ABSTRACT
Background:
Diabetes is associated with a range of psychosocial stressors that could lead to considerable distress and increased risk of depressive symptoms. There is a pressing need to understand the underpinnings of diabetes-related distress and how it evolves in connection with depressive moods, and fears related to hypoglycaemia. Our current study attempts to fill this knowledge gap and further explore the interconnections between distress, fear, and depression among Saudi diabetic patients.
Methods:
Descriptive questionnaire-based cross-sectional study of type II diabetes patients in a specialist diabetes clinic in Taif, Saudi Arabia. We carried out Poisson regression modelling to evaluate the correlates of depressive and distress symptoms.
Results:
The study included (n = 365) patients living with type II diabetes. Cronbach’s alpha for the DDS-17 was 0.93, and for HABS was 0.84, indicative of excellent internal consistency. Diabetes-related distress affected (n = 114, 22.8%) patients, whereas depressive symptoms affected (n = 190, 52.1%) patients. The mean HABS score was 32.7 points (out of 70 points) (SD = 9.8 points). High physical activity levels were found only in (n = 23, 6.3%) patients and moderate physical activity in (n = 65, 17.8%), whereas patients with low physical activity were (n = 277, 75.9%). Diabetes-related distress was associated with increased HbA1c, presence of eye disease, comorbid mental illness, heart disease, stroke, and low physical activity levels. Depressive symptoms were associated with increased HbA1c, longer diabetes duration, presence of eye disease, comorbid mental illness, comorbid neuropathy, heart disease, and low physical activity levels.
Conclusions:
Distress and depression levels are worryingly higher than previous estimates from Saudi Arabia among patients with type II diabetes, indicative of an upward trend and/or a pandemic-related jump. One significant finding from our results is the substantial effect of glycaemic control on increased distress, and depression among our type II diabetes patients. This interaction is likely due to effects on self-care and medication adherence. We also confirmed the association between depressive symptoms and the duration of diabetes. Our results indicated a connection between comorbid medical illness with depressive and distress symptoms.
Keywords: Depression, diabetes distress-17 scale, diabetes type two, Saudi Arabia, Taif
Introduction
Type 2 diabetes (T2D) is a complex disorder with intense and inter-related physical, psychological, and social burdens, and is prevalent in Saudi Arabia. Family physicians manage the bulk of diabetes patients in their primary care clinics. T2D is estimated to affect over 18% of the Saudi population. Worse, the prevalence of T2D in Saudi Arabia is increasing year by year,[1] making it a substantial public health problem.
Depressive symptoms and diabetes are intertwined with a multitude of practical and theoretical links between the two disorders. The prevalence of depression among diabetic patients is double the prevalence of depression in the general public.[2] Among depressive subjects, the risk of acquiring diabetes is increased by up to 60%.[3]
A diagnosis of diabetes is associated with significant lifestyle and dietary modifications and frequent visits to healthcare workers. Thus, diabetes is associated with a range of psychosocial stressors that could lead to considerable distress.[4]
Diabetes-related distress can profoundly affect the quality of life among diabetic patients. Diabetes-related distress can be defined as a multidimensional syndrome of discouragement, worry, conflict, and frustration that can potentially arise from living with diabetes.[5]
Severe diabetes-related distress is estimated to affect over 7% of diabetic patients, whereas moderate levels of distress affect a quarter of all diabetic patients worldwide.[6] It is estimated that 36% of all diabetic patients experience substantial levels of diabetes-related distress.[7] This figure is of considerable concern as distress in the context of diabetes leads to a wide array of emotional and dysfunctional repercussions. Some estimates for distress related to diabetes were as high as 49.2%.
Female gender and comorbid depressive symptomology are established risk factors in the development of distress related to diabetes.[7] Macrovascular and microvascular diabetic complications were significantly related to diabetes-related distress.
