients with COPD and other chronic respiratory diseases who have consistent evidence of significant hypoxaemia at rest (PaO2 ≤ 55 mm Hg or PaO2 ≤59 mm Hg in the presence of hypoxaemic sequalae) while in a stable state. Evidence does not support the use of LTOT for patients with COPD who have moderate hypoxaemia or isolated nocturnal hypoxaemia. In the absence of hypoxaemia, there is no evidence that oxygen provides greater palliation of breathlessness than air. Evidence does not support the use of supplemental oxygen therapy during pulmonary rehabilitation in those with COPD and exertional desaturation but normal resting arterial blood gases. Both positive and negative effects of LTOT have been described, including on quality of life. Education about how and when to use oxygen therapy in order to maximize its benefits, including the use of different delivery devices, expectations and limitations of therapy and information about hazards and risks associated with its use are key when embarking upon this treatment.

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There have been no nationwide studies of patient opinions regarding telehealth in Saudi Arabia to identify the factors that might influence patients' perceptions and satisfaction. This was a prospective cross-sectional study of adults in the general population who last engaged with a healthcare practitioner via a virtual appointment. The participants were recruited by convenience sampling across Saudi Arabia between November 2023 and January 2024, completing a questionnaire that gathered data on (i) basic demographic and virtual consultation information and (ii) telehealth service delivery and technology based on the Telehealth Usability Questionnaire. Of the 916 participants, 53.7% were female, with a mean age of 47.2 (14.1) years. Nearly half attended primary care appointments, with the remainder attending a range of hospital specialties. Over 90% preferred having a virtual appointment over an in-person visit. About half had telephone consultations, while about a third had video calls through hospital-provided platforms; >90% found virtual appointments useful and convenient, easy to use, effective, reliable, and produced a favorable clinical interaction; and 97.4% were satisfied with their remote consultation experience despite the technical interruptions. The individuals who were less happy with their virtual consultation were significantly younger, lived in urban areas, attended specialty clinics, were seen by a psychologist, preferred in-person appointments, and had consultations by telephone. These data provide momentum to continue with and expand telehealth, especially through video calls, supported by educational initiatives.

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Pancreatic cancer, a highly fatal malignancy, has shown a global rise in the incidence and mortality rates. However, these rates vary significantly across different regions worldwide. This study aims to assess the incidence and mortality of pancreatic cancer in Saudi Arabia. We collected the data from 16 annual cancer incidence reports in Saudi Arabia for the study period (2005-2020) and from the WHO's IARC Global Cancer Observatory website. Although the burden of pancreatic cancer in Saudi Arabia is relatively lower compared to global rates, the disease incidence has shown a steady increase over the study period, in addition to regional variations within the country. The disease predominantly affects the elderly population, aged 50 years and above in both genders, with males exhibiting higher rates than females. Further studies are required to identify the potential risk factors for pancreatic cancer in the Saudi population.

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Purpose: The European Community Respiratory Health Survey (ECRHS) questionnaire has been widely used in epidemiological studies to quantify respiratory symptoms and screen for asthma, but there is no formally validated Arabic version. This study developed an Arabic ECRHS screening questionnaire, comprehensively evaluated its reliability and validity, and used it to estimate the population prevalence of respiratory symptoms and asthma in Saudi Arabia. Methods: The ECRHS screening questionnaire was adapted to Arabic through translation and back-translation by bilinguals with consultation to a professional committee and lay panel. Reliability and validity were evaluated in a prospective, cross-sectional convenience sample of adults (>18 years) between January and July 2022 in Riyadh, Saudi Arabia. A subgroup completed the questionnaire again three weeks later to assess test-retest reliability. All respiratory symptom-positive participants were invited for spirometry to diagnose asthma according to GINA criteria. Internal consistency was assessed using Cronbach's α coefficient, test-retest reliability with Cohen κ coefficients, and reliability by calculating the sensitivity and specificity for diagnosing asthma. Results: Of 2500 invited individuals, 1881 participated (75.2%). A total of 668 (35.5%) participants reported respiratory symptoms according to the ECRHS questionnaire, and 157/1881 (8.3%) had a current diagnosis of asthma on ECRHS questions. Cronbach's α coefficient for internal consistency was 0.831, "good" internal consistency. The test-retest reliability (n = 303) was "excellent" for all questions (Cohen's κ≥0.75). A total of 543 (81.3%) screening-positive participants underwent spirometry, of whom 278 (52%) were diagnosed with asthma according to GINA guidelines, an overall estimated prevalence of 14.8%. Most questions showed good-to-fair specificity and variable sensitivity for physician-diagnosed asthma. Conclusion: This Arabic version of the ECRHS screening questionnaire is conceptually similar to the English version, comprehensible, and reliable. Many asthma cases remain hidden and undiagnosed. In addition to utility in epidemiological studies, the ECRHS screening questionnaire might be a simple, quick, and useful tool for asthma case finding.

