Lessons Learned From COVID-19 Lockdown: An ASPED/MENA Study on Lifestyle Changes and Quality of Life During Ramadan Fasting in Children and Adolescents Living With Type 1 Diabetes.

Background: Lockdown was a unique experience that affected many aspects of life, particularly during the challenge of Ramadan fasting (RF). Studying this can increase understanding of the effects of lifestyle changes on quality of life (QoL) for children with type 1 diabetes (T1D) during RF. Methods: A cross-sectional study that assessed the effect of lockdown on lifestyle and QoL on fasting children living with T1D during Ramadan in the Middle East and North Africa region (2020-2021). We compared the child (self) and parent (proxy) reports using PEDQoL v3.0 disease specific questionnaire during lockdown and non-lockdown periods, and assessed correlations with lifestyle changes using regression and gap analyses. Results: A total of 998 reports from 499 children with T1D aged 8 to 18 years (study = 276, control = 223), and their parents during RF in lockdown and non-lockdown periods. Fathers were more involved in their children's care during lockdown (P = .019). Patients had better compliance with treatment (P = .002), a reversed sleep pattern (P = .033), increased food intake (P ⩽ .001), and less exercise (P < .001). Children and parents perceived better QoL during lockdown (P ⩽.001) with no differences between their reports in "Diabetes Symptoms", "Treatment Adherence," and "Communication" domains. Self and proxy reports were different in all domains during non-lockdown (P = <.001-.009). In gap analysis, although not statistically significant, the gap was approximated between children's and parents' perceptions in all domains during lockdown. Conclusion: COVID-19 lockdown had a positive impact on QoL of children living with T1D during RF, possibly due to lifestyle changes and superior psychosocial family dynamics.

The clinical characteristics and quality of life of 248 pediatric and adult patients with Congenital Adrenal Hyperplasia.

Background: Congenital Adrenal Hyperplasia (CAH) is a chronic disease that requires lifelong treatment. Patients may face stigmatization, which may affect their quality of life (QoL). Therefore, we assessed the clinical characteristics and QoL of patients with CAH in the Middle East. Methods: This case-control study included patients with CAH aged >5 years from two tertiary centers (2020-2021). The patients were matched to a healthy control group and were then divided into pediatric and adult groups. Data were collected from their electronic medical records. Additionally, the EQ-5D-5L QoL questionnaire was completed by both the patients and control group to assess five domains (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression). Results: The study included 248 patients with CAH (females: 58.8%), with a family history of the condition (57.3%) and/or parental consanguinity (68.1%). The most frequently reported gene defect was CYP21A2, while the most commonly reported symptoms/signs were ambiguous genitalia and obesity. Almost all female patients had received corrective surgery. The questionnaire response rate was 86.3% (n=214/248). The CAH patient group's mean total QoL score was 85.2 compared with 99.8 in the control. Further, CAH patients had lower QoL scores in all domains compared to those in the control group (p ≤ 0.0001-0.0023). The pain/discomfort and anxiety/depression domains were affected significantly more than the other domains were, with 47.7% and 44.4% participants, respectively, p<0.0001. Additionally, obesity was found to be a predictor of reduced mobility following a logistic regression analysis (p ≤ 0.04, OR (0.18-0.98)). Conclusion: Patients with CAH reported lower QoL overall, particularly in the pain/discomfort and anxiety/depression domains. Based on this, we recommend the early involvement of psychologists in a multidisciplinary team approach, pre-marital screening, and the implementation of awareness programs for people diagnosed with CAH in communities with high consanguineous mating.

Opportunities, barriers and expectations toward international voluntary medical missions among health trainees in Saudi Arabia.