Previous work in Saudi Arabia indicated that a fifth of patients with diabetes suffers from depression and a further quarter have distress symptoms, particularly the emotional subtype. However, a knowledge gap exists in terms of how these two conditions overlap and affect each other. We undertook the current investigation to help further our understanding of the two conditions. International studies showed that baseline diabetes-related distress is associated with higher levels of depressive symptoms by two and a half folds.[8] Certainly, distress-associated daily experiences share several phenomenological depressive features, such as fatigue, imbalance, and falling leading to loss of independence, poor life quality, and limitations in terms of social and physical activities.[9] Diabetes-related distress causes poor glycaemic control.[10]
The impact of diabetes-related distress on diabetic care and patients’ life quality is substantial. There is a pressing need to understand the underpinnings of diabetes-related distress and how it evolves in connection with depressive moods, and fears related to hypoglycaemia. Our current study attempts to fill this knowledge gap and further explore the interconnections between distress, fear, and depression among Saudi diabetic patients.
The main objective of the current study was to estimate the prevalence of depressive and distress symptoms in diabetic patients in Saudi Arabia and examine its correlates and moderators such as glycaemic control and diabetes complications.
Methods
Study design
This study was a cross-sectional questionnaire-based descriptive study. The study took place over 12 months between January 1, 2021, and December 31, 2021.
Study area
The study was carried out in the tertiary specialist endocrinology centre, affiliated with the Prince Mansour Military Hospital in Taif, Saudi Arabia.
Study population
The study targeted all type 2 diabetic patients who are registered and attending the specialist endocrinology centre, affiliated with Prince Mansour Military Hospital in Taif, Saudi Arabia.
Inclusion criteria
Established type 2 diabetes diagnosis for at least 6-month duration, attendance at the endocrinology centre in Prince Mansour Military Hospital in Taif, Saudi Arabia, and being over 18 years old.
Exclusion criteria
Refusal to participate, cognitive impairment, severe behavioural disturbance, or suicidality, and patients under 18 years of age.
Sample size
Based on the reported pooled prevalence for distress symptoms of 36% reported by a large systematic review carried out by Perrin et al.,[7] for 5% significance, 5% error margin, and 80% power, we required at least (n = 355) participants.
Sampling scheme
A simple random sampling scheme was adopted when choosing participants for the current study. The sampling frame was constructed using data from all patients attending the specialist endocrinology unit during the last 6 months. A series of computer-generated random digits were used to identify potential participants to be included in the study. All were contacted and during their usual visit were approached by the designated member of the research team and invited to participate. Written consent was obtained from each participant before engagement in answering the data collection tool. Participants were informed that it was up to them to agree to participate. If they chose to refuse to participate, their care would not be compromised in any way.
Data collection tool
Data were collected using face-to-face interviews through a questionnaire that was pre-designed to contain the following components:
Socio-demographic data: It included background personal information pertaining to age, gender, marital status, education, occupation, and the number of children.
Clinical data: It included data related to diabetes complications, diabetes duration, and glycated hemoglobin A1c level.
Diabetes distress was assessed through Diabetes Distress Scale-17 (DDS-17) items.
Diabetes distress scale-17 items (DDS-17)
The DDS-17 consists of 17 phrases with a specific distressing situation that could potentially affect diabetic patients during their handling of diabetes. Each distressing situation is marked by the patient between (0) if it caused them no bother at all, or (6) if it extremely affected them. The sum of the DDS-17 is used to categorize total diabetes-related distress. Over 51 is considered high distress, and over 34 is considered moderate distress.[11]
Primary health questionnaire PHQ-9[12]
This provides a list of nine common depressive symptoms. The patient was asked to rate each symptom as how persistently they felt about it during the previous fortnight. The score ranges between(0) if they never experienced the symptom and (3) if they experienced it nearly every day. The sum of the scores suggests mild depression if it was over 4, and moderate depression if it was over 9.
International physical activity questionnaire IPAQ
For calculation of the IPAQ MET score and assigning appropriate physical activity categories we used the guidance provided at https://sites.google.com/site/theipaq/scoring-protocol and the Excel calculator available on their website.
Data collection method
The face-to-face self-filled questionnaire was provided to the selected sample of type 2 diabetes patients. Patients were interviewed by the principal researcher. The study purpose was explained in simple plain Arabic, and they were given ample opportunity to ask questions about the study. They were provided with pen and paper containing the three tools that would measure the depressive symptoms and demographic factors.
Data analysis
Demographic variables and background clinical characteristics of patients were presented with numbers and percentages and were displayed as bar plots for categorical variables; median, mean, and interquartile range (IQR), and standard deviations (SD) for continuous variables.
Data were entered into an Excel document as they are collected. The document was saved in the personal computing device of the principal researcher. It was password protected.