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Hereditary angioedema (HAE) is a potentially life-threatening autosomal dominant disorder affecting roughly 1:50,000 individuals. It is commonly characterized by swelling of the larynx, gastrointestinal tract, extremities, and skin. There is growing genetic heterogeneity associated with this disease but more than 95% of mutations are found in SERPING1, the gene which encodes complement 1 inhibitor (C1-INH). HAE cohorts from several populations have been published but no large scale study has been reported from the Arab world to date. Here we document the clinical and genetic findings of HAE patients from a single Saudi institution, which is a major referral center at the national level. A total of 51 patients across 17 unrelated families were recruited including two large multi-generational families, of which one contained an in-frame exonic deletion that was resolved through MLPA. Two cases were negative for all the genes we tested (including F12, PLG, ANGPT1, MYOF, KNG1, and HS3ST6). The predominant HAE subtype in our cohort was type I, at 76%. We were able to uncover a mutation in 49 patients (96%). No type III (normal C1-INH) patients were encountered in the clinic, suggesting that this subtype does not play a major role in HAE pathogenesis in Saudi Arabia. Additionally, the existence of four patients with consistently normal complement 4 (C4) levels alongside abnormal C1-INH profiles highlights the utility of dual screening for both proteins in suspected patients.

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Background: Multiple drug allergy and multiple drug intolerance syndrome (MDAS/MDIS) labels are an impediment to clinical care and knowledge regarding these conditions is limited. This systematic review investigated the characterization, epidemiology, risk factors, clinical impact and pharmaco-economics of MDAS and MDIS. Methods: Systematic literature search across 11 databases (01 January 2000-06 November 2020) for MDIS, MDAS and related terminology. Studies were reviewed for quality of evidence and risk of bias by employing Critical Appraisal Skills Programme cohort study checklist. A narrative synthesis approach facilitated by systematic textual descriptions, tabulation and thematic analysis was adopted. Results: There was heterogeneity in terminology and methodology. Few studies applied standard drug allergy diagnostic methods. There is some evidence to suggest that multiple drug hypersensitivity syndrome (MDHS; i.e., confirmed allergies in MDAS) is a distinct clinical entity. Prevalence of MDIS and MDAS labels in unselected & selected populations varied between 2.1%-6.4% & 4.9%-90% and 1.2% & 0%-36% respectively. Reported risk factors included female gender, increasing age, body mass index, anxiety, depression, co-morbidities, concurrent allergies and increased healthcare utilization. Drugs commonly implicated were antibiotics and non-steroidal anti-inflammatory drugs. No studies relating to clinical impact and pharmaco-economics were found. Conclusion: There is considerable burden of MDAS and MDIS labels. Data needs cautious interpretation as majority of studies described involved unverified labels. Despite this limitation and heterogeneity of studies, there is some evidence to suggest that MDHS is a distinct clinical entity. Well-designed multi-centre studies applying standardized terminology and diagnostic methodology are needed to gain further insight into these conditions.

