Exam anxiety in the undergraduate medical students of Taibah University.

BACKGROUND AND OBJECTIVES: Assessment is perceived to create highly stressful environment among medical students. Several studies have reported exam-related anxiety symptoms but the contributing factors seem to differ across institutions. This study aimed to determine the prevalence of exam anxiety, gender differences and the variables that moderate exam anxiety among students of a Saudi medical school. METHODS: A cross-section study was done on 5th year medical students by administering a 12-statement self-administered questionnaire. The degree of exam anxiety was gauged by a visual analog scale. RESULTS: Of 125 students, 111 responded (response rate 89%). About 65% students experienced exam anxiety due to various reasons. Studying all night before exam (28 students; 25.2%) and extensive course load (26 students; 23.4%) were the major confounding factors. Female students experienced more stress due to extensive course load as compared with male students (p = .00). CONCLUSIONS: The data about the identified risk factors for exam anxiety can help medical educators to deeply understand the reasons for exam anxiety. There is a need to reassess the amount of study material in undergraduate medical curricula and students need to organize their time management skills to cope with exam anxiety.

Stapled hemorrhoidectomy; results of a prospective clinical trial in saudi arabia.

OBJECTIVES: This study was designed to evaluate the effectiveness of stapled hemorrhoidectomy (SH) in terms of cure of the symptoms and post-operative pain control. MATERIAL AND METHODS: In this prospective clinical study, SH (Ethicon Endo-surgery, Cincinnati, OH) was performed for all patients with grade III and grade IV hemorrhoids, presenting to the surgical clinics of Ohud and Meeqat Hospitals Almadinah Almunawwarah Saudi Arabia. The results of SH were evaluated by a questionnaire focusing on the relief of symptoms, severity of post operative pain, and complications of SH. RESULTS: Thirty patients (21 males and 9 females); with a mean age of 39.6 years were recruited in this study. Twenty six (86%) patients had grade III and 4 (14%) presented with grade IV hemorrhoids. Perianal prolapse was the most frequent presentation reported in 23 (76%). Mean operating time was 21.7 minutes (range; 17-36 minutes) whereas mean hospital stay was 1.9 days. Post-operative pain was tolerable (non-persistent) in 28 (93%) cases whereas 2 (7%) experienced mild pain requiring additional analgesia. Urinary retention was the most common complication found in 5 (16%) patients. All patients were cured of the hemorrhoids Conclusion: SH is a safe, rapid, and convenient surgical remedy for grade III and grade IV hemorrhoids with low rate of complications, minimal postoepative pain, and early discharge from the hospital.

Surgical management of retrosternal goiter: Local experience at a university hospital.

BACKGROUND AND OBJECTIVE: Retrosternal goiter (RSG) is a term that has been used to describe a goiter that extends beyond the thoracic inlet. Surgery plays an important role in the treatment of these patients, but whether all or selected patients with RSG should undergo this operation remains controversial. Our aim is to look into the demographics, presentation, and treatment of patients with RSG and essentially to determine the role of surgery in its treatment. SETTING AND DESIGN: Retrospective study, teaching hospital-based. METHODS: Retrospective analysis of 537 thyroidectomies performed at King Khalid University Hospital between 2003 and 2010. The twenty-six patients with RSG were analyzed further, with regard to demographics, presentation, indications, and outcome of surgical treatment. Statistical analysis was performed, where age was expressed as mean and range, and other variables were presented as numbers and percentage. RESULTS: There were 26 patients (4.8%) with RSG out of 537 thyroidectomies, who underwent an operation for removal of RSGs, in a seven-year period. The most common presentation was dyspnea (34.6%) and the surgical procedure predominantly used was total thyroidectomy. The RSGs were removed by collar incision in 96% of the cases. The final histological diagnosis revealed malignancy in 26.9% of the thyroid specimens. There was no mortality and minor complications occurred in nine patients. CONCLUSIONS: The presence of an RSG is an indication for surgery owing to the lack of effective medical treatment, the higher incidence of symptoms related to compression, low surgical morbidity, and the risk of malignancy.

Improvement of psychometric properties of the objective structured clinical examination when assessing problem solving skills of surgical clerkship.

