This the last issue for this year for the journal. We would like to send a special thanks for the authors who submitted papers to the journal, our readers, reviewers and production staff headed by our publishing manager and the editorial office.

This issue is rich with various papers from the World and touch different themes of interest to primary care. Dr. Basheikh did a Cross sectional analysis of anonymous adults in Saudi Arabia participated in an electronic format questionnaire by social media to measure the awareness toward witnessed seizure in prehospital setting. The correct reaction toward a seizing patient was only chosen by 18 participants (4.3%). The author conclude that the study results suggest that general public awareness about reaction to seizures in Saudi Arabia is inadequate and in need for increasing awareness.

A number of paper looked at issues related to Diabetes in the region which is very high in the Gulf. The prevalence of diabetes mellitus (DM), in Saudi Arabia, is growing at a fast rate. About 25% of the 30 - 70 years old subjects suffer from DM; this figure is further predicted to double by the year 2030. El-Gamal, et al., did a cross-sectional study to investigate the occurrence of DM among different age groups, and explore the determinants, risk factors and clinical aspects of DM among Saudis in Jeddah. The study included 1106 subjects. The authors concluded that DM is a major health problem among Saudis in Jeddah city. Our results demonstrate the need for major intervention to reduce this burden and to engage other sectors of the government and the community in these efforts. Al-Mallah, et al., evaluated the effectiveness of clinical pharmacist intervention in lifestyle modification to improve glycemic control and diabetic peripheral neuropathic symptoms. The authors concluded that the provision of lifestyle modification has positive effects on glycemic control and a clinically effective approach for patients with DPN that improves peripheral neuropathic symptoms, its severity, and pain interference.

Aldhabaan. Et al., did a descriptive cross-sectional study to assessed the knowledge, attitude and practice of diabetic retinopathy among the Diabetic Patients in Aseer Region. A total sample of 915 participants was included in the study with nearly half of them aged 40 years or more. The authors concluded that the study revealed that the patients' awareness level and practice regarding diabetic retinopathy was intermediate. The patients who were recently diagnosed were more compliant for periodic checkup and had higher awareness level. More effort should be paid to improve patients' awareness regarding diabetes as a chronic health problem and its related complications nature. Dr. Almoutaz & Almulla tried to assess the magnitude of economic burden of diabetes care in low- and middle-income African countries. Literature review using systematic approach was conducted for the evidences on the cost of diabetes in low- and middle-income African countries. The authors concluded that there is a considerable economic burden associated with diabetes mellitus. Future researches should focus on standardization of the methodologies for cost calculation, enhancing the interpretation of study findings and facilitating comparisons between studies.

In two papers diabetic foot disease were discussed. Dr Ahmed, reviewed diabetic foot disease and its management. She stressed that Diabetic foot ulcer (DFU) without treatment and regular review will progress from an ulcer to an infection. An estimated 10-15% of people with diabetes will have a DFU at some point in their lives. More than 80% of the amputations in patients with diabetes are due to DFU. Hassan et al., did a study to assess the effect of honey use in treating diabetic foot ulcer on Saudi diabetic patients. Thirty-two diabetic patients having diabetic foot infections were included in this study. The study proved that honey can be used as an effective, cheap, easily available, non-toxic adjuvant without adverse side effects in treatment of diabetic foot infections.

Dr. Sheikh, looked at Sulfonylureas and Mortality Risk. He stressed that Sulfonylureas have been used as second line option after metformin worldwide for better glycaemic control since last few decades. Recently newer evidence has emerged highlighting the adverse effects of sulfonylureas in terms of increased cardiovascular risks, stroke risk and increased mortality overall. His review This focused on literature review giving evidence around sulfonylurea and associated mortality risks. Dr. Musallam did a quality project for Improving albuminuria screening in Type 2 diabetes mellitus patients. She stressed that Diabetic kidney disease, which occurs in 20-40% of diabetic patients. The author concluded that the intervention showed
improvement in the percentages of albuminuria screenings in type 2 diabetic patients.

Almalki et al., followed a cross-sectional study was done on 398 diabetic women to assess the prevalence for UI in women with diabetes. The prevalence of UI was 34%. Participants with an age ? 50 year, having DM type 2, UTI, Ovarian cyst, neuropathy higher levels of HbA1 and FBG had a significant higher percent of those having UI. The author concluded that there is a need of educating diabetic women about UI and methods of management. Dr . Alfaifi did a retrospective cohort study design was applied through record reviewing of type 2 diabetic patients at the Armed Forces Hospital. The author concluded that a considerable proportion of type 2 diabetic patients have thyroid dysfunction. Screening for early detection of thyroid dysfunction in patients with type 2 diabetes mellitus should be done routinely in all places taking care of those patients .