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Objectives: There have only been a few studies on electronic device use and sleep in adult populations, so we sought to investigate the impact of bedtime technology use on sleep quality and excessive daytime sleepiness (EDS) through a population-wide survey of Saudi Arabian adults. Material and Methods: This cross-sectional survey of 10,106 Saudi Arabian adults gathered data on the number and frequency of electronic device use (smartphones, tablets, computers, televisions, radios, and music players) at bedtime, sleep quality, and EDS as measured by the Epworth sleepiness scale. Associations between electronic device number and frequency of use and sleep-related outcomes were evaluated using binary logistic regression. Results: Twenty-eight percent and 9.7% of respondents reported "fairly" or "very bad" sleep quality in the preceding month, respectively. 95.1% of respondents had smartphones in their bedrooms, which were used regularly (a few nights a week, every or almost every night) by 80.7% of respondents. The number of devices in the bedroom had little effect on sleep quality parameters and EDS, but regular use of almost all devices was associated with "bad" or "very bad" sleep quality (odds ratios (ORs) 1.32-2.12); smartphone or tablet use was associated with sleep latency >30 minutes (smartphones OR 1.98, 95% CI: 1.51-2.60; p<0.0001; tablets OR 1.44, 95% CI: 1.05-1.99; p<0.05). Electronic device use was associated with a 1.3-1.9-fold risk of moderate to severe EDS. Discussion: This large study strengthens the limited evidence in adults that electronic device use during bedtime usually reserved for sleep impacts sleep quality. Sleep hygiene advice must be updated to include limiting electronic device use in the bedroom.

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BACKGROUND: Although there have been indirect comparisons of the relative efficacy of mepolizumab (anti-IL-5) and benralizumab (anti-IL-5Rα) in severe asthma patients, long-term direct head-to-head comparisons are lacking. Here, we (i) examined the effect of mepolizumab, benralizumab, and omalizumab on symptom control and lung function parameters over time; and (ii) compared the efficacy of mepolizumab and benralizumab on symptom control and lung function outcomes. METHODS: This was a retrospective study of patients with severe asthma taking anti-IgE (omalizumab; n = 24), anti-IL5 (mepolizumab, n = 23), or anti-IL-Rα (benralizumab; n = 12) therapy. Data were extracted on (i) Asthma Control Questionnaire (ACQ-5) scores; (ii) forced expiratory volume over 1 second (FEV1); and (iii) peak expiratory flow rate (PEFR) at 4-6 months and 1 year and documented reductions in exacerbations. Clinical and lung function outcomes were compared between patients taking mepolizumab and benralizumab and over time. RESULTS: There were significant decreases in ACQ-5 scores (3.3 ± 0.93 to 1.7 ± 0.98 for mepolizumab, 3.5 ± 0.72 to 1.6 ±0.89 for benralizumab, and 3.5 ± 0.95 to 1.7 ± 1.1 for omalizumab; t-test, all p < 0.0001) but not increases in FEV1 and PEFR for all three agents after 4-6 months of therapy, which persisted but did not decrease further at one year. There were trends toward a greater percentage increase in FEV1 and PEFR from baseline and a decrease in the number of exacerbations in patients taking benralizumab than those taking mepolizumab. CONCLUSION: Although limited by a small sample size, this real-world, head-to-head comparison of mepolizumab and benralizumab is consistent with comparative data on asthma biologicals and indirect comparisons showing no major difference in efficacy. The study also generates new testable hypotheses about the efficacy of asthma biologicals in different patient populations.

