Rare Oral Hemangioma in Pregnancy: A Case Series Providing Clinical Insight into Patient Care.

BACKGROUND Hemangiomas are defined as benign soft tissue vascular tumors that are histologically classified as capillary, cavernous, or mixed types. Hemangiomas can also be described based on clinical appearance as superficial, mixed, or deep lesions. Following a thorough search, only 3 case reports of superficial protruding lip mass were found in the literature. Other cases of tongue hemangioma have been reported in infants or young toddlers, and only rarely in adults. CASE REPORT The first case was a 43-year-old pregnant woman, with an unremarkable medical and surgical history, in the second trimester who presented to the Otolaryngology Clinic with a chief concern of a progressively growing lesion, measuring 0.7×0.5 cm, over the lateral right side of the tongue for the last 2 weeks after accidentally biting her tongue during dinner. The second case was a 26-year-old woman with unremarkable medical and surgical history who presented to our Otolaryngology Clinic with a chief concern of a non-painful soft fungating pink-red lip lesion 1.5×1 cm across the right lower lip growing for the last 4 months. This lesion appeared during the third trimester of pregnancy following a lip injury that was described as minor trauma. CONCLUSIONS Although hemangiomas can occur anywhere on the body, they are most commonly found in the head and neck. These lesions are usually recognized quickly by patients and treating physicians and are thus clinically diagnosed. Most vascular benign lesions regress on their own, but if detected early, they are surgically excised for cosmetic and functional reasons.

Validation and clinical application of the Arabic rhinoplasty outcomes evaluation questionnaire.

OBJECTIVES: To carry out translation, cross-cultural adaptation, and validation of the rhinoplasty outcome evaluation (ROE) into Arabic. METHODS: This non-randomized, prospective study included 50 patients from the Otorhinolaryngology Department, King Saud University, Riyadh, Saudi Arabia who underwent primary rhinoplasty from January to October 2020 and a control group of 89 healthy individuals. The reliability of the Arabic (ROE) was tested using Cronbach's alpha. The test-retest reliability was assessed by estimating the intra-class correlation coefficient for the total Arabic (ROE) score and individual items. Discriminant validity was used to examine the validity of the Arabic (ROE) by comparing the scores of the patients and the control group. The Friedman test was used to measure differences in Arabic (ROE) ratings within the study patients' group, including preoperative, and 2 weeks, and 3 months postoperative ratings. RESULTS: The internal consistency and reliability of the Arabic (ROE) were good. There was a significant difference in ratings between rhinoplasty patients and the control group regarding both the individual questions and total scores. Significant improvement was observed in the patient group ratings at 2 weeks and 3 months postoperatively compared to the preoperative rating (p<0.0001). CONCLUSIONS: The Arabic version of the (ROE) showed good reliability and validity and can be used in the assessment of rhinoplasty outcomes in the Arabic population.

Performance of the Arabic Population on the Adolescent-Adult Sensory Profile: An Observational Study.

BACKGROUND: The Adult-Adolescent Sensory Profile (AASP) is a questionnaire developed to measure the way in which people in different age groups respond to different sensory stimuli. These sensory stimuli may uncover different behavioral problems that may affect activities of daily living. This observational study aimed to validate the Arabic version of the AASP used to assess the sensory processing abilities of healthy individuals. METHODS: Participants comprised 560 Jordanians aged 11 years and older. Participants were recruited from different community centers in Amman, Jordan during 10th March 2017 to 10th September 2017. The English version of the AASP was translated into Arabic and all participants were instructed to complete this version of the scale. RESULTS: Internal consistency was 0.78 and 0.79 for the Arabic and the English version, respectively. The ranges of cut-off scores in the Arabic version were higher than the English version for all the quadrants of the scale. The biggest differences were found in the sensation seeking and sensory sensitivity quadrants. In certain age groups (11-17 and 18-64 years), women were more sensitive compared with men. CONCLUSION: The Arabic version of the AASP showed good internal consistency and can be used to assess the sensory processing abilities of healthy individuals.

Translation and cultural adaptation of an Arabic version of the patient scar assessment scale for thyroidectomy patients.