Generalized linear regression modelling was used to examine the effect of background factors on distress scores.
All analyses were conducted using the R Statistical Software 3.6.0.
The study was approved by the local research and ethics committee based in Al-Hada Armed Forces Hospital in Taif, Saudi Arabia.
Results
The total number of patients included in the study was (n = 365) with type 2 diabetes who were attending the specialist diabetes centre in Prince Mansour Military Hospital, in Taif.
We estimated Cronbach’s alpha for the DDS-17 to be 0.93 (95% from 0.92 to 0.94), indicative of excellent reliability and internal consistency. The prevalence of diabetes-related distress in our sample of type two diabetes patients was (n = 114, 22.8%), of whom (n = 80, 21.9%) reported moderate distress, and (n = 34, 9.3%) reported high distress level. See Table 1 and Figure 1 below.
Table 1.
Prevalence of diabetes-related distress and depression among the participating type 2 diabetes patients
| Distress/Depression | Count (%) |
|---|---|
| Diabetes-related distress | 114 (22.8%) |
| High | 34 (9.3%) |
| Moderate | 80 (21.9%) |
| No distress | 251 (68.8%) |
| Depression | 190 (52.1%) |
| Severe depression | 32 (8.8%) |
| Moderate depression | 42 (11.5%) |
| Mild depression | 116 (31.8%) |
| No depression | 175 (47.9%) |
Figure 1.
Prevalence of diabetes-related distress among the participating type 2 patients
We estimated Cronbach’s alpha for the HABS to be 0.84 (95% from 0.82 to 0.87), indicative of good reliability and internal consistency.
See Table 1 and Figures 1 and 2 for a display of the prevalence of depressive and distress symptoms. Table 2 shows the baseline demographic results of the participating patients and the adjusted effect on diabetes-related distress and depressive symptoms. Table 3 shows the baseline clinical results of the participating patients and the adjusted effect on diabetes-related distress and depressive symptoms.
Figure 2.
Prevalence of depressive symptoms among the participating type 2 patients
Table 2.
Baseline demographic results of participating patients and the adjusted effect on diabetes-related distress and depressive symptoms
| Factor | Count (n)/mean | %/SD | Distress | Depression | ||
|---|---|---|---|---|---|---|
|
|
|
|||||
| Odds | P | Odds | P | |||
| Age | µ=56.9 years | SD=13.8 years | 0.997 | 0.051 | 0.991 | 0.008 |
| Gender | 1.004 | 0.940 | 0.790 | 0.067 | ||
| Male | 163 | 45.7% | ||||
| Female | 200 | 54.8% | ||||
| Marital status | ||||||
| Married | 291 | 79.7% | 0.766 | <0.001 | 0.713 | <0.001 |
| Single | 24 | 6.6% | 0.663 | 0.000 | 0.974 | |
| Divorced | 27 | 7.4% | Ref | 0.057 | Ref | Ref |
| Widowed | 11 | 3.0% | 0.732 | Ref<0.001 | 1.121 | 0.498 |
| Education | ||||||
| Uneducated | 116 | 31.8% | 1.060 | <0.001 | 1.084 | 0.003 |
| Primary | 65 | 17.8% | ||||
| Intermediate | 52 | 14.2% | ||||
| Secondary | 33 | 9.0% | ||||
| University | 44 | 12.0% | ||||
| Employment | ||||||
| Employed | 98 | 26.8% | Ref | Ref | Ref | Ref |
| Retired | 34 | 9.3% | 1.042 | 0.068 | 1.535 | <0.001 |
| Unemployed | 143 | 39.2% | 1.122 | 0.384 | 1.637 | <0.001 |
| Housewife | 36 | 9.9% | 1.324 | <0.001 | 2.072 | <0.001 |
| Nationality | ||||||
| Saudi | 358 | 98.1% | 1.443 | 0.098 | 0.624 | 0.274 |
| Non-Saudi | 7 | 1.9% | ||||
| Kids count | M=7.1 kids | SD=2.8 kids | 0.993 | 0.170 | 1.032 | 0.007 |
μ=mean; SD=standard deviation
Table 3.