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Objectives: Restless legs syndrome (RLS) is a neglected diagnosis, and most individuals with RLS do not access effective therapies. There has yet to be a nationwide study of the prevalence of and associated risk factors for RLS in Saudi Arabia. Materials and methods: A population-wide survey was administered to Saudi Arabian adults to assess RLS prevalence and its association with other clinical and demographic variables. RLS was defined according to 2012 IRLSSG Diagnostic Criteria. Persistent RLS was defined as symptoms occurring more than a few nights each week, and RLS causing significant daytime impairment was defined as symptoms causing "severe" excessive daytime sleepiness measured by the Epworth Sleepiness Scale. Associations were evaluated using univariate analyses and binary logistic regression. Results: 10,106 individuals completed the survey. Persistent RLS was reported in 11.9% of participants, which caused significant daytime impairment in 1.2% of participants. In multivariable analysis, younger age (OR 0.96, 95% CI 0.95-0.97; p < 0.001), tobacco smoking (OR 1.28, 95% CI 1.07-1.53; p = 0.008), anxiety (OR 1.34-1.42; p < 0.05), and moderate to severe depressive symptoms (OR 1.52-2.40; p < 0.01) were associated with persistent RLS. Younger age (OR 0.96, 95% CI 0.93-0.99; p = 0.015), female gender (OR 2.28, 95% CI 1.32-3.94; p = 0.003), and moderately severe to severe depressive symptoms (OR 13.59 and 26.7, respectively; p < 0.001) were independently associated with RLS causing significant daytime impairment. Conclusion: RLS is common in adults in Saudi Arabia and is often co-morbid with moderate to severe depressive symptoms. Both RLS and depression represent a silent epidemic in Saudi Arabia requiring active inquiry by all healthcare workers to reduce their burden and impact.

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OBJECTIVE/BACKGROUND: Insufficient sleep can have fatal consequences, and up to 30% of motor vehicle accidents (MVAs) are related to driving when drowsy. The objective of this study was to investigate how sleep quality and excessive daytime sleepiness (EDS) affect falling asleep while driving and sleep-related MVAs/near-misses. PARTICIPANTS/METHODS: A population-wide sample of Saudi adults was surveyed. The questionnaire gathered data on sleep quality, EDS (Epworth Sleepiness Scale), and episodes of falling asleep while driving and sleep-related MVAs/near-misses in the previous year. Univariable and multivariable analyses were used to assess associations. RESULTS: A total of 19% (902/3802) and 10% (474/4229) of respondents had fallen asleep while driving or had a sleep-related MVA/near-miss in the preceding year, respectively. Being male, married, having a shorter sleep duration, being an office worker, having poor subjective sleep quality, and having moderate or severe EDS were associated with an increased risk of having fallen asleep while driving in the previous year. Younger age, male gender, having worse subjective sleep quality [OR 2.11 (95% CI 1.36-3.29); p < 0.0001 for "very bad" sleep quality], and having moderate or severe EDS [ESS ≥ 13; OR 1.90 (95% CI 1.38-2.60); p < 0.0001 and OR 2.39 (95% CI 1.56-3.67); p < 0.0001, respectively] were associated with having had/nearly had an accident due to being tired or falling asleep while driving in the previous year. CONCLUSIONS: Sleepy driving and sleep-related accidents/near-misses are common in Saudi Arabia, and sleep quality and EDS contribute to the burden of MVAs. Further efforts are required to quantify the contribution of sleepiness to MVAs to develop and prioritize interventions to prevent MVA-related injuries and death.

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INTRODUCTION: There are few population-level studies of the interactions between sleep quality/excessive daytime sleepiness (EDS) and occupational behavior. Here, we investigated the impact of sleep quality and EDS on occupational outcomes in a population-wide survey of adults in Saudi Arabia. METHODS: A population-wide survey was administered to Saudi Arabian adults to assess sleep quality, EDS was measured using the Epworth Sleepiness Scale (ESS), and sleep-related absenteeism, sleep-related errors at work, and falling asleep at work in the preceding three months. Associations were evaluated using univariate analyses and binary logistic regression. RESULTS: A total of 10,106 individuals completed all or part of the survey, of whom 8617 (85.3%) were employed. Of these, 28.7% and 8.8% of respondents reported "fairly bad" or "very bad" sleep quality in the preceding month. In binary logistic regression models, taking sleep medications was associated with absenteeism (odds ratio (OR) 1.92, 95% confidence intervals (CI) 1.67-2.22; p<0.001) and making errors at work (OR 1.89, 95% CI 1.62-2.20; p<0.001) but not falling asleep at work, and poor subjective sleep quality was associated with falling asleep at work (ORs 1.55, 95% CI 1.38-1.74; p<0.001). Severe EDS (ESS ≥16) was strongly associated with falling asleep at work (OR 3.39, 95% CI 2.51-4.48; p<0.001). Parameters associated with absenteeism, errors, and falling asleep at work were similar in blue- and white-collar workers. DISCUSSION: This first population-wide study of sleep quality and EDS in Saudi Arabia provides a comprehensive portrait of the prevalence of sleep problems and their effects on occupational outcomes. Sleep-related absenteeism, work errors, and sleeping at work are common, mandating tailored fatigue-reduction strategies in every workplace and reinvigoration of public health messages on sleep.

