Saudi Cultural Missions Theses & Dissertations
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Item Restricted The Scale of Problems Associated with High-Dose Methotrexate: A systematic review of Toxicity Patterns(Saudi Digital Library, 2025) Alruwaili, Aseel Mubarak; Goldring, Christopher EHDMTX is a cornerstone in the treatment of acute lymphoblastic leukaemia, osteosarcoma, and lymphoma, but its use is complicated by unpredictable toxicities. This systematic review synthesised evidence from 93 studies to identify consistent predictors of toxicity. Impaired elimination and elevated systemic exposure were the most consistent predictors of renal and downstream toxicities. Genetic variants, particularly in SLCO1B1, consistently predicted delayed clearance, while others, including MTHFR, showed weaker and less reliable associations. Demographic factors such as age and sex influenced risk mainly as modifiers rather than independent determinants once clearance was considered. Treatment-related factors, including high-dose intensity, interacting medications, and early biochemical changes, also shaped toxicity outcomes. Supportive care with hydration, alkalinisation, and leucovorin remains essential, while timely use of glucarpidase is the most effective intervention for severe delayed clearance or methotrexate-induced kidney injury. Overall, these findings support an exposure-driven model of HDMTX toxicity and highlight the importance of pharmacokinetic monitoring, careful management of drug-drug interactions, and prompt rescue strategies. Together, they provide a framework for safer and more individualised use of HDMTX in oncology.6 0Item Restricted Trust in Healthcare Public-Private Partnerships in Delhi NCR: A Systematic Review of Stakeholder Perceptions and Governance Challenges(Saudi Digital Library, 2025) Alsaqabi, Dimah; Bhardwaj, Simran; Sultana, Parveen; Albariqi, Yazeed; Chichani, Sushant; Alshrari, Zeyad; Preethi, JohnBackground: Trust is central to the success of healthcare public-private partnerships (PPPs) yet remains poorly understood in the Indian context. This review examines trust dynamics in PPPs within Delhi NCR, a region marked by complex governance and significant PPP activity. Objectives: To identify key trust factors and its dynamics discussed in the literature on healthcare PPPs across Delhi NCR; and to provide recommendations for building and sustaining trust in future healthcare PPPs. Methods: A systematic review was conducted following PRISMA 2020 guidelines. Searches were performed in PubMed, Scopus, Elsevier, institutional library repositories, and Google Scholar encompassing studies published between January 2000 – May 2025. Inclusion criteria targeted empirical studies, policy papers, and case reports on trust in Indian healthcare, particularly Delhi-NCR context. Data were thematically synthesised using Braun and Clarke’s Thematic Analysis method and analysed through McKnight’s and Institutional Trust frameworks. Case study analysis was conducted using Porter’s Value Chain. Results: Forty studies met inclusion criteria. Five interrelated trust factors were identified: transparency, accountability, stakeholder engagement, regulation, and payment. Transparency and accountability showed strong positive correlation (r = 0.72). A Delhi-based dialysis PPP case study validated thematic findings, highlighting systemic trust breakdowns. Limitations: This review's findings are limited by being sector specific, as trust dynamics in healthcare PPPs may not translate directly to other sectors. Geographic bias is evident, with limited representation of regions beyond Delhi NCR, reducing national applicability. Additionally, the cross-sectional nature of most studies restricts insight into how trust evolves over time. Conclusion: This review examined what builds and breaks trust in healthcare PPPs, with a focus on Delhi-NCR. Five interconnected trust factors: transparency, accountability, stakeholder engagement, regulation, and payment were consistently identified. Transparency emerged as the most foundational, enabling or disabling other trust mechanisms. Theoretical frameworks helped explain paradoxes, such as low trust in high-influence stakeholders. Ultimately, trust must be intentionally embedded into PPP design through inclusive, transparent, and accountable governance.19 0Item Restricted The Impact of Generative AI on Teaching, Learning, and Integrity in Higher Education: A Systematic Review(Saudi Digital Library, 2025) Alghamdi, Abdullah Ali A; Kang, KyeongThis systematic review investigates the impact of Generative Artificial Intelligence (GenAI) on teaching practices, student learning, and academic integrity within higher education. This review conducted a qualitative thematic synthesis of 25 peer reviewed studies published 2020−2025, and using PRISMA 2020 framework for the review. The results will prove that GenAI will enable greater teaching efficiency, allow for more personalized learning routes, and will make education more accessible. GenAI tools are now being used by educators to automate feedback, create fresh assessments, and create