Curriculum development for the Saudi sleep medicine fellowship program.

Objectives: Given the rapid global development of sleep medicine, well-qualified sleep medicine physicians are necessary to meet the demand. Although sleep medicine was accredited as an independent specialty in KSA in 2012, national data suggest that the number of trained and accredited sleep medicine specialists remains comparatively low. A structured sleep medicine fellowship programme was established in KSA in 2009. However, universities issued training and certification without a national training programme under the auspices of the Saudi Commission for Health Specialties (SCFHS). Therefore, plans have been made to establish a national interdisciplinary sleep medicine training programme to serve the whole country. Methods: In 2020, the SCFHS mandated the Specialty Curriculum Development Committee of the Sleep Medicine Fellowship Program to develop the National an adult sleep medicine national program. Results: The committee developed an adult sleep medicine fellowship programme curriculum and requirements to ensure that trainees become competent at assessing, diagnosing, and managing various sleep disorders. The curriculum was approved by the head of the Curricula Editorial Board of the SCFHS. Conclusions: This paper presents the curriculum and admission requirements for the newly developed Saudi Sleep Medicine Fellowship Program.

Sleep quality and insomnia during the COVID-19 lockdown among the Saudi public: A cross-sectional study.

OBJECTIVES: To measure the Saudi population's sleep quality during the lockdown of COVID-19. METHODS: An internet-based questionnaire that was performed during the lockdown of the COVID-19 pandemic among the Saudi population over 2 weeks from April 1 to April 15, 2020. We used the instant messaging application WhatsApp and Twitter to reach the targeted population. Saudi citizens and non-Saudi residents who can read and understand the questionnaire were recruited. Data were analyzed using Stata and SPSS. RESULTS: A total of 790 responses were included. The majority of participants were the Saudi population 735 (92.9%). The prevalence of insomnia and poor sleep quality were 54.4% and 55.5%, respectively. Saudi citizenship was associated with longer sleep duration (p=0.031). Female gender and being married were associated with worse global PSQI, sleep quality, sleep distribution, sleep latency, and daytime dysfunction. CONCLUSION: Our findings showed that during the COVID-19 pandemic, the Saudi population had a high prevalence of insomnia and poor sleep quality. Routine monitoring of the psychological impact of life-threatening outbreaks and the adoption of effective early mental health actions should be considered.

Histopathology of Middle East respiratory syndrome coronovirus (MERS-CoV) infection - clinicopathological and ultrastructural study.

AIMS: The pathogenesis, viral localization and histopathological features of Middle East respiratory syndrome - coronavirus (MERS-CoV) in humans are not described sufficiently. The aims of this study were to explore and define the spectrum of histological and ultrastructural pathological changes affecting various organs in a patient with MERS-CoV infection and represent a base of MERS-CoV histopathology. METHODS AND RESULTS: We analysed the post-mortem histopathological findings and investigated localisation of viral particles in the pulmonary and extrapulmonary tissue by transmission electron microscopic examination in a 33-year-old male patient of T cell lymphoma, who acquired MERS-CoV infection. Tissue needle biopsies were obtained from brain, heart, lung, liver, kidney and skeletal muscle. All samples were collected within 45 min from death to reduce tissue decomposition and artefact. Histopathological examination showed necrotising pneumonia, pulmonary diffuse alveolar damage, acute kidney injury, portal and lobular hepatitis and myositis with muscle atrophic changes. The brain and heart were histologically unremarkable. Ultrastructurally, viral particles were localised in the pneumocytes, pulmonary macrophages, renal proximal tubular epithelial cells and macrophages infiltrating the skeletal muscles. CONCLUSION: The results highlight the pulmonary and extrapulmonary pathological changes of MERS-CoV infection and provide the first evidence of the viral presence in human renal tissue, which suggests tissue trophism for MERS-CoV in kidney.

IL-4 receptor alpha single-nucleotide polymorphisms rs1805010 and rs1801275 are associated with increased risk of asthma in a Saudi Arabian population.