The objective is to assess the feasibility, barriers, expectations and motivation of health trainees in Saudi Arabia regarding medical missions. This study seeks to fill the gap in global health curricula and regulations, as well as provide guidance for trainees participating in international health electives in Saudi Arabia. This cross-sectional survey of health trainees (in medical, surgical and other allied health professions) was conducted across Saudi Arabia from March 2017 to February 2018 using a standardised survey adapted to assess expectations, barriers, awareness of available opportunities and the effect of mentorship in improving motivation toward medical missions. A total of 589 respondents completed the survey, with a response rate of 83.7%. Most respondents were under 35 years old, with an equal sex distribution. Furthermore, the respondents primarily had medical and surgical specialties training and graduated from the western region of Saudi Arabia. Health trainees who considered volunteering during training but did not have previous experience in missions acknowledged that the presence of a staff member experienced in missions in their training environment positively affected their interest in missions (p = 0.038). The most common reasons for interest in volunteerism were to enhance one's own technical and clinical skills and help others in need. Interest in tourism and learning about new cultures are additional reasons. Only 7/589 participants had experience and expressed the barriers they faced during volunteerism. Interestingly, their colleagues who did not have a similar experience perceived almost the same barriers. A major barrier faced by experienced participants was the 'lack of elective time', compared to the 'lack of available organised opportunities' by the inexperienced group. In conclusion, coordinating health trainees' missions through a unified authoritative body would provide better opportunities, override challenges and improve their perceptions and participation in these missions.

Prevalence and factors associated with dyslipidemia among adolescents in Saudi Arabia.

Dyslipidemia is a major risk factor for atherosclerosis. Screening for dyslipidemia at an early age is essential to prevent and control its consequences. This study aimed to determine prevalence of dyslipidemia and its correlates among adolescents in Saudi Arabia. Data of 5854 adolescents aged 10-19 years from all 13 regions of Saudi Arabia were obtained from the Jeeluna study; a national cross-sectional, multistage stratified cluster sample survey. Dyslipidemia was defined based on the National Heart Lung and Blood Institute and National Cholesterol Education Program guidelines for adolescents. We found that a quarter of Saudi adolescents have dyslipidemia (males: 33.3%, females: 17.9%). Significant variation was observed by region (p < 0.001). Prevalence of abnormal Total Cholesterol was 6.7%, LDL-C 7.1%, HDL-C 12.8%, Non-HDL-C 8.3%, and Triglycerides 9.6%. Factors independently associated with dyslipidemia were male gender (OR = 2.19, 95% CI 1.78-2.70, p < 0.001), BMI (underweight OR = 0.80, 95% CI 0.69-0.94, overweight OR = 1.76, 95% CI 1.50-2.06, obese OR = 2.80, 95% CI 2.34-3.34, p < 0.001, vs. normal) and serum ferritin (high OR = 7.02, 95% CI 1.49-34.79, low OR = 0.82, 95% CI 0.67-1.01, p = 0.04 vs. normal) and ≥ 1 daily intake of carbonated beverage (OR = 1.10, 95% CI 1.00-1.20, p = 0.03 vs. no or not daily intake). Public health interventions for improving lipid profile of adolescents are urgently needed.

Timing of Puberty and Late Pubertal Height in Saudi Schoolboys: Riyadh Puberty Study II.

Objective: Puberty has a significant contribution to the final height. Therefore, it is crucial to understand the normal variations in the onset and tempo of puberty in a specific population. In this study, we aimed to provide normative data on the timing of puberty and late pubertal height (LPH) in Saudi schoolboys in Riyadh. Methods: This is a cross-sectional field study (2011-2013) including Saudi schoolboys (grades 1-12; aged 6 to 19 years). Schools were chosen to represent the population from urban and rural areas in the Riyadh region. Pubertal maturity staging for gonads was assessed by measuring testicular size using a Prader orchidometer and assessing the Tanner staging of pubic hair. The marginal mean age was calculated using regression analysis. Results: We recruited 1086 schoolboys. The estimated mean age of pubertal onset at G2 was 11.8 (95% CI 11.60-12.0) years, for gonadal development at G3 was 13.2 (95% CI 12.9-13.5), G4 = 15.0 (95% CI 14.7-15.2), and G5 = 16.1 (95% CI 15.9-16.3) years, and for pubic hair stage 2 (PH2) was 12.6 (95% CI 12.4-12.9) years. The estimated time from G2/PH2 to G5/PH5 was 4.3 and 3.9 years, respectively. At the onset of puberty, the mean height was 144.7 cm and it reached 167.8 cm at G5 with a pubertal height gain of 23.1 cm. Conclusion: Our data present the norms of the timing of puberty and LPH in Saudi schoolboys. Saudi adolescent males are shorter than some European and American comparatives mainly due to shortness during childhood. However, they could have shorter LPH than Turkish, Greek, Thai, and Japanese due to a less pubertal height gain.