differentiated instruction, while students use its AI powered platforms for academic’s support, language help, and creative exploration. The study also reveals some critical challenges. Misuse of GenAI can lead into superficial engagement and hinder the growth of critical thinking skills. The one major consideration is the development of the academic misconduct patterns, which GenAI-generated content is not being detected by traditional plagiarism detection tools. Higher education institutions may struggle to maintain academic integrity when there is robust human judgment, and redefined standards of academic authorship, in an AI enhanced environment. Responses to GenAI adoption by institutions are still uneven, going from proactive policy formulation to restrictive bans. Similar attitudes vary among disciplines, age, and tolerance for the prior digital exposure. The review highlights the necessity of universities to have clear, adaptive policy in place, incorporate AI literacy into curricula, redesign of assessments to encourage authentic learning processes, and university faculty development. To contribute to the growing dialogue on AI and education this study provides a synthesized thematic understanding of GenAI integration’s opportunities, risks, and institutional strategies. Second, it contends that GenAI must be embraced by higher education by both leveraging its benefits and mitigating its challenges for the sake of technology that offers no benefit and, even worse, threatens to undermine academic values.76 0Item Restricted Delivering Immersive Virtual Reality as an Intervention to Patients with Chronic Low Back Pain in The Kingdom of Saudi Arabia: A Mixed-Methods Feasibility Study(Saudi Digital Library, 2025) Alotibi, Fahad Salman; Hendrick, Paul; Moffatt, FionaBackground: Chronic low back pain (CLBP) has been recognised as a leading cause of disability in adults for three decades. Literature constantly calls for improved CLBP healthcare services. Immersive virtual reality (IVR) can encourage patients with CLBP to engage in exercise regimes and remain active, but the feasibility of IVR in the Kingdom of Saudi Arabia (KSA) among patients with CLBP is unknown. Aims: To investigate the feasibility of delivering IVR to patients with CLBP in the KSA. Method: Two studies were conducted. Part 1: an umbrella review of systematic reviews (SRs) aimed to identify, summarise, synthesise and critically appraise existing SRs regarding the effectiveness of VR in individuals with chronic MSK pain and disability, focusing on CLBP. The results of this previous review, along with patients and public involvement, informed the design of a protocol for testing the feasibility of delivering IVR to treat patients with CLBP in the Saudi context. Part 2: a sequential explanatory mixed-methods feasibility study aimed to examine predefined progression criteria of the feasibility of delivering IVR to a sample of individuals with CLBP and explore their experiences along with relevant healthcare practitioners in the Saudi context in outpatient department (OPD) settings. The feasibility study adopted a sequential explanatory mixed-methods design comprising two phases: the quantitative (Phase 1) and qualitative (Phase 2). Findings: Part 1: the overall confidence in the identified SRs ranged from low to critically low, whereas the certainty in the body of evidence ranged from moderate to very low. Although the results suggest that VR, either as an alternative form of treatment or in combination with other interventions, may provide a short-term positive impact on patient-reported outcomes for pain in patients with chronic primary MSK pain, it remains uncertain which specific VR intervention shows the most promise, as the included SRs grouped various types of VR together. However, results on patient-reported outcomes for disability and kinesiophobia were inconsistent. Adverse events included motion sickness, nausea, and vertigo. Part 2, Phase 1: the recruited patients included 31 males and two females over 12 weeks. The feasibility a priori criteria were met for recruitment, retention, dropout, completeness of questionnaire data, and treatment compliance and fidelity. No serious adverse events were experienced among patients. However, some incidences of non-serious, short-lasting, minor adverse events were reported. Part 2, Phase 2: analysis of qualitative data from interviews with eight male patients and three physiotherapists (the latter of whom comprised two males and one female) revealed four overlapping themes: sociocultural considerations, facilitators, barriers, and feasibility. Sociocultural considerations included visual (e.g., avatar outfit), auditory (e.g., music), contextual (e.g., same-gender IVR administrator), and IVR-specific factors (e.g., feeling ashamed to play like a child). From the patients’ perspectives, the study process and materials were described as feasible, and recommendations were discussed for IVR implementation. From the physiotherapists’ perspectives, recommendations for the success of IVR integration into the KSA healthcare system included using multiple devices and an efficient scheduling system. Facilitators, from the patients’ perspectives, included ‘positive IVR experience,’ and ‘IVR is motivational.’ Additionally, from patients’ and physiotherapists’ perspectives, facilitators included ‘IVR is therapeutically useful, easy to use, and tolerable.’ Barriers to delivering IVR, from the patients’ perspectives, were ‘personal challenges’ related to time and travel. Furthermore, the physiotherapists-related barrier was ‘time-consuming for physiotherapists.’ Moreover, from both patients’ and physiotherapists’ perspectives, barriers included ‘lack of knowledge’ and ‘support and infrastructure issues.’ Implications: The results indicate that IVR was feasible, acceptable, and tolerable among patients with CLBP and healthcare professionals in the KSA within OPD settings. IVR can be utilised to support patients’ engagement in physiotherapy OPD settings. Further research focusing on the effectiveness is warranted in this field. Furthermore, further mixed-methods research within the context of this study and other MSK conditions is warranted in the Saudi Context to reveal more sociocultural considerations.11 0Item Restricted Is there a Relationship between the Number of Consultations with a Clinician or Exercise Provider and Outcomes of Pain and Physical Function Following an Exercise Program for People with Knee Osteoarthritis?(Saudi Digital Library, 2025) Alhjjaji, Nouf; Lawford, Belinda1. Abstract 1.1 Background Knee osteoarthritis (OA) is a common disease that presents a significant health burden, causing chronic joint pain and physical function limitation. Given that there is no cure, exercise therapy is recommended as the first-line treatment by all current international clinical guidelines. 1.2 Objectives This systematic review aimed to investigate whether the number of consultations with a clinician or exercise provider is associated with changes in pain and physical function following an exercise intervention in individuals with knee OA. 1.3 Methods We conducted a systematic review with meta-regression and subgroup meta- analyses. A comprehensive literature search was performed using three electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase, from inception until 26 February 2025, with no language restrictions. We included randomised controlled trials (RCTs) comparing exercise interventions for knee OA to no treatment, usual care, attention control/placebo, or co- interventions. The primary outcomes were changes in self-reported pain and physical function. Meta-regression were used to evaluate associations between the number of consultations and outcome changes. Additionally, subgroup meta-analyses were conducted across eight consultation-frequency groups (0, 1–3, 4–6, 7–9, 10–15, 16– 20, 21–25, and 26+ sessions). Sensitivity analyses were conducted to address potential outliers and reduce heterogeneity. 1.4 Results A total of 145 RCTs involving 12,633 participants were included. The number of consultations across studies ranged from zero to over 26 sessions. Meta-regression analyses revealed no statistically significant association between the number of consultations and changes in pain (slope coefficient = −0.003 standardised mean difference [SMD], 95% CI: −0.008 to 0.002; p = 0.203) or physical function (slop coefficient = −0.003 SMD, 95% CI: −0.008 to 0.002; p = 0.250). Subgroup meta- analyses similarly found no meaningful differences in outcomes across the different consultation-frequency groups. Substantial between-study heterogeneity was observed, and evidence of publication bias was detected. Sensitivity analyses, which excluded outliers (20 trials for pain and 24 for function with SMD > ±2), did not alter the overall findings. 1.5 Conclusion There was no association between the number of consultations and changes in pain or function following an exercise program for people with knee osteoarthritis (OA). Given the overall poor quality of the included studies, as well as the heterogeneity among studies, the findings should be interpreted with caution.16 0Item Restricted Does Integrating Cognitive Behavioural Therapy into Cardiac Rehabilitation Improve Depression and Quality of Life in Adults with Cardiovascular Disease? A Systematic Review.(Cardiff University, 2025) Alqahtani, Ola; Gale, NicholaDoes Integrating Cognitive Behavioural Therapy into Cardiac Rehabilitation Improve Depression and Quality of Life in Adults with Cardiovascular Disease? A Systematic Review. Background & Rationale Cardiovascular disease (CVD) is the world’s leading cause of death and disability, placing significant clinical and economic burdens on healthcare systems. While cardiac rehabilitation (CR) encompassing exercise, education, and routine psychosocial support has been shown to improve clinical outcomes, up to thirty percent of cardiac patients experience clinically meaningful depressive symptoms which reduce CR adherence and long-term success. Cognitive behavioural therapy (CBT) offers a structured approach to modifying maladaptive thoughts and behaviours, potentially addressing psychological barriers more effectively than generic psychosocial