OBJECTIVES: To translate and validate an Arabic version of the patient scar assessment scale (PSAS). The cosmetic appearance of a thyroidectomy scar can critically influence a patient's self-esteem. Moreover, scar evaluation tools are necessary for an evidence-based approach to scar management. METHODS: This  quantitative, observational, cross-sectional study was conducted by administering an Arabic-translated version of the PSAS. The translation process included a forward translation into Arabic by 3 fluently bilingual otolaryngologists, a back-translation into English, and a comparison with the original items. The questionnaires were distributed to patients who underwent thyroidectomies. We included patients who underwent surgery at least 2 months previously. RESULTS: A total of 50 patients were included in this research. The internal consistency was 0.89, with a 95% confidence interval (CI) of 0.88-0.90. The score distributions showed high correlations for all items. The Arabic-translated PSAS showed good test-retest reliability, and the Pearson correlation coefficient between the test and retest administrations was 0.84 (p<0.001). With a possible range of 6-60 points, the standard error of the mean was 5.14, and the minimal detectable change was 14.2. CONCLUSION: This Arabic version of the PSAS was reliable for use in Arabic-speaking communities. It will allow for comparisons between the results of investigations conducted in different countries, which aids in the exchange of information within the international scientific community.

Does skin thickness affect satisfaction post rhinoplasty? Middle Eastern population as an example.

OBJECTIVES: To determine the mean nasal skin thickness in the Middle Eastern population and to assess the effect of skin thickness on patients' satisfaction following rhinoplasty surgeries. Methods: Radiological measurements of skin thickness at the 3 vertical thirds of the nasal dorsum were taken. A total of 154 patients (80 females and 74 males) who were scheduled for computed tomography scan for the paranasal sinuses were included in the study. The patients were then categorized into 3 groups: thick, medium, and thin nasal skin. A scale from 10% to 100% was used to assess patient satisfaction following rhinoplasty. Satisfaction and skin thickness were analyzed using the Kruskal-Wallis test. Results: Nasal skin thickness for males was 6.13, 2.76 millimeter (mm) from the upper and 3.70 mm to the lower third. For females, it was 5.34, 2.13 mm from the upper and 3.21 mm to the lower third. There was no statistically significant difference in patient satisfaction among the 3 skin thickness groups (p=0.089). Conclusion: This study provides baseline results of nasal skin thickness in the Middle Eastern population. The results also show that nasal skin thickness may not be a strong factor affecting patient satisfaction.

Failure of Synthetic Implants: Strategies and Management.

Dorsal augmentation with synthetic implants is the most commonly performed rhinoplasty procedure, especially in the East-Asian region. However, as in all other surgical procedures, complications are inevitable. Complications that need to be managed surgically include displacement, deviation, suboptimal aesthetic outcome, extrusion, inflammation, infection, and changes in skin quality. Most complications can be easily managed with revision surgery. After the removal of the synthetic implant from the nasal dorsum, different dorsal implant materials such as dermofat, alloderm, or fascia-wrapped diced cartilage, conchal cartilage with perichondrial attachment, and costal cartilage are preferred. An irreversible change in the skin/soft tissue envelope poses a challenge that usually requires reconstructive surgery with a local flap. Therefore, early detection and prompt management of the complication are essential for minimizing the severity of the deformity and the complexity of the surgical procedures.

Correlation between Allergic Rhinitis and Laryngopharyngeal Reflux.

BACKGROUND AND OBJECTIVES: Laryngopharyngeal reflux (LPR) exhibits nonspecific clinical presentations, and these symptoms may be associated with other conditions such as allergies, including allergic rhinitis and laryngitis. However, there is a gap in the literature regarding the correlation of laryngopharyngeal reflux with allergic rhinitis/laryngitis. Hence, the aim of this study is to explore the correlation between these two conditions. PATIENTS AND METHODS: A total of 126 patients with suggestive manifestations of laryngopharyngeal reflux were included in this study. Patients were classified into LPR positive and negative groups based on the results of a 24-hour oropharyngeal pH monitoring system while allergic rhinitis status was assessed with the score for allergic rhinitis (SFAR). THE RESULTS OF THE TWO GROUPS WERE COMPARED REGARDING THE SFAR SCORE CORRELATION BETWEEN THE PH RESULTS AND SFAR SCORE WAS EXPLORED RESULTS: The LPR positive group demonstrated significantly higher SFAR scores compared to the negative LPR group (p < 0.0001). In addition, the Ryan score was significantly correlated with the SFAR total score and its symptomatology-related items (r ranged between 0.35 and 0.5). Conclusion. It seems that laryngopharyngeal reflux increases patients' self-rating of allergic manifestations. It appears that there is an association between laryngopharyngeal reflux and allergic rhinitis/laryngitis.