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OBJECTIVES: This study aimed to compare the effectiveness of peer-led learning with faculty-led teaching activities in fifth-year students during their Internal Medicine II placement. METHODS: We conducted a retrospective analysis of the results of multiple-choice questions exams at the end-of-placement for 2016 to 2017. RESULTS: During the study period, 120 students in three cohorts completed the placement. There was a statistically significant difference (p < .001) between the mean student grade (% of correct answers) for questions related to lectures (n = 85, M = 68.7, 95% CI: 66.4-70.9), case scenarios (n = 24, M = 68.6, CI: 65.1-72.1), tutorials (n = 15, M = 64.9, CI: 59.9-69.8), and seminars (n = 24, M = 60.0, CI: 56.5-63.5). The first cohort had statistically significant better grades (M = 79.7, CI: 77.9-81.6) than the other two cohorts (group 2 M = 57.2, CI: 51.8-62.5; group 3 M = 60.5, CI: 58.1-63.0; p < .001). CONCLUSIONS: In our study, students performed worse on questions drawn from reciprocal peer-taught seminars. This result could be attributed to students' poor teaching quality, as they were randomly selected to lead a seminar. However, this study was limited by heterogeneity in the number and topics of different teaching activities and certain other factors.

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OBJECTIVES: The College of Medicine at Imam University has incorporated reciprocal peer-teaching into the curriculum in the form of peer-led seminars. The aim was to evaluate this program and ascertain student perceptions. METHODS: A cross-sectional survey of medical students attached to the Internal Medicine I and II courses was conducted in 2018. The questionnaire evaluated perceptions about the peer-teaching program, tutors' knowledge, skills and attitudes, both from a student and a tutor perspective. RESULTS: Based on a 63% response rate from a total of 410 students, 34.5% of learners agreed that peer-tutoring was the most effective method of clinical teaching and 30.3% disagreed. More students reported that peer-led seminars did not prepare them for their exams (38.4%) compared to those who reported it did (27.9%). More than 40% of participants reported the tutors were approachable, created a welcoming learning environment and provided targeted information. From a tutor perspective, more than 70% of participants reported that they developed personally and professionally, improved their collaborative, communication, tutoring and presentation skills and confidence. Female students reported they benefited more as tutors compared to male students. CONCLUSION: Students regard obligatory reciprocal peer-teaching in the form of peer-led seminars as similar to faculty teaching and an overwhelming majority report that they benefit both personally and professionally from leading seminars. As doctors are expected to teach and train younger generations, medical schools should prepare all students for such roles. A system that provides an opportunity for every student to become a peer-teacher can fulfil this need.

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OBJECTIVES: To determine the association between emergency department (ED) visits, glycemic control and the quality of preventive diabetes care among diabetic patients in a Saudi community. Methods: This study was an observational, cross-sectional study that collected data through interview-based surveys between February and April 2017. Data were collected from 530 diabetic patients in the diabetes clinics at King Saud Medical City, the tertiary center of Riyadh, Kingdom of Saudi Arabia.  Results: This study found statistically significant relationships (p less than 0.05) between ED visits and patient age, the glycated hemoglobin (HbA1c) and education level. Emergency department visits increased by 43% for each unit of increase in HbA1c (odds ratio [OR]=1.43, 95% confidence interval (CI)=1.26-1.62). Graduating from high school decreased the odds of visiting the ED by 43% (OR=0.57, 95% CI=0.34-0.94). Most of the participants were not followed for possible microvascular complications; the majority did not visit nephrology (96.2%), ophthalmology (78.3%) and neurology (97.9%) clinics within the 12 months prior to the interviews. Conclusion: Emergency department visits can indicate poor glycemic control in diabetic patients. Additionally, the current practices of preventive diabetes care in Saudi Arabia are not sufficient, according to the diabetic standards of care recommended by the American Diabetes Association.