BACKGROUND: The IL-4 receptor alpha subunit (IL-4Rα), when associated with the common gamma chain receptor, or the IL-13Rα1 subunit, transduces signals to STAT6 in response to IL-4 and IL-13 stimulations. This results in a number of cell-specific responses including Th2 differentiation, lymphocyte proliferation and IgE production. Given the prominent role of IL-4Rα in allergic disorders, several single-nucleotide polymorphisms (SNPs) have been found associated with asthma and other atopic disorders, including rs1805010 (I75V) and rs1801275 (Q576R) SNPs; however, lack of significant association have also been reported for some ethnic groups. The objective of this study was to determine whether IL-4Rα rs1805010 and rs1801275 polymorphisms are associated with asthma in patients from Saudi Arabia. MATERIALS AND METHODS: One hundred and ninety severe asthmatic patients (11-70 years old) and 194 healthy subjects of equivalent age range were recruited for blood donation. DNA was purified and genotyping for rs1801275 and rs1805010 polymorphisms in the IL-4Rα gene was performed by PCR amplification, followed by cycle sequencing of the purified PCR fragments using BigDye chain terminator and capillary electrophoresis. RESULTS: Pearson's Chi-square tests showed that the minor alleles, G, for both rs1805010 and rs1801275 SNPs, were significantly more frequent in asthmatics than in the healthy group (Yates' P < 0.05); conversely, the major alleles, A, were significantly more frequent in healthy than in asthmatics (P < 0.05). Concerning association analysis, odds for A/G-G/G genotypes were significantly higher to be associated with asthma predisposition (rs1801275: OR = 2.12; 95% CI = 1.39-3.22; P < 0.001*; rs1805010: OR = 1.6; 95% CI = 1.01-2.53; P < 0.05*; dominant model). Analysis of gender-genotype interactions, with genders nested within A/G-G/G, indicated higher odds for females than males of significant association with asthma (rs1801275: OR = 5.19, 95% CI = 2.09-12.94*; rs1805010: OR = 3.73, 95% CI = 2.06-6.74*). Rs1805010 and rs1801275 were in linkage disequilibrium (D' = 0.27; P < 0.0004*), with G-G haplotype being more frequent in asthmatics than in healthy subjects (OR = 2.43, 95% CI = 1.59-3.71*). CONCLUSIONS: The risk alleles, G, of IL-4Rα rs1805010 and rs1801275 SNPs and corresponding A/G-G/G genotypes were significantly associated with asthma predisposition in asthmatics from Saudi Arabia.

The Saudi Guidelines for the Diagnosis and Management of COPD.

The Saudi Thoracic Society (STS) launched the Saudi Initiative for Chronic Airway Diseases (SICAD) to develop a guideline for the diagnosis and management of chronic obstructive pulmonary disease (COPD). This guideline is primarily aimed for internists and general practitioners. Though there is scanty epidemiological data related to COPD, the SICAD panel believes that COPD prevalence is increasing in Saudi Arabia due to increasing prevalence of tobacco smoking among men and women. To overcome the issue of underutilization of spirometry for diagnosing COPD, handheld spirometry is recommended to screen individuals at risk for COPD. A unique feature about this guideline is the simplified practical approach to classify COPD into three classes based on the symptoms as per COPD Assessment Test (CAT) and the risk of exacerbations and hospitalization. Those patients with low risk of exacerbation (<2 in the past year) can be classified as either Class I when they have less symptoms (CAT < 10) or Class II when they have more symptoms (CAT ≥ 10). High-risk COPD patients, as manifested with ≥2 exacerbation or hospitalization in the past year irrespective of the baseline symptoms, are classified as Class III. Class I and II patients require bronchodilators for symptom relief, while Class III patients are recommended to use medications that reduce the risks of exacerbations. The guideline recommends screening for co-morbidities and suggests a comprehensive management approach including pulmonary rehabilitation for those with a CAT score ≥10. The article also discusses the diagnosis and management of acute exacerbations in COPD.

Physicians' attitudes toward reporting medical errors-an observational study at a general hospital in Saudi Arabia.

OBJECTIVE: : Accurate medical error reporting is crucial for reducing the occurrence of such errors and their adverse consequences. This study aims to investigate the views of physicians about medical error reporting in a tertiary care hospital in Saudi Arabia. METHODS: : This is a cross-sectional self-administrated survey study. All physicians in the hospital were invited to complete an anonymous survey questionnaire addressing demographic details, as well as attitudes, practice, and views on medical error reporting. RESULTS: : One hundred seven physicians completed the questionnaires (66.5% response rate). Mean (SD) age was 39.8 (9.0) years. One-fifth of the respondents worked in the emergency department, and half had a workload of 40 to 59 h/wk. The reason given by 41.1% for not reporting a medical error by a colleague was that "it is not their responsibility." However, the gravity of the outcome of a medical error by a colleague to the patient was thought to be an important incentive for reporting. Of the physicians, 43% agreed that they would conceal the occurrence of a medical error they incurred to "avoid punishment." Nevertheless, most of the respondents held the view that there exists an ethical underpinning for reporting medical errors and that reporting of medical errors serve a valuable purpose. CONCLUSIONS: : The physicians in our study are likely to disclose errors made by a colleague only if the error resulted in a severe damage to the patient, and as such, medical errors go underreported for a variety of reasons. It was felt that assurance of confidentiality and protection from backlash would promote medical error disclosure.