Bone and Soft Tissue Nasal Angles Discrepancies and Overlying Skin Thickness: A Computed Tomography Study.

BACKGROUND: The aim of this study was to derive the normal values for bone and soft tissue nasal angles as well as the overlying skin thickness and to attempt to determine the correlation between differences in bone and soft tissue angles and overlying skin thickness in Middle Eastern patients. MATERIALS AND METHODS: Three-dimensional cephalometric analysis was performed for 100 patients who underwent computed tomography of the paranasal sinuses. The nasofrontal angle, pyramidal angle-nasal root, pyramidal angle-tip of the nasal bone, and overlying skin thickness were measured, and the results were analyzed according to sex, age, and body mass index (BMI). RESULTS: All soft tissue angles were significantly larger than the bone angles, with the mean difference being 11.62°, 30.80°, and 27.05° for the nasofrontal angle (P = 0.000), pyramidal angle-nasal root (P = 0.000), and pyramidal angle-tip of the nasal bone (P = 0.000), respectively. The mean overlying skin thickness was 3.89 ± 1.48 mm at the nasion, 1.16 ± 0.6 mm at the rhinion, and 2.93 ± .97 mm at the nasal tip. Differences in the nasofrontal angle were strongly correlated with the skin thickness at the nasion (P = 0.001). CONCLUSION: A simple clinical exam of the soft tissue nasal angles does not reflect the underlying bone angles that will be encountered during rhinoplasty. BMI does not influence nasal shape, and rhinoplasty surgery should take into account the ethnic group, age, and sex of the patient. Surgeons should leave a minor skeletal hump at the end of the nasal bone for Middle Eastern patients. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Alterations in Nasal Sensibility Following Calcium Hydroxyapatite Dorsal Augmentation.

BACKGROUND: There are a many types of filler products that surgeons used for soft tissue augmentation. Soft Tissue Fillers, also known as injectable grafts, is a medical device implants. One of the materials used in soft tissue fillers is calcium hydroxylapatite (CaHA) that is commonly used for treating nasal deformities and nasal reshaping too. Calcium hydroxylapatite is a kind of mineral that can be found in human teeth and bones. It is considered long-lasting but nonpermanent filler and is biocompatible with human tissue. AIM: The aim of this study is to measure the alterations in sensibility and patient satisfaction following CaHA filler injection. PATIENT/METHODS: In a prospective study, 30 patients who underwent CaHA filler injections from January to December 2016 at a Private Tertiary Care Hospital in Riyadh, Saudi Arabia were included. RESULTS: Means and standard deviations were measured for pressure threshold values at each test area preprocedure 2 weeks after procedure (). Alterations between pre and postprocedure values were verified using the match-paired Student t test preprocedures. None of the patients had any subjective sensory symptoms. Majority of patients were extremely satisfied with the results.(Table is included in full-text article.) CONCLUSION:: With correct anatomic knowledge and precise technique in doing the CaHA gel injection procedure, nasal sensibility will not be altered. In addition, injection of CaHA gel can be valuable tool for plastic surgeons to consider for nasal reshaping.

Validation of the Arabic version of the score for allergic rhinitis tool.

BACKGROUND: Allergic rhinitis (AR) is a common inflammation of the nasal mucosa in response to allergen exposure. We translated and validated the Score for Allergic Rhinitis (SFAR) into an Arabic version so that the disease can be studied in an Arabic population. OBJECTIVES: SFAR is a non-invasive self-administered tool that evaluates eight items related to AR. This study aimed to translate and culturally adapt the SFAR questionnaire into Arabic, and assess the validity, consistency, and reliability of the translated version in an Arabic-speaking population of patients with suspected AR. STUDY DESIGN: Cross-sectional. SETTING: Tertiary care hospital in Riyadh. PARTICIPANTS AND METHODS: The Arabic version of the SFAR was administered to patients with suspected AR and control participants. MAIN OUTCOME MEASURE: Comparison of the AR and control groups to determine the test-retest reliability and internal consistency of the instrument. RESULTS: The AR (n=173) and control (n=75) groups had significantly different Arabic SFAR scores (P < .0001). The instrument provided satisfactory internal consistency (Cronbach's alpha value of 0.7). The test-retest reliability was excellent for the total Arabic SFAR score (r =0.836, P < .0001). CONCLUSION: These findings demonstrate that the Arabic version of the SFAR is a valid tool that can be used to screen Arabic speakers with suspected AR. LIMITATIONS: The absence of objective allergy testing.