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A positive attitude to organ donation among doctors is key to increasing organ donation. Education of medical students is suggested to be central to achieving this. This study examined whether knowledge of organ donation and transplantation (ODT) correlates with attitudes and beliefs relevant to ODT among medical students in Saudi Arabia. Two hundred and thirty-three students completed a self-administered questionnaire. A knowledge score was calculated for each student and correlated with answers on attitudes and beliefs with regard to ODT. This study revealed a complex interaction between knowledge, attitudes, and beliefs to ODT. The majority of students support ODT in general, but a significant proportion have negative beliefs when asked about specific details of the process and concern for family members with regard to both deceased and live donation is evident. Despite almost all students believing that Islamic beliefs do not preclude ODT, 27.1% believe transplantation to be unacceptable in the Society in which they live. Education is an important strategy to improve donation rates. These findings can guide development of medical student education programs suggesting inclusion of open debate about views in society and the importance of discussion with family members to be essential.

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BACKGROUND: Despite the acknowledgment that the services of diabetes educator and dietician affect outcome, the level of utilization of these services in the Saudi Arabian public health-care system is not known. The aims of the study were to establish the percentage of patients with diabetes mellitus (DM) followed up by a diabetic educator and a dietician in a tertiary center in Saudi Arabia and associations between follow-up by a diabetic educator and a dietician and glycemic control. MATERIALS AND METHODS: This was a cross-sectional study of 490 diabetic patients who attended the diabetic outpatient clinic consecutively at a public health-care institution in Riyadh. Patients answered interview questions on clinicodemographic variables and diabetic educator or dietitian follow-up during their care. Hemoglobin A1C (HbA1C [%, mmol/mol]) and fasting blood glucose (mg/dL, mmol/L) levels were recorded. RESULTS: The majority of patients were male (68.8%), Saudi (71%), married (91.6%), high school or college educated (55.5%), had type 2 DM (85.5%), and were taking oral hypoglycemics (57.3%). 69.0% and 19.8% of the patients had had at least some follow-up with a diabetic educator and dietician, respectively. HbA1C levels were significantly lower in patients who had had a follow-up with a dietitian (9.1 ± 4.5% [76 ± 26 mmol/mol] vs. 7.8 ± 2.2% [62 ± 13 mmol/mol]; unadjusted odds ratio [OR]: 0.80, 95% confidence intervals [CIs]: 0.71-0.89, P < 0.0001), including in multivariable analysis (adjusted OR: 0.84, 95% CIs: 0.72-0.99, P = 0.04). Follow-up with a diabetic educator was not associated with glycemic control. CONCLUSIONS: Follow-up with a diabetic dietitian had the greatest impact on glycemic control in type 1 and type 2 DM patients. A review of the national standards of best practice of diabetes education and nutrition in Saudi Arabia is required to optimize the outcomes.

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Kleine-Levin syndrome (KLS) is the commonest recurrent sleep disorder, with a prevalence of 1-2 per million population. Clear diagnostic criteria are now defined, but effective treatment remains elusive. The significant body of published literature allows consideration of possible aetiological mechanisms, an understanding of which could guide the development of therapeutic strategies. Functional imaging studies have been inconclusive; although diencephalic abnormalities are a common finding, no consistent pattern has emerged, and these studies have not revealed the mechanism(s) underlying the development of the abnormalities detected. An autoimmune aetiology is consistent with the available data. In this review, we argue that, in order to further our understanding of KLS, there needs to be a co-ordinated international effort to standardise approaches to functional imaging studies, genetic analyses that specifically address the possibility of an autoimmune aetiology, and clinical trials of immunosuppressive therapies.

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