Solitary pulmonary nodule: A diagnostic algorithm in the light of current imaging technique.

The solitary pulmonary nodule (SPN) is frequently seen on chest radiographs and computed tomography (CT). The finding of a SPN usually provokes a flurry of clinical and imaging activity as an SPN in at-risk population is an alert signal of possible lung cancer. The frequency of malignant nodules in a given population is variable and depends on the endemicity of granulomatous disease. The percentage of malignant nodules also rises when dealing with at-risk population. The problem is compounded by the fact that with the present generation of CT scanners, 1-2 mm nodules are discovered in approximately half of the smokers aged 50 years or older scanned. A variety of management approaches are applied in the work-up of SPN often requiring evaluation over a long period of time to establish a benign or malignant diagnosis. Comparison with previous imaging studies and morphologic evaluation of the size, margins, and internal characteristics are usually the first step in the evaluation of these nodules. It is often necessary to use additional imaging techniques and occasionally invasive procedures such a percutaneous needle lung or a surgical biopsy. Until recently, the guidelines for follow-up of indeterminate noncalcified nodules detected on nonscreening CT was a minimum of 2 years. However, during the past few years due to further refinements in CT technology and better understanding of tumor behavior, it has prompted a revision of the guidelines of the follow-up of small indeterminate nodules. These guidelines have been endorsed by the Fleischner Society.

Imaging lung manifestations of HIV/AIDS.

Advances in our understanding of human immunodeficiency virus (HIV) infection have led to improved care and incremental increases in survival. However, the pulmonary manifestations of HIV/acquired immunodeficiency syndrome (AIDS) remain a major cause of morbidity and mortality. Respiratory complaints are not infrequent in patients who are HIV positive. The great majority of lung complications of HIV/AIDS are of infectious etiology but neoplasm, interstitial pneumonias, Kaposi sarcoma and lymphomas add significantly to patient morbidity and mortality. Imaging plays a vital role in the diagnosis and management of lung of complications associated with HIV. Accurate diagnosis is based on an understanding of the pathogenesis of the processes involved and their imaging findings. Imaging also plays an important role in selection of the most appropriate site for tissue sampling, staging of disease and follow-ups. We present images of lung manifestations of HIV/AIDS, describing the salient features and the differential diagnosis.

The calcified lung nodule: What does it mean?

The aim of this review is to present a pictorial essay emphasizing the various patterns of calcification in pulmonary nodules (PN) to aid diagnosis and to discuss the differential diagnosis and the pathogenesis where it is known. The imaging evaluation of PN is based on clinical history, size, distribution and the gross appearance of the nodule as well as feasibility of obtaining a tissue diagnosis. Imaging is instrumental in the management of PN and one should strive not only to identify small malignant tumors with high survival rates but to spare patients with benign PN from undergoing unnecessary surgery. The review emphasizes how to achieve these goals. One of the most reliable imaging features of a benign lesion is a benign pattern of calcification and periodic follow-up with computed tomography showing no growth for 2 years. Calcification in PN is generally considered as a pointer toward a possible benign disease. However, as we show here, calcification in PN as a criterion to determine benign nature is fallacious and can be misleading. The differential considerations of a calcified lesion include calcified granuloma, hamartoma, carcinoid, osteosarcoma, chondrosarcoma and lung metastases or a primary bronchogenic carcinoma among others. We describe and illustrate different patterns of calcification as seen in PN on imaging.

Insomnia in chronic renal patients on dialysis in Saudi Arabia.