Medical residents' attitudes and emotions related to Middle East respiratory syndrome in Saudi Arabia. A cross-sectional study.

OBJECTIVES: To determine medical residents' emotions, attitudes, and knowledge related to Middle East respiratory syndrome (MERS) outbreaks. Methods: In this is a cross sectional study, self-administered questionnaires were distributed and collected before resident education activities in 4 tertiary hospitals in Riyadh, Kingdom of Saudi Arabia, between November 2015 and January 2016. The questionnaire included questions related to residents' demographic data and their emotions, attitudes, and knowledge related to an MERS outbreak. Results: Of the 228 participants analyzed, 85.5% believed their work put them at risk of infection, and two-thirds believed their family was exposed to a greater risk of infection. However, only 2.6% would change their job. Nearly half of the residents indicated that their hospital had a clear plan, and only 28% considered themselves not well prepared for an MERS outbreak. Conclusions: Our study highlights medical residents' attitude and emotions related to MERS outbreaks. Residents' concerns and emotions in relation to MERS should be considered in greater detail by hospital policymakers.

Nasal Septal Deformity in Relation to the Mode of Delivery.

OBJECTIVE: The aim of this study was to find the relation between mode of delivery and the types of septal deviation. MATERIALS AND METHODS: Records of patients treated for a deviated nasal septum from March 2003 to October 2015 were reviewed. Those with previous facial trauma were excluded. Information retrieved included basic demographic data, mode of delivery, sibling birthing order, type and date of surgery, and postoperational outcomes. RESULTS: A total of 130 records were recovered. According to Guyuron's classification of nasal septal deviation, we found that type 5 was the most common type for patients delivered normally, whereas type 2 was the most common type for those who were delivered by cesarean section. CONCLUSION: Mode of delivery may be related to a certain type of deviation. However, studies with larger samples are required to support the finding in our study.

Trends and demographic characteristics of Saudi cosmetic surgery patients.

OBJECTIVES: To  present the demographic characteristics of Saudi patients undergoing cosmetic procedures.  Methods: This prospective study survey was conducted in 3 private cosmetic surgery centers in different regions of Saudi Arabia (Riyadh and Jeddah) between January and August 2016. Validated questionnaire with modification was used and the following patient's information were provided: age group, height and weight, marital status, number of children, age of the patient's spouse, educational level, monthly income, name of the cosmetic procedure, names of any previous cosmetic procedures and their reason for cosmetic procedure. Results: The present study revealed that a typical Saudi cosmetic surgery patients are university graduates, married (46.8%), employed (68.3%), and middle aged 20-40 years of age (70%), with a fairly high typical monthly income.  Conclusion: There is a possible positive correlation between gender and undergoing cosmetic procedure. Laser hair removal, botox, liposuction, filler, and scar revision are common among females, while rhinoplasty is a common procedure among males.

Common nasal deformities among rhinoplasty patients in a university hospital in Saudi Arabia.

BACKGROUND: Rhinoplasty has become one of the most common aesthetic procedures in the world. Few studies from the Middle East have described rhinoplasty patients in the region. OBJECTIVE: To investigate common nasal deformities in individuals seeking rhinoplasty at a single institution in Saudi Arabia. DESIGN: Retrospective study and chart review. SETTING: King Abdulaziz University Hospital, Riyadh, Saudi Arabia. PATIENTS AND METHODS: All patients seeking primary rhinoplasty who were 15 years of age and older were included. The types of external nasal deformities were compared by gender and age groups. MAIN OUTCOME MEASURE: Types of external nasal deformities. RESULTS: Of the 248 patients investigated, 113 were male and 135 female. The most common external nasal deformity was a broad dorsum (n=163; 65.7%), followed by a bulbous columella (n=154; 62.1%), and deviation (n=150; 60.5%). Upward columella was most common in older patients, and deviation decreased with age. CONCLUSION: The most common deformity among the study population of Saudis was a wide nasal dorsum, bulbous nasal tip and deviated nose. Studying nasal deformity in some ethnic groups has an influence in selecting and practicing specific rhinoplasty approaches. LIMITATIONS: Study conducted in one hospital and may not be generalizable.