support. However, many reviews have evaluated heterogeneous ‘psychological interventions’ rather than isolating CBT’s specific impact. This systematic review set out to determine whether CBT, when integrated into CR, alleviates depression and enhances health-related quality of life (HRQoL) more effectively than CR alone. Methods A systematic literature search was conducted across five major databases (Medline, EMBASE, CINAHL, Cochrane CENTRAL, and PsycINFO) from inception to the most recent feasible date, adhering to PRISMA guidelines for study selection and reporting. Six randomised controlled trials, totalling 708 participants, satisfied the inclusion criteria by focusing on adults (≥18 years) undergoing CR for various cardiac conditions (such as myocardial infarction, heart failure, or post-cardiac surgery). Studies which integrated structured CBT sessions into standard CR were compared to CR alone or other forms of standard care. The primary outcome was the reduction in depressive symptoms, measured by validated scales (e.g., the Hamilton Rating Scale for Depression or the Hospital Anxiety and Depression Scale (HADS)). Secondary outcomes involved changes in HRQoL, assessed by either generic or cardiac-specific instruments (such as the Minnesota Living with Heart Failure Questionnaire). Quality appraisal followed the Joanna Briggs Institute guidelines and due to heterogeneity in intervention formats, population characteristics, and outcome measures, a narrative synthesis approach was applied rather than a meta-analysis. Key Findings and Discussion Although the six trials varied in terms of sample size, intervention intensity, and follow-up duration, they shared an overarching conclusion that integrating CBT within CR can lead to notable reductions in depressive symptoms and meaningful improvements in HRQoL. The degree of benefit was generally greater in patients presenting with moderate-to-severe baseline depression. Face-to-face CBT delivery typically achieved better adherence (often exceeding 75%) and larger effect sizes, whereas fully digital CBT programmes suffered from low engagement (approximately 15% module completion). These findings suggest that the personal interaction and therapeutic alliance inherent in face-to-face sessions remain critical for maximising CBT’s clinical impact in cardiac populations, particularly those facing multiple stressors related to their disease. CBT combined with exercise, in several trials, appeared to deliver synergistic benefits for depression and HRQoL, possibly through complementary behavioural (cognitive restructuring and skill-building) and physiological (improved cardiovascular function) mechanisms. The interplay between exercise encouragement and cognitive-behavioural strategies against fear-avoidance thinking also emerged as an important determinant of enhanced functional capacity and sustained improvements in mood. Limitations Several limitations may constrain the generalisability of these results. First, the overall sample predominantly comprised of male participants (approximately two-thirds were male), leaving questions regarding whether women, who often exhibit different depressive symptom profiles and a greater prevalence of depression post-myocardial infarction, would experience similar outcomes. Second, varied measures of depression and HRQoL, along with wide differences in the intervention ‘dose’ (ranging from five-session brief interventions to twelve-week combined programmes), precluded direct quantitative comparisons across studies. Some trials were also underpowered and only a few extended follow-up beyond six to twelve months. Digital CBT approaches did not yield strong results in this review but that may reflect poor adherence rather than intrinsic ineffectiveness, highlighting a need for more engaging and personalised technological platforms. Finally, these RCTs spanned multiple healthcare settings in Europe and the United States where infrastructural and cultural factors might influence both the feasibility of CBT delivery and participant engagement. Conclusions and Recommendations This review provides evidence that structured CBT, when delivered in tandem with cardiac rehabilitation, can significantly alleviate depressive symptoms and promote better quality of life. The most robust outcomes were observed in trials that targeted moderate-to-severe depression, employed face-to-face group or individual CBT sessions, and ensured consistent patient follow-up. These findings strengthen the case for systematically screening CR entrants for depressive symptoms and offering a dedicated CBT component to those above a certain severity threshold. Practical feasibility can be enhanced by training nurses, physiotherapists, or other allied professionals in CBT skills, as illustrated in studies where task shifting maintained strong outcomes. Policy-making bodies, such as national cardiac societies and health agencies, may wish to recommend CBT as a priority psychological intervention in CR programmes, particularly for patients with moderate or severe depression. Future research should further refine the optimal ‘dose’ of