BACKGROUND: Studies have shown that insomnia is a common sleep disorder among patients with end-stage renal disease (ESRD). This study aimed to assess the prevalence of insomnia in Saudi patients with ESRD who are on maintenance dialysis. METHODS: This was an observational cross-sectional study carried out over a period of five months in two hemodialysis centers in Saudi Arabia. To assess the prevalence of insomnia, we used the ICSD-2 definition. We also examined the association between insomnia and other sleep disorders, the underlying causes of renal failure, dialysis duration, dialysis shift, and other demographic data. RESULTS: Out of 227 enrolled patients, insomnia was reported by 60.8%. The mean patient age was 55.7 +/- 17.2 years; 53.7% were male and 46.3% were female. Insomnia was significantly associated with female gender, afternoon hemodialysis, Restless Legs Syndrome, high risk for obstructive Sleep Apnea Syndrome and excessive daytime sleepiness (P-values: 0.05, 0.01, < 0.0001, < 0.0001, and < 0.0001, respectively). No significant association was found between insomnia and other variables, including BMI, smoking habits, underlying etiology of renal failure, dialysis duration, association with hemoglobin, ferritin, and phosphorus or dialysis adequacy as measured by the Kt/V index. CONCLUSION: Insomnia is common in dialysis patients and was significantly associated with other sleep disorders. Greater attention needs to be given to the care of dialysis patients with regard to the diagnosis and management of insomnia and associated sleep disorders.

Factors associated with decision-making about end-of-life care by hemodialysis patients.

The current cross sectional study is based on a questionnaire database on patients with end-stage renal disease (ESRD) to determine their preferences about end-of-life care and differences of certainty regarding the application of cardiopulmonary resuscitation and life sustaining measures in case of cardiac arrest. The study was performed on 100 patients on hemodialysis for at least 2 years and not on the transplant list in two tertiary hospitals in Saudi Arabia; King Fahad National Guard in Riyadh and King Faisal Specialist Hospital in Jeddah in March 2007. More than two thirds of the surveyed patients were willing to make decisive decisions. Having more than 5 children was the only factor significantly associated with the ability to make decisive decisions; there was an insignificant association with factors such as marital status or non-Saudi nationality. Factors such as self-perception or disease curability, previous admissions to hospital or intensive care units, prior knowledge of mechanical ventilation, or cardiopulmonary resuscitation did not have any influence on making certain decisions on end-of-life care. There was a significant lack of knowledge in our study patients of cardiopulmonary resuscitation, mechanical ventilation, and disease outcome.

Saudi guidelines for testing and treatment of latent tuberculosis infection.

Pulmonary tuberculosis is a common disease in Saudi Arabia. As most cases of tuberculosis are due to reactivation of latent infection, identification of individuals with latent tuberculosis infection (LTBI) who are at increased risk of progression to active disease, is a key element of tuberculosis control programs. Whereas general screening of individuals for LTBI is not cost-effective, targeted testing of individuals at high risk of disease progression is the right approach. Treatment of those patients with LTBI can diminish the risk of progression to active tuberculosis disease in the majority of treated patients. This statement is the first Saudi guideline for testing and treatment of LTBI and is a result of the cooperative efforts of four local Saudi scientific societies. This Guideline is intended to provide physicians and allied health workers in Saudi Arabia with the standard of care for testing and treatment of LTBI.

The Saudi Initiative for Asthma.

The Saudi Initiative for Asthma (SINA) provides up-to-date guidelines for healthcare workers managing patients with asthma. SINA was developed by a panel of Saudi experts with respectable academic backgrounds and long-standing experience in the field. SINA is founded on the latest available evidence, local literature, and knowledge of the current setting in Saudi Arabia. Emphasis is placed on understanding the epidemiology, pathophysiology, medications, and clinical presentation. SINA elaborates on the development of patient-doctor partnership, self-management, and control of precipitating factors. Approaches to asthma treatment in SINA are based on disease control by the utilization of Asthma Control Test for the initiation and adjustment of asthma treatment. This guideline is established for the treatment of asthma in both children and adults, with special attention to children 5 years and younger. It is expected that the implementation of these guidelines for treating asthma will lead to better asthma control and decrease patient utilization of the health care system.

Restless legs syndrome in patients on dialysis.