Surgical Outcomes of Bony Batten Grafting to Correct Caudal Septal Deviation in Septoplasty.

IMPROTANCE: Correction of caudal septal deviation with a batten graft has been popularized recently. However, few reports have documented the surgical outcomes of this technique, especially the use of bony batten grafts in septoplasty. OBJECTIVE: To evaluate the surgical outcomes of bony batten grafting for the management of caudal septal deviation in endonasal septoplasty. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study evaluates the medical records of 141 patients with caudal septal deviation who underwent septoplasty using bony batten grafts from September 1, 2011, through February 29, 2016, at a tertiary referral hospital. Patients were divided into primary and secondary surgery groups. Patients were also divided into the septoplasty plus turbinate surgery and the septoplasty only group. Endoscopic assessment of deviation correction was performed, and postoperative complications were analyzed. MAIN OUTCOMES AND MEASURES: Patient satisfaction and symptom improvement were evaluated via telephone interviews by using the Nasal Obstruction Symptoms Evaluation (NOSE) scores. RESULTS: Of the 141 patients (24 women [17%] and 117 men [83%]; mean [SD] age, 32.8 [12.9] years), 86 (61%) rated their symptoms in the postoperative survey as much improved; 50 (35.5%), improved; 4 (2.8%), no change; and 1 (0.7%), worse. All patients had significantly improved mean (SD) postoperative NOSE scores (28.7 [22.0]; 95% CI, 25.0-32.4) compared with preoperative scores (70.5 [26.7]; 95% CI, 66.0-75.0; P < .001). No significant intergroup differences were observed in surgical outcome between the 116 patients undergoing primary surgery (mean [SD] NOSE score, 28.2 [21.9]) and 25 undergoing secondary surgery (mean [SD] NOSE score, 30.8 [24.3]; P = .34). No significant difference in surgical outcome was found between the 102 patients in the turbinate surgery group (mean [SD] NOSE score, 28.1 [20.8]) and 39 in the septoplasty only group (mean [SD] NOSE score, 30.4 [23.7]; P = .65). On endoscopic examination for surgical outcome, 128 patients (90.8%) had a straight septum and 13 (9.2%) had improved but residual caudal deviation. Postoperative complications included septal hematoma in 4 patients, hyposmia in 2, and chondritis in 1; all patients were treated successfully. Four patients required revision surgery because of incomplete functional correction or a desire for rhinoplasty. CONCLUSIONS AND RELEVANCE: Septoplasty using bony batten grafts is useful for correcting caudal septal deviation with favorable surgical outcomes and an acceptable complication rate. LEVEL OF EVIDENCE: 3.

Bilateral peritonsillar abscess: A case report and pertinent literature review.

INTRODUCTION: The peritonsillar space is defined as the area between the palatine tonsillar capsule medially and the superior pharyngeal constrictor muscle laterally. Unilateral peritonsillar abscess (PTA) is more common than the bilateral condition. To the best of our knowledge, only 13 cases of bilateral PTA have been reported worldwide; this is the first case reported from Saudi Arabia. PRESENTATION OF CASE: We present a case involving a 16-year-old boy who presented to the emergency department with a5-day history of sore throat, dysphagia, trismus, drooling, and a muffled "hot-potato" voice, but with no symptoms of airway compromise. After several examinations, we diagnosed bilateral PTA. We performed an incision and drained the pus from both sides, which was positive for Streptococcus pyogenes. Postoperatively, the patient improved dramatically, and tonsillectomy was scheduled for 6 weeks later. DISCUSSION: The difficulty in diagnosing bilateral PTA stems from the fact that it does not present with the usual clinical characteristics as unilateral PTA. These symptoms include asymmetry of the tonsils and palate, deviation of the uvula, and unilateral otalgia. As these cases carry the risk of impending airway compromise, we recommend airway management as the first step in treating such cases. CONCLUSION: Based on our case and literature review, we recommend airway management as the first step, followed by further examinations, especially contrast-enhanced computed tomography, in cases of bilateral PTA. This condition lacks the hallmark of unilateral disease and may mimic many conditions, which will have different management approaches.