Baseline clinical results of participating patients and the adjusted effect on fear of hypoglycaemia, diabetes-related distress, and depressive symptoms
| Factor | Count (n)/mean | %/SD | Distress | Depression | ||
|---|---|---|---|---|---|---|
|
|
|
|||||
| Odds | P | Odds | P | |||
| HbA1c% | µ=8.4% | SD=1.96% | 1.056 | <0.001 | 1.043 | 0.019 |
| DM duration | µ=12.4 years | SD=8.9 years | 1.004 | 0.013 | 1.010 | <0.001 |
| Eye disease | 78 | 21.4% | 1.329 | <0.001 | 1.936 | <0.001 |
| Mental illness | 13 | 3.6% | 1.224 | <0.001 | 2.358 | <0.001 |
| Insulin | 99 | 27.1% | 0.985 | 0.614 | 0.955 | <0.001 |
| Oral medications | 96 | 26.3% | 0.905 | 0.001 | 0.925 | 0.282 |
| Medical illness | 101 | 27.7% | 0.971 | 0.339 | 1.005 | 0.941 |
| Neuropathy | 27 | 7.4% | 1.071 | 0.196 | 1.544 | <0.001 |
| Nephropathy | 21 | 5.8% | 1.024 | 0.661 | 0.809 | 0.108 |
| Retinopathy | 44 | 12.1% | 0.796 | <0.001 | 0.831 | 0.073 |
| Limb amputation | 5 | 1.4% | 1.168 | 0.120 | 0.720 | 0.104 |
| Heart disease | 28 | 7.7% | 1.200 | <0.001 | 1.428 | <0.001 |
| Stroke | 3 | 0.8% | 1.473 | <0.001 | 1.016 | 0.949 |
| FBG | µ=150* | SD=50.8* | 1.000 | 0.900 | 0.998 | <0.001 |
| BMI | µ=30.4 | SD=6.7 | 0.998 | 0.230 | 0.992 | 0.003 |
| Physical activity: high | 23 | 6.3% | Ref | Ref | Ref | Ref |
| Physical activity: moderate | 65 | 17.8% | 1.048 | 0.422 | 0.823 | 0.148 |
| Physical activity: low | 277 | 75,9% | 1.114 | 0.039 | 1.113 | 0.353 |
μ = mean; SD=standard deviation; y=years; * = mg/dL; FBG=fasting blood glucose; BMI=body mass index
Figure 1 shows that the prevalence of depressive symptoms among the participating type 2 diabetes patients was (n = 190, 52.1%). There were (n = 32, 8.8%) patients with severe depressive symptoms, (n = 42, 11.5%) patients with moderate depressive symptoms, and (n = 116, 31.8%) patients with mild depressive symptoms.
Figure 2 shows that the prevalence of depressive symptoms among the participating type 2 diabetes patients was (n = 190, 52.1%). There were (n = 32, 8.8%) patients with severe depressive symptoms, (n = 42, 11.5%) patients with moderate depressive symptoms, and (n = 116, 31.8%) patients with mild depressive symptoms.
Diabetes-related distress, as shown in Figure 3, was associated with increased HbA1c (odds ratio = 1.056, P < 0.001), presence of eye disease (odds ratio = 1.329, P < 0.001), comorbid mental illness (odds ratio = 1.224, P < 0.001), heart disease (odds ratio = 1.200, P < 0.001), stroke (odds ratio = 1.473, P < 0.001), and low physical activity levels (odds = ratio = 1.114, P = 0.039). In contrast, prescription of oral hypoglycaemic medications was associated with lower diabetes-related distress (odds ratio = 0.905, P = 0.001), as did the presence of retinopathy complication (odds ratio = 0.796, P < 0.001).
Figure 3.
Clinical factors significantly impacting diabetes-related distress among the participating patients
Depressive symptoms, as shown in Figure 4, were associated with increased HbA1c (odds ratio = 1.043, P = 0.019), longer diabetes duration (odds ratio = 1.010, P < 0.001), presence of eye disease (odds ratio = 1.936, P < 0.001), comorbid mental illness (odds ratio = 2.358, P < 0.001), comorbid neuropathy (odds ratio = 1.554, P < 0.001), heart disease (odds ratio = 1.428, P < 0.001), and low physical activity levels (odds ratio = 1.114, P = 0.039). In contrast, prescription of insulin was associated with lower depressive score (odds ratio = 0.955, P < 0.001), as did high FBG levels (odds ratio = 0.998, P < 0.001) and increased BMI (odds ratio = 0.992, P = 0.003).