Restless legs syndrome (RLS) is an extremely distressing problem experienced by patients on dialysis; the prevalence appears to be greater than in the general population, with a wide variation from 6.6% to 80%. The diagnosis of RLS is a clinical one, and its definition has been clarified and standardized by internationally recognized diagnostic criteria, published in 1995 by the International Restless Legs Syndrome Study Group (IRLSSG). This study was designed to find out the prevalence of RLS in Saudi patients with end-stage renal disease (ESRD) on maintenance dialysis. This is a cross sectional study carried out between May and Sept 2007 at two centers, King Abdulaziz Medical City-King Fahad National Guard Hospital (KAMC-KFNGH), Riyadh and King Faisal Specialist Hospital and Research Centre (KFHRC), Jeddah, Saudi Arabia. Data were gathered on 227 Saudi patients on chronic maintenance hemodialysis or chronic peritoneal dialysis. The prevalence of RLS was measured using IRLSSG's RLS Questionnaire (RLSQ). Potential risk factors for RLS including other sleep disorders, underlying cause of chronic renal failure, duration on dialysis, dialysis shift, biochemical tests and demographic data were also evaluated. The overall prevalence of RLS was 50.22% including 53.7% males and 46.3% females. Their mean age was 55.7 +/- 17.2 years and mean duration on dialysis 40.4 +/- 37.8 months. Significant predictors of RLS were history of diabetes mellitus (DM), coffee intake, afternoon dialysis, gender and type of dialysis (P= 0.03, 0.01, < 0.001, 0.05 and 0.009 respectively). Patients with RLS were found to be at increased risk of having insomnia and excessive daytime sleepiness (EDS) (P= < 0.001 and 0.001, respectively). Our study suggests that RLS is a very common problem in dialysis population and was significantly associated with other sleep disorders, particularly insomnia, and EDS. Optimal care of dialysis patient should include particular attention to the diagnosis and management of sleep disorders.

Levels of acceptance of Asthma Control Test questionnaire among Saudi patients attending 5 tertiary care hospitals in Saudi Arabia.

OBJECTIVE: To explore the levels of acceptance of asthma control test (ACT) among Saudi patients. METHODS: A cross-sectional survey was carried out in 5 hospitals in Riyadh, Kingdom of Saudi Arabia, namely; Security Forces Hospital, King Abdul-Aziz Medical City, King Khalid University Hospital, King Faisal Specialist Hospital, and Riyadh Armed Forces Hospital, from the first of September to the 30th of November 2006. Patients attending the pulmonary clinic were asked to answer the ACT. This was followed by an interview to assess their view on the questions and their level of difficulty. RESULTS: The total number of patients was 1060. Males constituted 41%. A third of the patients were uneducated. The majority of patients (94%) found the ACT questions easy. The younger patients found the ACT questions easier to answer than the older patients. Ninety-five percent of males found the ACT easy, while only 92% of females found the ACT easy. Educated patients found the ACT questions easy to perform more often than uneducated patients. There are no significant differences for age and gender, and for the question on whether the test helped to understand the patient's condition. There are no significant differences for age and education, and for the question on whether the patient is willing to perform the test in each clinic visit. CONCLUSION: The majority of Saudi patients found the ACT easy, and they are willing to repeat the test every clinic visit.

Advance care planning preferences among dialysis patients and factors influencing their decisions.

To determine the resuscitation preferences of hemodialysis (HD) Saudi patients, we con-ducted a cross-sectional, observational descriptive questionnaire study in two major tertiary hospitals in Saudi Arabia from March to December 2007. We enrolled all the patients on HD for two years or more, and excluded the patients who were transplant candidates, confused, or demented. The questionnaire was com-posed of 4 sections. The first 3 sections were concerned with demographic data, education levels, employ-ment, family size, number of children, and functionality status besides knowledge about cardiopulmonary resuscitation (CPR), mechanical ventilation, and ICU admission. The fourth section contained different sce-narios and questions on personal and preferences such as end of life decisions, medical interventions, CPR, ICU admission, and the decision maker in these events. A total of 100 patients (53% males, 67% Saudis, and 85% married) were enrolled in the study. The mean duration on dialysis was 6.0 years (+/- 4.1). More than 70% of the patients viewed themselves as above average in the religiosity score, and 44% disclosed a good life quality. More than 95% had little or no knowledge about cardiac resuscitation, intubation, and mechanical ventilation. The majority of the patients authorized their treating physician to decide for them about cardiac resuscitation in case they did not make advanced directives and only 22% believed that this decision should be made by their family members. If their physician believed their condition was hopeless, 77% preferred to stay at home. We conclude that the majority of our patients had limited awareness about cardiac resuscitation measures. The majority of the patients trust their physicians to decide about the futility of resuscitation. Patients were able to decide reasonably well when they are well informed.