Perception and Attitude of Emergency Room Resident Physicians toward Middle East Respiratory Syndrome Outbreak.

Introduction. Middle East respiratory syndrome (MERS) outbreaks have had a considerable negative impact on health systems in Saudi Arabia. We aimed to study the psychological impact of a Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak on emergency room resident physicians (ERRPs). Methods. We assessed the MERS-related psychological impact and concerns of ERRPs using a self-report questionnaire. Results. The majority (91%) of the ERRPs agreed that their work put them at risk of infection, but most (65%) did not agree that they should not be looking after patients infected with MERS. Despite that, 54% of ERRPs reported being afraid of contracting the infection from infected patients and only 4.2% of them were willing to change their current job. The majority of the ERRPs (85%) felt that their job would expose their families to risk of infection. Conclusions. Our study demonstrated the considerable psychological impact of MERS outbreaks on ERRPs. The ERRPs' concerns and the psychological impact of MERS outbreaks should be considered in greater detail by hospital policymakers.

Physicians' attire. Parents preferences in a tertiary hospital.

OBJECTIVES: To assess Saudi mother's preferences regarding Saudi children's physicians' attire, and its influence on the parents' level of trust and confidence. Methods: A cross-sectional survey was conducted from January to April 2014. Our sample comprised mothers of pediatric patients in both inpatient and outpatient settings at National Guard Hospital, Riyadh, Kingdom of Saudi Arabia. Mothers answered multiple questions, including their preferences regarding male and female pediatric physicians' attire, their preferences regarding their children's physician's gender, and the impact of physician's appearance on mothers' confidence. Results: There were 259 female participants. Of all caregivers, 51.4% were 32-years-old or younger. Of those, 170 (65.6%) were educated (had completed high school or higher). Forty-four percent preferred that male physicians wear scrubs, while 5.4% preferred formal attire (tie, shirt, and trousers) and 27.8% preferred Saudi national attire (Thobe and shemagh). Most caregivers (57.9%) preferred that female physicians wear long skirts. Most caregivers (87.6%) preferred physicians to wear a white coat. Most (89.2%) believed that a physician's appearance is very important. Conclusion: Gender of the treating physician is insignificant to mothers. However, the level of trust in a physician is related to his/her external appearance. Most mothers prefer their children's physicians to wear scrubs.

Anthropometry of Arabian nose using computed tomography scanning.

BACKGROUND: The nose plays a critical role in determining the external appearance of an individual. We studied the craniofacial anthropometrics by CT scanning since previous studies in the field were conducted in Saudi populations using photometric analysis. OBJECTIVES: Obtain objective and quantitative data that can help surgeons plan cosmetic procedures for the nose. DESIGN: A cross-sectional analytical study. SETTING: Department of Otorhinolaryngology, Head and Neck Surgery, King Abdulaziz University Hospital, King Saud University, Riyadh, Saudi Arabia from February 2015 to December 2015. PATIENTS AND METHODS: Facial CT scans were performed on native Saudis who underwent CT of the paranasal sinuses. MAIN OUTCOME MEASURE(S): Three anthropometric parameters: the nasofrontal angle, the pyramidal angle, and the linear distance between the nasion and the tip of the nasal bone. RESULTS: In 160 native Saudis (86 males and 74 females) who underwent CT, the mean nasofrontal angle was 125.3° in males and 135.6° in females. The mean linear distance between the nasion and the tip of the nasal bone was 23.0 mm for males and 20.9 mm for females. The mean nasal pyramidal angle was 110.8° in males and 111.9° for females at the level of the nasal root, 105.6° in males and 104.8° in females at the mid-level of the nasal bone, and 116.8° males and 107.9° in females at the level of the tip of the nasal bone. CONCLUSION: Nasal bone lengths and angles can be obtained accurately from CT scans. These angles differ in different ethnic groups. LIMITATIONS: The sample represents native Saudis but not a cross section of the Saudi population. The relatively small sample size is a limitation of the study, but we consider these to be initial findings.