Figure 4.
Clinical factors significantly impacting depressive symptoms score among the participating patients
Figure 3: Diabetes-related distress was associated with increased HbA1c (odds ratio = 1.056, P < 0.001), presence of eye disease (odds ratio = 1.329, P < 0.001), comorbid mental illness (odds ratio = 1.224, P < 0.001), heart disease (odds ratio = 1.200, P < 0.001), stroke (odds ratio = 1.473, P < 0.001), and low physical activity levels (odds ratio = 1.114, P = 0.039). In contrast, prescription of oral hypoglycaemic medications was associated with lower diabetes-related distress (odds ratio = 0.905, P = 0.001), as did presence of retinopathy complication (odds ratio = 0.796, P < 0.001).
Figure 4 shows that depressive symptoms were associated with increased HbA1c (odds ratio = 1.043, P = 0.019), longer diabetes duration (odds ratio = 1.010, P < 0.001), presence of eye disease (odds ratio = 1.936, P < 0.001), comorbid mental illness (odds ratio = 2.358, P < 0.001), comorbid neuropathy (odds ratio = 1.554, P < 0.001), heart disease (odds ratio = 1.428, P < 0.001), and low physical activity levels (odds ratio = 1.114, P = 0.039). In contrast, prescription of insulin was associated with lower depressive score (odds ratio = 0.955, P < 0.001), as did high FBG levels (odds ratio = 0.998, P < 0.001) and increased BMI (odds ratio = 0.992, P = 0.003).
Discussion of Key Findings
The current survey included a random sample of 365 patients living with type 2 diabetes attending the specialist diabetes clinic in Taif, Saudi Arabia.
Prevalence of depressive symptoms and diabetes-related distress
The main finding of our survey is that depressive symptoms are prevalent among patients with type 2 diabetes, as more than 52% of our patients reported a degree of depression. However, as per our results, only 8.8% reported severe symptoms and 11.5% reported moderate symptoms with 31.8% had mild depressive symptoms. Our results exceed the 29% prevalence estimate reported recently in a large-scale survey in Kuwait.[13] We noted that previous studies in Saudi Arabia among diabetic patients indicated prevalence estimates of between 20% and 37.1%.[14] Clearly, our results are far higher than previous estimates from Saudi Arabia. However, we included patients with mild depressive symptoms in our final estimate, and that would explain how inflated our results were. We do believe that patients with mild depression struggle emotionally and psychologically and require specialized health intervention to help alleviate their depressive symptoms, ideally offered in the context of diabetes care.
One further main finding in our study was the high prevalence of diabetes-related distress in our sample of type 2 diabetes patients. There were 22.8% of patients with diabetes-related distress, of whom 9.3% reported high distress symptoms. This is higher than the figure of 15% reported by a previous study in the same setting. It could indicate increased distress related to diabetes in Saudi Arabia over recent years, given the difficulties created by the COVID-19 pandemic. Patients with diabetes were found to have increased worry about the effects of the COVID-19 pandemic, which is reflected in higher distress scores compared to pre-pandemic levels.
Correlates of depressive symptoms and diabetes-related distress
One significant finding from our results is the substantial effect of glycaemic control on increased distress and depression among our type 2 diabetes patients. Our results are intuitive and agree with many studies from the region that indicate worsening of glycaemic control among patients with higher distress and depression levels.[15] However, some other studies could not find a direct relationship between glycaemic control and depressive symptoms among diabetes patients in Saudi Arabia[16] or other countries.[17] Many authors suggest that anxiety and depression exert their effect on glycaemic control by affecting self-care and medication adherence. Our results pack the notion that depressive and distress symptoms interfere negatively with adherence to effective glycaemic control interventions. Studies have indeed confirmed that improving depressive and anxiety symptoms would have a positive impact on glycaemic control among patients with diabetes.[18]
We also confirmed the association between depressive symptoms and the duration of diabetes. This association between diabetes and duration was reported in past surveys.[19] Some confirmed that a longer duration of diabetes would increase the risk for later life depression.[20] However, other authors would argue that early during the course of diabetes, patients would feel more helpless and depressed. However, further longitudinal research should be dedicated to establishing the variability in terms of depressive symptoms along the course of diabetes over a prolonged period of time. A longer duration of diabetes is theorized to invoke depressive symptoms through the emergence of micro and macrovascular changes, deterioration in cognitive functioning, and impairment in sexual performance.[21]
Our results indicated a connection between comorbid medical illness (particularly eye disease, heart disease, and neuropathy) with increased odds of the presence of depressive symptoms. Depression in the context of diabetes was shown to be a notorious risk factor for the development of coronary heart disease among Saudi patients and the mortality related to it.[22] Therefore, our findings on depression-cardiac disease morbidity association are quite intuitive and fall in line with the available literature. Similarly, eye diseases in Saudi diabetes patients were found to correlate with depressive symptoms.[23] Furthermore, neuropathy (and other diabetes complications) predisposes patients with diabetes toward increased depressive and distress symptoms.[24] However, the interaction between depression, diabetes, and medical illnesses is complex and, at best, tri-directional.[14] Longitudinal studies could help elucidate any potential causal relationship between depression and heart disease; however, the underlying pathophysiological mechanism remains unclear and may well be related to inflammatory responses or neuroendocrine malfunction.