Reply to Alsarwani, R.M. Comment on "Alghnam et al. The Association between Obesity and Chronic Conditions: Results from a Large Electronic Health Records System in Saudi Arabia. Int. J. Environ. Res. Public Health 2021, 18, 12361".

We genuinely thank Dr. Alsarwani for his insights [...].

Frequency and Risk Factors of Diabetic Ketoacidosis in a Specialized Children's Hospital, Riyadh: A Cross-sectional Study.

Objectives: Diabetic ketoacidosis (DKA) is a life-threatening complication and a leading cause of hospitalization in patients with type 1 diabetes mellitus (T1DM). We aimed to assess the risk factors of admissions of children with DKA in a specialized children's hospital to reduce morbidity and inform appropriate prevention and intervention strategies. Methods: We conducted a retrospective review of all DKA admissions at King Abdullah Specialized Children's Hospital, Riyadh (March 2015-December 2017). Data were gathered from newly diagnosed patients with T1DM and known patients ≤ 14 years old with DKA criteria. The main variables were frequency, precipitating factors, and other characteristics of DKA admissions in both groups. Results: A total of 116/562 patients with T1DM (mean age 8.9±3.0 years) had 146 DKA episodes, of which 42/116 (36.2%) were newly diagnosed. The frequency of DKA admissions were 146/562 (26.0%), of which 42/141 (29.8%) were newly diagnosed versus 104/421 (24.7%) known T1DM patients. The majority were 10-14 years old (p ≤ 0.001), and 77.8% were females. Missing insulin was the main cause of DKA (p = 0.001) among known patients with T1DM. Recurrent episodes (n = 30/146, 20.5%) occurred in 15/116 patients and were more common in children ≥ 10 years of age (p = 0.024). The mean length of stay was 2.6±2.0 days and increased with DKA severity (p = 0.008). Conclusions: Most DKA episodes were in patients with known T1DM and missing insulin was the leading cause of DKA. In addition to awareness campaigns to prevent DKA as an initial presentation, intervention strategies should also target high-risk groups of known patients of T1DM such as adolescents and patients with recurrent episodes.

An Infant with Asymptomatic Vitamin D Intoxication: A Prolonged and Sustainable Recovery.

Vitamin D intoxication (VDI) usually develops due to inappropriate use of vitamin D in high doses by the families of infants with complaints suggestive of vitamin D deficiency such as delayed teething, knock knees, or delayed walking. We present here an experience of treating an infant with asymptomatic VDI that had a prolonged course of recovery and a sustainable level of vitamin D over a follow-up period of 2.5 years. In our patient, vitamin D started to drop steadily after a month of stopping vitamin D supplements but not to a normal level. It reached an acceptable level only after six months. This case emphasizes the importance of educating parents about the empirical use of vitamin D over the counter, assessing the baseline level of serum vitamin D level prior to initiation of treatment and highlights the value of verifying additional dietary sources of vitamin D or oral supplements in patient's history.

Clinical characterization of pediatric supratentorial tumors and prediction of pituitary insufficiency in two tertiary centers in Saudi Arabia.