OBJECTIVE: To improve the psychometric properties of the objective structured clinical examination (OSCE) and elevate staff motivation. METHODS: The OSCE was conducted in May 2006 at the Department of Surgery, King Saud University, Riyadh, Saudi Arabia as a pilot study for 95 students split over 2 consecutive days lasting 120 minutes each day. There were 15 actual stations on each day consisting of 10 stations that addressed problem solving skills, and 5 addressed clinical skills testing. RESULTS: The stability of the OSCE measured by Cronbach's alpha on day one was 0.87, and 0.88 on day 2. The internal consistency of the OSCE measured by Carmine's theta on day one was 0.76, and 0.79 on day 2. Overall, OSCE's reliability for each day was high (r=0.8), without a significant difference between the 2 days. Credibility and comprehensiveness of the the OSCE were considered good by both staff and students. Accuracy of the OSCE measured by Pearson's correlation with multiple choice question scores was 0.65. Feasibility of the OSCE has also improved remarkably compared with previous OSCEs. CONCLUSION: The OSCE proved to be highly reliable, and a valid format when more problem solving skills testing has been emphasized for the final year surgical clerkship. Feasibility has also improved remarkably after using this strategy, marked by more staff participation and enthusiasm.

Surgical residency training program. Are changes needed?

OBJECTIVE: To obtain a collective opinion of practicing surgeons on the current state of general surgical residency training. METHODS: A data collection sheet was completed by the practicing surgeons involved in the residency training in 5 cities in Saudi Arabia, from January 2004 to December 2005. The survey questions covered mainly 3 aspects of surgical education: problems within the current education system, how education should be conducted, and the best approaches to correct education deficits. RESULTS: A total of 96 surgeons involved in the training program responded. Thirty-three (34.4%) were from the Ministry of Health, 59 (61.5%) of the surgeons agreed that surgical skills can be acquired outside the operating theater. The majority (58.3%) considered that, the biggest deficit in graduating residents that must be corrected is technical skills. CONCLUSION: Changes are necessary to improve our surgical training program. Collaboration between hospitals to combine the current diverse efforts to train residents outside the operating rooms is necessary to establish a structured skills training center to teach and train both junior and senior residents. Formal education courses for the educators and encouraging residents to accept more responsibilities are additional efforts to improve the process of learning.

Breast carcinoma during pregnancy.

The medical records of patients with pregnancy associated breast carcinoma were critically reviewed to identify the tumor characteristics, maternal details, type of treatment delivered, and disease outcome. Over the last 5 years, there were 5 patients out of 220 giving a percentage prevalence of 2.27%. The median age at presentation was 33 years. Three patients were diagnosed by the sixth week of gestational age. Three out of 5 presented with stage IIIA. Four patients has > or = 6 positive axillary lymph nodes and grade III disease. So in spite of the discovery of the tumor in the early weeks of pregnancy, our patients presented with advanced disease, which is consistent with the presentation of breast carcinoma in non-pregnant women in this part of the world. So it could be an ignored disease, which became evident with the pregnancy. We highly encourage the obstetricians to perform thorough breast examination during the prenatal period with prompt referral of any suspicious cases.

Validity of leukocyte count to predict the severity of acute appendicitis.

OBJECTIVE: To ascertain whether white blood cell (WBC) count with differential analysis may predict severity of disease in acute appendicitis. METHODS: We conducted this retrospective study on appendectomy patients from 1996 to 2001, at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia. We reviewed patient's age, gender, duration of symptoms, temperature on admission, WBC count including differential and the histological diagnosis of the appendicular specimen. We further analyzed the data of those patients found to have acute, gangrenous and perforated appendicitis to determine the correlation between a high WBC count and a more advanced form of appendicitis. RESULTS: Out of an aggregate of 232 patients, 162 were males and 70 females with a mean age of 23.7 years (range, 12-70 years). Mean duration of symptoms was 1.9 +/- 1.1 days, mean temperature 37.8 +/- 1.4 degrees C, with reported elevated WBC count in 167 (71.9%) and normal in 65 (28.1%) cases. Mean WBC counts in acute were 14.5 +/- 7.3 x 10(9)/L, gangrenous 17.1 +/- 3.9 x 10(9)/L and perforated appendicitis 17.9 +/- 2.1 x 10(9)/L. This reflected a persistently higher WBC count in the complex (gangrenous, perforated) appendicitis compared with acute appendicitis (p < 0.05). The differential analysis showed neutrophilia in 123 (53%) and lymphopenia in 112 (48%) cases and out of these, 116 (94%) with neutrophilia and 107 (95%) with lymphopenia were reported to have appendicitis. CONCLUSION: A high WBC with differential count is a reliable indicator of the severity of appendicitis and signifies a more advanced stage.