A paper from Canada looked at myths with diuretic. The authors mentioned that observational data suggest an association between hydrochlorothiazide and the risk of Squamous Cell Carcinoma. He reviewed 55 patients who were on HTCZ already. The author concluded that This unproven link direct us to start a discussion of skin cancer patients (as one of my patients was taking HTCZ and getting recurrent SCC) link to HTCZ and lawsuit against manufacturers. It also lead us to think whether any other kind of medication subjected to cause skin lesions or cancers, which required more observation and research in future.

A cross sectional hospital based study done in Saudi Arabia during the period from January 2010 to December 2011 to study the clinical pattern of tuberculosis in malnourished children below five years of age admitted as diagnosed cases of tuberculosis. The author concluded that the clinical diagnostic scores are sensitive but they use non-specific parameters. Screening of children with adult TB contact and sufficient rehabilitation of malnourished children before labelling them as tuberculous is recommended.

Alfaya et al., did a descriptive cross-sectional tried to assess the general population awareness regarding club foot in Aseer region. A total of 744 participants were included in the survey. The authors concluded that, the survey revealed that public awareness regarding club foot in Aseer region was very low especially among females with high level of education. Also, health care providers had no role in improving this public awareness

A paper from Saudi Arabia evaluated communication skills of resident physicians at different health care facilities in Saudi Arabia through a cross-sectional, questionnaire-based study. A total of 210 resident doctors participated, of which 31.4% were internal medicine trainees, and 27.1% were family medicine trainees. Results of this study point towards a lingering need to focus on training of physicians in effective communication and efforts should be made to include it as a core competency in medical curriculum.

In two paper colorectal cancer was discussed. Farsi, et al., did a cross-sectional study to assess medical students' attitude and knowledge toward CRC screening and to determine the obstacles that they face. The authors concluded that medical students have not reached their full potential as CRC screening proponents for a variety of reasons, including inadequate knowledge and suboptimal attitudes, as well as the presence of various barriers that hinder them. El-Gamal et al., did a cross sectional survey to study the pattern of Knowledge, Attitude, and Practice (KAP), of CRC in Jeddah city, SA. The total number enrolled was 364 subjects. The authors concluded that although CRC is a major cause of morbidity and mortality in KSA, yet the KAP of the studied subjects were defective. There is an urgent need to implement health education programs to raise the KAP standards of the community about CRC. More researches, about this issue, in different regions of the Kingdom need to be conducted.

A number of papers looked at awareness issues. Dr. Al-Hefdhi, did An interviewer- administered questionnaire was used to study infant-feeding knowledge and practice. This study explores some of the factors related to knowledge and practice of infant feeding which are: mother's age and her level of education, father's age and his educational level and occupational status, family size and monthly income, prenatal plan and prenatal health education of infant feeding and practice of breastfeeding with the previous child. Alhazmi et al., did a cross sectional study was done on 620 Saudi children to assess the relationship between using alcohol swab cleaning of umbilical cord and the time of healing of the umbilicus till cord separation and associated complications. The authors concluded that further studies that include a larger sample of children is required, and heath educational programs regarding umbilical cord directed to pregnant mothers during antenatal visits is needed. Shehata et al., did a descriptive cross-sectional study was used to assess awareness, attitude, and practice regarding E-cigarettes among students at King Khalid University, Saudi Arabia. The authors concluded that, the current study revealed that half of the students were knowledgeable regarding E-cigarettes and its effect. Also, using E-cigarettes was not high (less than one fifth) especially among young female students.

Wani et al., did a record based retrospective cohort study to determine the incidence of dyspnoea and/or bleeding as side effects of ticagrelor and compare it with commonly used P2Y12 platelet receptor inhibitors, clopidogrel. The authors concluded that significant number of patients who are started on ticagrelor develop dyspnoea but not compromising the therapeutic superiority of drug as compared to clopidogrel and can be replaced as first line drug in Saudi population Other side effect profiles of ticagrelor are comparable to conventional anti platelet drugs with no significant statistical variability.

Dr Ahmed, presented a case of Of hyperemesis gravidarum. The patient a
24years old lady, Gravida 2 parity 1 with one previous vaginal delivery recurrently presented to her health center from 7 to 10 weeks gestation with symptoms of nausea and vomiting up to 10 times/day. Antenatal USS showed a viable pregnancy with fetal growth consistent with the gestational age at 11 weeks. After 10days, she was discharged home with oral pantoprazole and general advice regarding symptoms management and return if symptoms of nausea and vomiting recurred. A paper from Yemen did a retrospective medical charts of patients presenting to the ENT Units of two private hospitals in Aden, to describe the characteristics of the patients and to evaluate the endoscopic septoplasty: outcome and complications. The author concluded that endoscopic septoplasty is an effective technique that can be performed safely.