Background: Post-operative pituitary insufficiency (PI) occurs in children with supra-tentorial tumors (STT) because of surgery or the mass effect of the tumor. We assessed the prevalence and clinical characteristics of STTs and predicted postoperative PI in our patients. Methods: This retrospective cohort study included children who underwent surgery for STT in two tertiary hospitals in Saudi Arabia (2009-2019). We focused on clinical, radiological, and histopathological features of STTs. We also used a linear regression model to predict post-operative PI. Results: The study included 55 children (1-18 years, mean: 9.5 ± 4.9 years, 32 [54%] females) with an initial presentation of STT that required surgery excluding recurrent episodes. The calculated period prevalence of STT was 18.2%, and the prevalence of postoperative PI was 58.2% (n = 32/55). The most common symptoms were headache and visual disturbances, and 20% patients had preoperative symptoms of PI. Baseline preoperative investigations for PI were performed in 60% of patients, and dynamic tests were conducted in only seven patients. A residual cortisol deficiency was presumed in 24 (43.7%) patients and 18 (32.7%) patients who developed central diabetes insipidus (DI) post-operatively. Overall, the brain imaging correlated well with the histopathological diagnosis (kappa = 0.48; P < .001). Craniopharyngioma (n = 15/55, 27.3%) was the commonest STT. Predictive factors for a postoperative residual PI included age (10.9 ± 4.8 years; p-value = .027), female gender (p-value = .016 [OR = 8.31; 95% CI (1.48-46.71)], presentation with headache (P value = .039 [OR = 9.27; 95% CI (1.12-76.72)]), and visual disturbances (p-value = .044 [OR = 5.07; 95% CI (1.04-24.61)]. Conclusion: STTs commonly occurred in our study population, and females were more prone to develop a residual PI. On-time surveillance of an intact endocrine system during the perioperative period is essential for the prediction and early management of PI.

The Association between Obesity and Chronic Conditions: Results from a Large Electronic Health Records System in Saudi Arabia.

This cross-sectional study aimed to estimate the prevalence of obesity and its association with diabetes and hypertension among beneficiaries in the National Guard Health Affairs system of Saudi Arabia. We included individuals aged 17 years and older, and patients were classified as diabetic or hypertensive if they had any visit during the 4 years where the primary diagnosis was one of those conditions or they were taking diabetes or hypertension medications. The association between obesity (body mass index ≥30) and diabetes and hypertension were evaluated using a multiple logistic regression model, adjusting for age, gender, nationality, and region. A total of 616,092 individuals were included. The majority were Saudi nationals (93.1%). Approximately 68% of the population were either obese (38.9%) or overweight (29.30%). Obesity was more prevalent among Saudi nationals (39.8% vs. 26.7%, p < 0.01) and females (45.3% vs. 31.2%, p < 0.01). Obesity was independently associated with diabetes mellitus (OR = 2.24, p < 0.01) and hypertension (OR = 2.15, p < 0.01). The prevalence of obesity in the study population was alarming and more pronounced among women. Our findings call for efforts to intensify preventive measures to reduce obesity and associated conditions. Using electronic records to examine the impact of interventions to reduce obesity and chronic conditions may help monitor and improve population health.

Short stature with low insulin-like growth factor 1 availability due to pregnancy-associated plasma protein A2 deficiency in a Saudi family.

In 2016 a new syndrome with postnatal short stature and low IGF1 bioavailability caused by biallelic loss-of-function mutations in the gene encoding the metalloproteinase pregnancy-associated plasma protein A2 (PAPP-A2) was described in two families. Here we report two siblings of a third family from Saudi Arabia with postnatal growth retardation and decreased IGF1 availability due to a new homozygous nonsense mutation (p.Glu886* in exon 7) in PAPPA2. The two affected males showed progressively severe short stature starting around 8 years of age, moderate microcephaly, decreased bone mineral density, and high circulating levels of total IGF1, IGFBP3, and the IGF acid-labile subunit (IGFALS), with decreased free IGF1 concentrations. Interestingly, circulating IGF2 and IGFBP5 were not increased. An increase in growth velocity and height was seen in the prepuberal patient in response to rhIGF1. These patients contribute to the confirmation of the clinical picture associated with PAPP-A2 deficiency and that the PAPPA2 gene should be studied in all patients with short stature with this characteristic phenotype. Hence, pediatric endocrinologists should measure circulating PAPP-A2 levels in the study of short stature as very low or undetectable levels of this protein can help to focus the diagnosis and treatment.