Low physical activity among our patients was associated with depressive symptoms as did high BMI. Indeed, obesity and high fasting glucose readings were found to be key risks for the development of depressive symptoms among diabetes patients.[25] In the context of type 2 diabetes, the depression–obesity duet remains a consistent and elusive association across epidemiologic studies with an overarching complex pathophysiology and health implications.[26] One novel finding from our current investigation is the complex interaction between depressive symptoms, low physical activity, and obesity, particularly in Saudi Arabia. It is intuitive to believe that the higher the physical activity level, the better the satisfaction and life quality among diabetes patients.[27] To make matters worse, in diabetes, the link between physical activity and depressed mood seems to be shaped by the weight of patients, as more obese patients were less depressed despite minimum physical activity.[28] Our results confirm such findings.
Unfortunately, the sheer majority of our patients failed to meet the physical activity standards. This was also a consistent finding among studies.[29] Recent surveys showed, alarmingly, that nearly half of adults in Saudi Arabia do not engage in meaningful or health-promoting physical activities throughout the last two decades.[30]
Strengths and limitations and future research directions
The current survey possesses several strengths. We used validated research tools and conducted a random sampling of a large number of type 2 diabetes patients from a variety of backgrounds. However, the cross-sectional design remains a significant limitation for two reasons. First, the results may not be generalizable to different settings. Second, cause–effect relationship can not be ascertained without conducting a robust longitudinal study.
Future research on depression and distress should be longitudinal and analyze results collected at multiple timepoints to examine the variability in terms of depressive symptoms along the course of diabetes over a prolonged period of time.
Conclusion
Distress and depression levels are worryingly higher than previous estimates from Saudi Arabia among patients with type 2 diabetes, indicative of an upward trend and/or a pandemic-related jump. One significant finding from our results is the substantial effect of glycaemic control on increased distress and depression among our type 2 diabetes patients. This interaction is likely due to effects on self-care and medication adherence. We also confirmed the association between depressive symptoms and the duration of diabetes. Our results indicated a connection between comorbid medical illness with depressive and distress symptoms. Our results recommend that depressive symptoms and distress in the context of diabetes interfere with optimum glycaemic control. The take-home message is that specialist diabetes and family medicine care should include effective interventions that alleviate depressive and distress symptoms to achieve the key outcome of optimum glycaemic control. Furthermore, diabetes-related distress is quite prevalent among patients with type 2 diabetes in Saudi Arabia attending family medicine clinics. It should be routine practice to explore, identify, and effectively manage aspects of distress, fear, and worry during holistic health care provision in specialist diabetology services in Saudi Arabia. Moreover, future research on depression and distress should be longitudinal and analyze results collected at multiple timepoints to examine the variability in terms of depressive symptoms along the course of diabetes over a prolonged period of time. We note that medical disease and diabetes complications are associated with significant depressive symptoms among patients with diabetes. No healthcare is complete without addressing the emotional and psychological well-being of diabetes patients in Saudi Arabia. We highlight that physical activity remains poor among diabetes patients in Saudi Arabia. A special focus should be on promoting and educating patients with regard to the minimum standards of physical activity required to lead a satisfactory and healthy life.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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