Dr. Alshyarba, followed a retrospective approach, of all patients who underwent nephrectomy from January 2008 to December 2017. Data were reviewed with regards to clinical presentation, nephrectomy indication, and histopathological report. The author conclude that although, the non-functioning kidney is still the leading indication of nephrectomy in this series, RCC cases have significantly increased to almost four times what being reported from this institute over twenty years. This mandates immediate and long term heath policy planning to address this shift. AlKhayat, et al., followed a cross sectional study was done on 340 primary school children to assess the prevalence of pediatric OSA and its association with school performance among Saudi children. The prevalence of OSA was 9%, where children > 12 years, obese, those having RTI, allergy, had a significant higher percent of having OSA. on the other hand, a non-significant difference was found between the presence of OSA and children overall academic level. There is a need for future school-based studies done on a larger sample to confirm the observed associations found in the present study.

Al-Towairqi et al., conducted a cross section study to determine the prevalence of GERD and their risk factors Among Female at Medical college. The authors concluded that
this study demonstrated a high GERD prevalence among studied students. There is a need to increase awareness of university students about modifiable risk factors of GERD. Dr Sumathipala stressed that thyroid nodules are a common condition and family medicine clinicians are likely to encounter them not least as incidental findings from a variety of imaging modalities. Most of these nodules are benign but often investigations will need to be undertaken to exclude malignancy. Therefore, family medicine clinician will need to know how to manage thyroid nodules, including how to assess for malignancy, including an understanding of the investigations required and what follow up is necessary.

A number of papers discussed Covid 19 issues in the region. Filfilan et al., did a cross-sectional study to assess the effects of COVID-19 on the psychological health of family physicians in Saudi Arabia. The study showed that this pandemic has created many high concerns among Family physicians about their health, family's health and also the public health. Moussa et al., surveyed the impact of Covid 19 on the healthcare sector. Results from this survey showed that family medicine residents got benefited from their experience as front-line staff managing patients during the covid-19 pandemic mostly in social, behavioral and skills aspects and to a minor degree in professional aspect. on the other hand, the family medicine educational aspect was negatively impacted. Haseeb, et al., discussed the challenge of virtual consultation in diagnosing acute medical conditions in primary care. The aim of virtual consultations is to protect both the patient and the clinician from the potential spread of the coronavirus. They looked at a specific case where the telephone consultation model had limitations in reaching a diagnosis and commencing appropriate timely treatment.

Alhamidi and Alyousef, did a study with the aim to gain insights into personal perceptions of the quarantine experience of patients and was undertaken with the hope of providing illumination to health care providers concerning this experience. Results were conceptual themes that fell into two broad categories - positive and negative beliefs and experiences. Alhamidi, and Almutairi, did a study to explore the caring experience of Saudi Arabian nurses who are manning the quarantines during the covid 19 epidemic. The authors concluded that professional needs and personal challenges faced by nurses during the delivery of care for quarantine and disasters may supply a valuable perspective to this aspect of practice and may assist in providing useful considerations for preparation to meet challenges of this type including nursing education and training in administration, infection control, health education, and disaster management.

Alkuwari, et al., did a metanalyses review between 1970 through 2015 to identify intrinsic predictors that are associated with increased risk of initial and lateral ankle sprain. Most studies not sufficiently powered, with fair to poor quality with not adequately mentioned concealment and blindness from the outcome measure. Different equipment was used to investigate the variables. The authors concluded that a previous history of ankle sprains as well as ankle plantar flexion strength put athletes and physically active individuals at risk for initial and recurrent ankle sprain.

Haseeb & Bashir looked at challenges faced by physicians and patients to provide adequate healthcare to patients, particularly the migrant population. They stressed that
large number of doctors currently working in hospitals and primary care in the Middle East have migrated from Asian and European countries and may not be adept at speaking the native Arabic language. In Primary Health Care Corporation (PHCC), Qatar, doctors and patients face r communication difficulties particularly in the first few years of their arrival to Qatar. They discussed strategy PHCC employs to overcome this problem and how other nations need to develop their own strategies as well. Bashir & Haseeb looked at depression as a silent killer from a South Asian perspective. They stressed that depression is a chronic illness having major impact on a significant population of the World. The problem continues to grow rapidly in the wider World. Due to the silent nature of the illness in the vast majority of the people, it continues to be underdiagnosed and untreated.

Aljehani & Algahtani Did a cross-sectional To estimate the psychological impact of acne vulgaris among female secondary school students. The study included 388 females; there were 93.5% Saudi, 98.7% single females, and 87.9% in secondary school. The author concluded that acne had a significant psychological impact on female students with varying degrees that were affected by age and education of students.

Abdulrazak Abyad
Chief Editor