CBT, compare blended or stepped-care digital and in-person models, and evaluate the cost-effectiveness to guide broader adoption. By focusing on cognitive restructuring and behaviour change within the supportive framework of CR, healthcare systems can potentially improve both the mental health and functional recovery of individuals with CVD.7 0Item Restricted Exploring Factors Influencing Nurse Attrition in Intensive Care Unit in Critical Care in Saudi Arabia: A Systematic Review(Queens University Belfast, 2025-02-10) McKenna, Niall; Brown, MichaelBackground Methodology & search strategy Result Discussion conclusion26 0Item Restricted Systematic Review The Impact of Sedentary Behaviour on Health Outcomes in Chronic Obstructive Pulmonary(Galway University, 2024-08-25) Alshareef, Ibrahim; Said, Marwa; Marah, FeghaliThe Impact of Sedentary Behaviour on Health Outcomes in Chronic Obstructive Pulmonary7 0Item Restricted Enhancing Colorectal Cancer Screening Participation via Text Message Interventions(King's College London, 2024-09) Almoallem, Ghader; Round, Thomas; Hamad, WasimBackground: Colorectal cancer (CRC) ranks as the third most frequently diagnosed cancer globally and is a significant contributor to cancer-related deaths. Early detection through regular screening is crucial, as it greatly improves treatment outcomes and survival rates. However, screening participation for CRC remains insufficient, especially among minority groups. Text message interventions have been proposed as a cost-efficient and scalable solution to increase screening adherence. Objective: This systematic review and meta-analysis aimed to assess the effectiveness of text messaging interventions in enhancing CRC screening participation. Methods: A comprehensive search was conducted across four major databases Embase, PubMed, MEDLINE, and Cochrane up to August 2024. The review included randomized controlled trials (RCTs), observational studies, mixed-methods studies, and qualitative research that evaluated the impact of text message reminders on CRC screening rates. Data were extracted on study characteristics, intervention specifics, and screening outcomes. Meta-analyses were carried out to calculate pooled effect sizes of text message interventions compared to usual care. Results: Eighteen studies met the inclusion criteria, consisting of 12 RCTs, two observational studies, two mixed-methods studies, and two qualitative studies. The meta-analysis indicated that text message interventions significantly improved CRC screening uptake compared to usual care (pooled relative risk: 1.23, 95% CI: 1.12–1.36, p < 0.001). Sensitivity analyses validated the robustness of these results across different study designs and populations. Text message interventions were especially effective in low-income and underserved groups, where traditional outreach methods tend to be less successful. Furthermore, cost analysis from the reviewed studies highlighted that text messaging is a highly cost-effective method for promoting CRC screening. Conclusion: Text message interventions offer a scalable and effective approach to increasing participation in CRC screening programs. Their affordability, wide reach, and simplicity make them an ideal tool for public health systems, particularly those operating in resource-constrained settings. Despite these encouraging results, further research is needed to refine the content, timing, and cultural relevance of messages to ensure maximum impact across diverse populations. Incorporating text messaging into broader public health strategies could be crucial in alleviating the global burden of colorectal cancer.49 0Item Restricted Restrictive Versus Liberal or Standard Intravenous Fluid Administration in Patients with Sepsis or Septic Shock: A Systematic Review(Queen Mary University of London, 2024-07-31) Khogeer, Tariq; Prowle, JohnSepsis and septic shock are leading causes of morbidity and mortality worldwide, with effective management being critical to improving patient outcomes. Intravenous (IV) fluid resuscitation is a cornerstone of treatment in septic patients; however, the optimal fluid management strategy remains controversial. This systematic review examines the impact of restrictive versus liberal or standard fluid resuscitation strategies on mortality in patients with sepsis or septic shock. The review included eight randomized controlled trials (RCTs) involving 2,375 patients. The primary outcome was mortality within 90 days. Secondary outcomes included the use of mechanical ventilation, vasopressor requirements, renal replacement therapy, and the occurrence of adverse events such as limb ischemia and acute kidney injury. The findings suggest no significant difference in mortality between restrictive and liberal fluid administration. However, restrictive strategies may reduce the need for mechanical ventilation and vasopressor support. These results highlight the need for individualized fluid resuscitation strategies in septic patients, tailored to clinical circumstances. Further large-scale studies are recommended to confirm these findings and optimize fluid management protocols.18 0