Post appendectomy small bowel obstruction.

OBJECTIVE: Postoperative small bowel obstruction is one of the adverse effects of appendectomy but its frequency varies from center to other. This study was conducted to determine the incidence of this complication among our patients who had appendectomy and identify the factors which may increase the risk. METHODS: Case notes of patients who underwent appendectomy from January 1998 to December 2003 in King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia were reviewed. Patients readmitted for adhesive small bowel obstruction were traced and their clinical data were analyzed. RESULTS: Six hundred and seven patients were eligible for the study. Six patients (1%) developed intestinal obstruction. Frequency of readmission of patients with features of intestinal obstruction ranged from 1-6 (mean of 2 times). CONCLUSION: The incidence of small bowel obstruction after appendectomy is low. The main risk factors were reviewed and measures to avoid them were suggested.

A new era in laparoscopic surgery. Evaluation of robot-assisted laparoscopic procedures.

OBJECTIVE: To present the experience with the advanced technology of robot-assisted laparoscopic surgery at our institute. METHODS: We reviewed and present patients who had robot-assisted laparoscopic surgical procedures, between April 2003 and March 2004, at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia. All procedures were carried out using the da Vinci system (Intuitive Surgical, Mountain View, Ca, USA). We recorded the time for system setup, operating time, morbidity and postoperative hospital stay. RESULTS: We performed 42 robot-assisted laparoscopic operations. The most frequently performed operations were robot-assisted cardiac procedures (n=25), laparoscopic cholecystectomy (n=9) other operations were: thymectomy (4), apical bullectomy (2), and one for each adrenalectomy, and lung volume reduction. The median time to install and drape the robotic system was 15 minutes. In 2 patients (4.7%) we converted the procedures to conventional laparoscopy or open. There was postoperative wound infection at the site of the port in one patient. The average postoperative hospital stay was similar to conventional laparoscopic procedures. CONCLUSION: Robot-assisted minimally invasive surgery is feasible, safe and may become the surgical procedure of the future.

Bilateral breast cancer. Incidence, diagnosis and histological patterns.

OBJECTIVE: Bilateral breast cancer is uncommon (1-2.6% of all patients with breast carcinoma). There are conflicting reports and inadequate data regarding the incidence and survival of such patients. This study examined the frequency, mode of detection, therapeutic modalities and histological features among the 2 breasts. METHODS: Medical records of patients who were treated for breast cancer were reviewed at Khartoum Teaching Hospital, Sudan during a 5-year period of 1994 to 1999. Data of patients found to have bilateral breast cancer was analyzed focusing on the demographic information, family history, menstrual status, surgical therapy, chemoradiation, staging and histopathological characteristics. RESULTS: Of 521 patients treated for breast cancer, 90 (17.2%) were reported to have advanced breast carcinoma (stage III, IV) and 7 (1.3%) revealed bilateral cancer: 5 (0.9%) synchronous and 2 (0.4%) metachronous breast cancer. The median age was 47.3 years (range, 24-81 years). Four (57.1%) patients had positive family history for breast cancer. First breast cancer was detected by mammogram in 2 cases while second cancer was diagnosed by the same study in 5 patients. Five (71.5%) underwent mastectomy and 2(28.5%) were treated by lumpectomy and axillary dissection. Six patients presented with stage III and one with stage IV breast cancer. Invasive ductal carcinoma was reported to be the most common type found in 10 (71.5%) breasts. Grade III breast carcinoma was revealed in 9 and Grade I cancer in 3 specimens. CONCLUSION: Bilateral breast cancer is invariably advanced when diagnosed. Mammogram is a valuable tool in early detection. Whether synchronous or metachronous, both breasts often share the same histological type.

Carcinoid tumors of the appendix. Our experience in a university hospital.