Quality of Life and Glycemic Control in Saudi Children with Type 1 Diabetes at Different Developmental Age Groups.

BACKGROUND: Children with type 1 diabetes (T1D) at different stages of development have age-specific needs, which can influence their perception of quality of life (QoL). In our study, we aimed to emphasize these age-specific needs and assess the perception of QoL in Saudi children with T1D, as well as their parents correlating QoL scores with children's glycemic control. METHODS: This is a cross-sectional study in which children with T1D and their parents from 2 tertiary institutes in Saudi Arabia have answered a standard diabetes-specific QoL questionnaire (PedsQL™ 3.0 diabetes module, translated in Arabic). We also reported glycated hemoglobin (HbA1c) results for these children within a month of completing the questionnaire. The QoL total aggregate and domain scores for self (children) and proxy (parents') reports were compared and correlated with children's HbA1c. RESULTS: A sample was 288 self and proxy reports from 144 children with T1D of 3 age groups: 5 to 7 years (7%), 8 to 12 years (49%), and 13 to 18 years (44%), and their parents. QoL differed significantly between self and proxy reports in the total aggregate and domain scores (P-values range from .02 to <.001). The impact on QoL was significantly higher in female patients (P = .043). Insulin pump users had better HbA1c (P = .007), and HbA1c level was worse in those who intended to fast at Ramadan (P = .005). CONCLUSION: Children with T1D at different developmental age groups perceive QoL differently than their parents. Adjusting management as per age-specific challenges could potentially improve these children's QoL and glycemic control.

The role of micronutrients in thyroid dysfunction.

Thyroid hormones are essential for normal growth and development in children. Nutritional factors are closely related to thyroid dysfunction due to deviation from normal physiology of the gland. Iodine, a main constituent of thyroid hormones (T3 and T4), deficiency is one of the commonest causes of hypothyroidism in children and adults, worldwide. Other micronutrients, such as Cruciferous vegetables, Pearl Millet, Soy products and Cassava, were also attributed to cause thyroid dysfunction. Environmental factors, namely, contamination of water with goitrogens could also contribute to the aetiology of goitre in some endemic areas. Dietary advice and avoidance of excessive use of goitrogens in diet are part of guidance on nutritional safety that needs to be established, especially in the areas of endemicity.

Correlations between Direct and Calculated Low-Density Lipoprotein Cholesterol Measurements in Children and Adolescents.

BACKGROUND: Low-density lipoprotein cholesterol (LDL-C), as a modifiable risk factor for atherosclerotic cardiovascular disease, should be assessed and monitored. This study compared directly measured and Friedewald-estimated LDL-C values in children and adolescents. METHODS: Blood samples were collected from 464 children and adolescents. Calculated LDL-C (CLDL-C) levels were estimated using the Friedewald formula for any triglyceride value below 4.6 mmol/L. Direct LDL-C (DLDL-C) levels were measured on an ARCHITECT c8000 Abbott Clinical Chemistry Analyzer. The differences in LDL-C were then calculated. RESULTS: The correlation coefficients (R) between DLDL-C and CLDL-C were 0.978 (P = .148) and R = 0.970 (P = .052) for children and adolescents, respectively. Children with LDL-C values above 4.92 mmol/L had a correlation value of 0.971 (P = .419). The correlation and agreement between DLDL-C and CLDL-C in adolescents were moderate for LDL-C below 2.85 mmol/L (R = 0.806; 84.1%) and improved above 2.85 mmol/L (R = 0.978; 91.5%). In children, good correlations between DLDL-C and CLDL-C were observed for normal (<0.85 mmol/L), borderline (0.85-1.12 mmol/L), and abnormal (≥1.13 mmol/L) triglyceride levels (R = 0.9782, 0.990, and 0.951, respectively). The rates of agreement were better for normal (80.5%) and borderline (82.9%) but not abnormal (68.2%) triglyceride levels. CONCLUSION: We observed good agreement between DLDL-C and CLDL-C in both children and adolescents. The Friedewald formula provided an adequate estimate of LDL-C for most fasting specimens. LDL-C difference percentage can also be used as a quality indicator to check laboratory analyzer performance in healthy subjects.