Asthma control assessment using asthma control test among patients attending 5 tertiary care hospitals in Saudi Arabia.

OBJECTIVE: Evaluation of asthma control using the Asthma Control Test (ACT). METHODS: The ACT was used to assess asthma control among patients with bronchial asthma visiting pulmonary clinics in 5 major tertiary care hospitals in Riyadh, Kingdom of Saudi Arabia. Each hospital had a target of 300 patients to recruit over the period of the study from the 1st September to 30th November 2006. RESULTS: The total number of patients studied was 1,060 patients. Males constituted 442 (42%) and females constituted 618 (58%), the median age was 38.56 years (range 15-75). One third of patients had no formal education. The ACT score revealed uncontrolled asthma in 677 (64%), well-controlled asthma in 328 (31%), and complete controlled in 55 (5%). There are no significant correlations between the age below 40 and above 40 years and level of asthma control (p=0.12). However, the younger age group less than 20 had better control of asthma in comparison with older patients (p=0.0001). There was a significant correlation between level of asthma control and gender, males (44%) had better asthma control than females (30%) (p=0.0001). CONCLUSION: Control of bronchial asthma is still a major concern in our population. Further studies are needed to explore the factors leading to poor asthma control.

Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman's Disease) as cause of isolated hilar lymphadenopathy and complete remission after high dose steroid.

Rosai-Dorfman's Disease, also known as sinus histiocytosis with massive lymphadenopathy (SHML), is a rare histiocytic proliferative disorder and a distinct clinico-pathological feature of unknown origin. Painless cervical lymphadenopathy is the most common clinical presentation. Different treatment modalities have been tried with variable responses, however, there is no consensus on the best modality of treatment. Here, we present a case report of SHML causing isolated hilar lymphadenopathy with complete remission for more than 6 years, after a short course of high dose steroid (dexamethasone 20 mg daily for 3 days).

Prevalence of symptoms and risk of sleep apnea in middle-aged Saudi males in primary care.

OBJECTIVE: The prevalence of obstructive sleep apnea OSA has not been assessed in Saudi Arabia. We aimed to assess the prevalence of individuals who were at risk of OSA in a sample of middle-aged Saudi males, using the Berlin questionnaire at primary care settings. METHODS: The study was conducted at King Khalid University and King Fahd National Guard primary health care clinics in Riyadh, Kingdom of Saudi Arabia between December 2005 and March 2006. Berlin Questionnaire was administered by trained medical students to consecutive Saudi male patients in the age group 30-65 years attending the primary health care clinics, after explaining the procedure of the study. Based on the data collected and defined criteria, patients were stratified into high risk and low risk according to responses. RESULTS: Five hundred and seventy-eight middle-aged Saudi males with a mean age of 45.02 +/- 9.3 year were surveyed in this study. Snoring was present in 52.3%, and breathing pauses more than once per week was noticed in 11.3%. Based on the Berlin questionnaire stratification for risk of OSA, 33.3% were considered as high risk patients for OSA. The occurrence of daytime tiredness >once/week was reported by 35.5%. The prevalence of snoring and risk for OSA is similar to that reported in the US. CONCLUSION: In primary care setting, one in 3 middle-aged Saudi males is at risk for OSA.

Perception of the role of inhaled corticosteroids and factors affecting compliance among asthmatic adult patients.

OBJECTIVE: To examine the patient characteristics linked with reduced adherence to inhaled corticosteroids (ICS) use. METHODS: A prospective study of adult asthmatic patients who were prescribed with ICS and are under regular follow-up at the pulmonary outpatient clinics between June 1st, and December 31st, 2001, at King Fahad National Guard Hospital in Riyadh. All patients underwent structured interviews with an investigator. RESULTS: Included in the study were 334 patients. Thirty eight percent (38%) of the patients reported irregular use of ICS. Factors associated with irregular ICS use were a negative perception of the role of ICS (p=0.03) and less than high school education (p=0.03). Almost 50% (169/334) of all patients had concerns regarding ICS safety resulting in reduced willingness to use them. These concerns were again significantly related to the level of education and the patient's attitude to ICS. Among the most common fears hindering regular ICS use were their potential to lead to addiction (60%) and worry from steroid side effects (41%). CONCLUSION: The result of this study raises the importance of patient's education and the importance of treatment of those involved in asthma care to educate the patient and discuss with them the role of asthma medications, particularly ICS, and to correct common fears and misconceptions.