OBJECTIVE: To present our experience of carcinoid tumors of the appendix managed at a university teaching hospital. Complex symptomatology, varied biochemical affections and different surgical therapeutic modalities are discussed. METHODS: The medical records of all the patients who underwent consecutive appendectomies at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia from 1994 to 1999 were retrospectively analyzed. The data of patients identified to have histological evidence of carcinoid tumors of the appendix were further reviewed for the demographic details, indications for surgery, surgical procedure, tumor localization in the appendix and size; concomitant appendicitis and further surgical procedures were considered. RESULTS: During the study period, 1547 appendectomies were performed and, out of these, 9 (0.6%) cases were reported to have carcinoid tumors of the appendix. There were 4 male and 5 female patients, age range 17-51 years (median 29.8 years). Seven subjects had a clinical evidence of appendicitis while 2 presented with chronic abdominal pain. There were 6 open and 3 laparoscopic appendectomies. Six carcinoid tumors were encountered at the appendiceal apex, 2 at the midportion, and one at the base with a mean diameter of 9.5 mm (range, 4-19 mm). One patient had histologically confirmed residual tumor, which necessitated a right hemicolectomy 3 weeks later. All patients remained disease-free during a mean follow up of 7 years (range, 4-10 years). CONCLUSION: Carcinoid tumors of the appendix are extremely rare and invariably remain asymptomatic. Simple appendectomy offers adequate relief while the need for further extensive surgery depends on tumor characteristics and dissemination. Despite an excellent prognosis, all reported patients should be followed up with urinary 5-hydroxyindoleacetic acid and abdominal ultrasonography.

Cholesterolosis. Incidence, correlation with serum cholesterol level and the role of laparoscopic cholecystectomy.

OBJECTIVE: To report the incidence of cholesterolosis in the surgically removed gallbladders, its association with serum cholesterol level and to review the role of laparoscopic cholecystectomy in the treatment. METHODS: This retrospective study included all patients who had consecutive cholecystectomies for various gallbladder disorders, performed by 2 consultants during a 5-year period from January 1997 through to December 2002, in the College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia. The clinical records of those found to have cholesterolosis on histopathological examination were reviewed, and the data were analyzed for their age, sex, fasting serum cholesterol level and the final outcome of cholecystectomy. RESULTS: The study group was comprised of 549 patients and out of which, 74 (13.4%) had cholesterolosis of the gallbladder. There were 59 (79.9%) female and 15 (20.1%) male patients. Age ranged from 18-64-years with a mean of 35.7-years. Sixty-three (85.1%) cases were reported to have abnormally high fasting serum cholesterol levels (>=5.5 mmol/L), whereas 11 (14.9%) had normal serum cholesterol level. Cholesterolosis with coexistent gallstones was documented in 47 (63.3%) patients while 27 (36.5%) subjects showed acalculous cholesterolosis. Laparoscopic cholecystectomy was performed in 71 (95.9%) individuals, whereas 3 patients ended up with open cholecystectomy (conversion rate of 4.2%). There were no postoperative complications. CONCLUSION: Cholesterolosis of the gallbladder is a distinct pathologic entity and carries a positive correlation with high serum cholesterol level. Laparoscopic cholecystectomy is effective, safe and a feasible treatment modality for cholesterolosis.

Feasibility and acceptability of objective structured clinical examination (osce) for a large number of candidates: experience at a university hospital.

OBJECTIVE: To assess the feasibility and acceptability of using objective structured clinical examination (OSCE) for a large number of medical students. METHODS: All medical students (291) who had completed the basic surgical course were examined by objective structured clinical examination (OSCE) at the College of Medicine, Riyadh, for the first time. A 5-scale questionnaire was filled by the examiners at the end of the examination each day. Another questionnaire was filled by the students as a feedback. RESULTS: All students agreed that the organizational aspect of the examinations was smooth and the time for each station was adequate. 86% of the students agreed that the stations were within the content of the course, 82% agreed that the examination was fair and objective and 93% wanted this method to be followed in the assessment of third year medical students, instead of the traditional examination (written and single long case). Similar responses were received from the examiners who were involved in the exams. CONCLUSION: OSCE is a practical and acceptable method for assessing medical students' basic surgical skills, even for a large number of candidates, if facilities are available in the examination center. Replacing written exams with OSCE depends on the design of stations to test knowledge adequately in scope and depth probably at problem solving level.