Higher serum alkaline phosphatase activity in infants born to vitamin D-deficient mothers.

Our research shows that the newborns of vitamin D-deficient mothers have higher serum alkaline phosphatase (ALP) activity compared with those of vitamin D-non-deficient mothers, which is likely related to increased bone turnover rather than just being a marker for bone formation. This has a potential negative impact on fetal bone development and subsequent skeletal growth. PURPOSE/INTRODUCTION: Low maternal serum 25-hydroxy vitamin D (25(OH)D) level during pregnancy contributes to vitamin D deficiency in infants at birth, which is associated with multiple potential adverse effects on fetal skeletal mineralization and growth. We studied the relationship between maternal 25(OH)D level and newborn serum alkaline phosphatase activity (ALP) at term. METHODS: In this prospective cross-sectional hospital-based study, venous blood samples of healthy pregnant mothers were drawn to measure 25(OH)D levels within 6 h of delivery. Cord blood samples were examined for calcium, phosphorus levels, and ALP activity immediately after birth. In addition, we also recorded the newborns' anthropometric measurements. RESULTS: Seventy-two percent (n = 108/150) of mothers in our study were vitamin D-deficient (serum 25(OH)2D < 25 nmol/l). In a multivariate logistic regression model, young maternal age (odds ratio (OR) = 0.94, 95% CI 0.88-0.99, p = 0.04) and increased weight (OR = 1.03, 95% CI 1.01-1.07, p = 0.02) as well as decreased milk intake (OR = 0.31, 95% CI 0.13-0.74, p = 0.009) were all significantly associated with maternal vitamin D deficiency. ALP activity was significantly higher in newborns of vitamin D-deficient compared with vitamin D-non-deficient mothers (median = 176 (IQR = 139-221) and 156 (IQR = 132-182), respectively, p = 0.04). A significant inverse correlation (Pearson's coefficient = - 0.18, p = 0.03) was observed between maternal 25(OH)D levels and babies' ALP activities. This association persisted in a multivariate logistic regression model (OR = 3.46, 95% CI 1.18-10.18, p = 0.024). CONCLUSIONS: Our findings indicate that newborns of vitamin D-deficient mothers have higher serum ALP activity than those of non-deficient mothers, which might be related to increased bone turnover rather than just being a marker for bone formation. This could have a potential negative impact on fetal bone development and subsequent skeletal growth.

Do poor patients suffer from inaccurate diagnoses more than well-to-do patients? A randomized control trial.

BACKGROUND: Poor patients have greater morbidity and die up to 10 years earlier than patients who have higher socio-economic status. These findings are often attributed to differences in life-style between groups. The present study aimed at investigating the extent to which physicians contribute to the effect by providing relative poorer care, resulting in relative neglect in terms of time spent with a poor patient and more inaccurate diagnoses. METHODS: A randomised experiment with 45 internal medicine residents. Doctors diagnosed 12 written clinical vignettes that were exactly the same except for the description of the patients' socio-economic status. Each participant diagnosed four of the vignettes in a poor-patient version, four in a rich-patient version, and four in a version that did not contain socio-economic markers, in a balanced within-subjects incomplete block design. Main measurements were: diagnostic accuracy scores and time spent on diagnosis. RESULTS: Mean diagnostic accuracy scores (range 0-1) did not significantly differ among the conditions of the experiment (for poor patients: 0.48; for rich patients: 0.52; for patients without socio-economic markers: 0.54; p > 0.05). While confronted with patients not presenting with socio-economic background information, the participants spent significantly less time-to-diagnosis ((for poor patients: 168 s; for rich patients: 176 s; for patients without socio-economic markers: 151 s; p < 0.01), however due to the fact that the former vignettes were shorter. CONCLUSION: There is no reason to believe that physicians are prejudiced against poor patients and therefore treat them differently from rich patients or patients without discernible socio-economic background.

Risk of diagnostic errors when dealing with aggressive patients: Experimental study.

Medical errors are still common despite advances in technology and policies to insure patients' safety. They can be traceable as in medications or surgical errors, but may not be so in diagnostic errors that are patient, physician, or system related. This study aimed to explore whether aggressive behavior of some patients might affect physicians' clinical reasoning and decision-making. The study was conducted in a format of observation skills clinical examinations (OSCEs). It included simulating patients (SPs) and family physicians in residency training in a clinical setup. The experiment included two arms of dealing with case scenarios with "Neutral" and "Aggressive" behaviors. Explanatory variables assessed were duration of consultation, correct diagnosis, and plan of appropriate management as well as patients' satisfaction. Participants were 14 trained SPs who played the roles of aggressive and nonaggressive patients when they encountered 35 residents (18 were males) in family physicians [year 2 (R2), year 3 (R3) and year 4 (R4)]; in a total of seventy patient/doctor encounters. Compared with nonaggressive patients, aggressive patients had statistically significantly prolonged OSCE duration [mean (standard deviation) = 6.89 (1.35) and 6.11 (157) min, respectively; P = 0.031] and more patient consultation satisfaction (P <0.0001). However, no statistically significant differences were found in diagnostic accuracy (P = 0.626) and management (P = 0.621). In a stratified analysis, junior doctors had longer duration of consultation and seemed to perform better in management (higher patient satisfaction and better management outline) than their senior counterparts. Patients' aggressive behavior led to longer duration of medical consultation. Poor management plan, albeit correct diagnosis, in senior doctors may be due to disruptive clinical reasoning in disturbed stressful situation. Coping strategies should be emphasized in medical education to ensure effective clinical reasoning in patient/doctor encounters.

Testosterone- and Cortisol-secreting Oncocytic Adrenocortical Adenoma in the Pediatric Age-group.

Oncocytic tumors are epithelial neoplasms that occur in various organs, including adrenal glands. Oncocytic adrenocortical adenomas and carcinomas are uncommon but well-known pathological entities in adults. However, generally oncocytic tumors, particularly in the adrenal glands, are very rare in the pediatric age-group. Most oncocytic adrenal tumors are not functional. We present a rare case of right-sided, functional oncocytic adrenocortical adenoma in a 5-year-old boy, who presented with clinical manifestations of precocious puberty and Cushing syndrome. Laparoscopic adrenalectomy showed a well-defined mass weighing 8.4 g and measuring 3 cm in maximum dimension. Histological examination demonstrated no features suggestive of aggressive biological behavior. The patient showed no evidence of recurrent or metastatic disease and continued to have normal serum hormonal levels 28 months following the surgery. In this report, we discuss the clinicopathological characteristics of this rare pathological entity and briefly review the literature on functional oncocytic adrenal tumors in the pediatric population.

Health related quality of life and family impact of type 1 diabetes among adolescents in Saudi Arabia.

AIM: To measure the health related quality of life (HRQoL) among Saudi Arabian adolescents with type 1 diabetes mellitus (T1DM) and the impact the disease has on the family. METHODOLOGY: A cross sectional study was conducted involving 315 adolescent patients (12-18 years) and their caregivers. Adolescent HRQoL was assessed by adolescents and their parents completing the Peds QL™ Diabetes Module 3.0. Family impact was assessed by the parent completing the Peds QL™ Family Impact module (FIM). RESULTS: Adolescents reported a cumulative mean HRQoL score of 64.8, while parents reported significantly lower scores of 60.3 (p=0.003). The lowest scores reported by both adolescents and parents were for "Worry". Female gender and late adolescent age were predictors of lower HRQoL for adolescents with T1DM. The FIM showed low scores for "Emotional functioning" (59.8) and high scores for "Family relationships" (80.9). CONCLUSION: These findings emphasize the importance of an interdisciplinary, biopsychosocial and family centered care approach to adolescents with a chronic disease. Future work could assess the effectiveness of direct care involvement of adolescent and mental health experts in improving the HRQoL for this population.