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1.  Total knee arthroplasty: Effect of obesity and other patients’ characteristics on operative duration and outcome 
World Journal of Orthopedics  2015;6(2):284-289.
AIM: To examine the effects of patients’ characteristics mainly obesity on operative duration and other outcome measures of knee arthroplasty.
METHODS: This is a retrospective chart review of 204 patients who had knee arthroplasty within the past five years (2007-2011) at King Abdulaziz Medical City in Riyadh, Kingdom of Saudi Arabia. The data collection form was developed utilizing the literature review to gather all the needed variables. Data were gathered from admission notes, nursing notes, operative reports and discharge summaries.
RESULTS: A feasible sample of 204 patients were included in the study. Of those patients, 155 (76%) were females. The mean age was 70.1 years for males (SD ± 9.4) and 62.7 years (SD ± 8) for females. Regarding the type of total knee replacement (TKR), 163 (79.9%) patients had unilateral TKR and 41 (20.1%) had bilateral TKR. Nine patients (4.4%) had a normal body mass index (BMI) (18.5 to < 25). Overweight patients (BMI 25 to < 30) represented 18.1%. Obesity class I (BMI 30 to < 35) and obesity class II (BMI from 35 to < 40) were present in 23% and 29.9% of the patients, respectively. Morbid obesity (BMI greater than 40) was present in 24.5%. The mean duration of surgery was 126.3 min (SD ± 30.8) for unilateral TKR and 216.6 min (SD ± 55.4) for bilateral TKR.The mean length of stay in the hospital was 12 d (SD ± 4.9). The complications that patients had after the operation included 2 patients (1%) who developed deep venous thrombosis, 2 patients (1%) developed surgical wound infections and none had pulmonary embolism. Patients' characteristics (including age, gender, BMI and co-morbidities) did not have an effect on the operative duration of knee replacement nor the length of hospital stay.
CONCLUSION: Our study shows that obesity and other patients’ characteristics do not have effect on the operative duration nor the length of hospital stay following TKR.
doi:10.5312/wjo.v6.i2.284
PMCID: PMC4363811  PMID: 25793169
Knee; Replacement; Arthroplasty; Implantation; Surgery; Orthopedics; Total knee arthroplasty; Total knee replacements
2.  Paramedics beliefs and attitudes towards pre-hospital thrombolysis 
Background:
Myocardial infarction is the third leading cause of death in the developing countries. Thrombolysis as a reperfusion therapy is shown to have a great role in decreasing mortality. The efficacy of thrombolytic therapy lies in its ability to reduce the duration of occlusion by early administration. Many of the studies have supported pre-hospital thrombolysis (PHT) therapy and proven that it is beneficial in acute myocardial infarction (AMI) patients.
Methodology:
Questionnaires adopted from studies of Humphrey et al., were distributed to paramedics in Saudi Red Crescent Authority and Emergency Medical Services Departments at King Abdulaziz Medical City, King Fahad Medical City, Prince Sultan Medical Military City and Security Forces Hospital in Riyadh. A total of 7 questions were about the knowledge of risk and benefit of PHT and 12 questions were about the beliefs and attitudes of paramedics toward PHT in AMI patients.
Results:
The response rate was 87%. Nearly 72% were believed to be capable of performing PHT, 87% are confident about recording 12-lead electrocardiogram in pre-hospital settings and 77% are confident in the interpretation. 94% believe that PHT will have a significant impact on pain to needle time. 77% consider PHT to be safe for use by paramedics. 66% preferred on-line medical direction or telemedicine linked with the supervision of a physician. Regarding the knowledge part, majority gave a correct answer, but the major concern was that 43% of the paramedics overestimated direct relation of bleeding to thrombolysis therapy.
Conclusion:
Majority of paramedics in Riyadh support the principle of PHT in patients with AMI via online medical direction. They believe that they are confident in their ability to administer PHT despite the concern of authorities on their level of training, the related risks and medico-legal issues. Nevertheless, since the total duration of PHT course for paramedics is just 2 days, we consider that the procedure should be performed under expert supervision until they achieve expertise.
doi:10.4103/2229-516X.125672
PMCID: PMC3931206  PMID: 24600571
Acute myocardial infarction; attitudes; beliefs; paramedics; pre-hospital thrombolysis; questionnaire
3.  Prevalence and characteristics of abnormal Papanicolaou smear in Central Saudi Arabia 
Saudi Medical Journal  2015;36(1):117-122.
Objectives:
To assess the prevalence and characteristics of abnormal pap smear in the central region of Saudi Arabia.
Methods:
In this retrospective case control study conducted in the Departments of Obstetrics and Gynecology, and Histopathology at King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia, all pap smears screened for Saudi women between 2008 and 2011 were reviewed. Approximately 5000 pap smears are screened annually at King Abdulaziz Medical City utilizing the Bethesda III System (2001). All abnormal smears patients’ data were collected and compared to the data of randomly selected 200 normal smears’ patients.
Results:
Abnormal pap smear prevalence was found to be 4.3% (841/19,650 Saudi patients were found with atypical epithelial cells abnormalities). Its prevalence in the years 2008 was 5.7%, 2009 was 4.9%, 2010 was 4.2%, and 2011 was 2.5%. Abnormal smear patients have lower parity (p=0.001), and were less likely to use intra-uterine devices (p=0.03) compared with normal smear patients. Presence of abnormal cervical appearance was associated with increased epithelial cell abnormalities (p=0.045). The only positive history that has characterized patients with epithelial cell abnormalities was their previous history of abnormal pap smear (p=0.001). Squamous cell abnormalities were identified in 91% of the patients (767/841), and glandular cell abnormalities were identified in 9% of the patients (74/841).
Conclusion:
Prevalence of abnormal pap smears in central Saudi Arabia is relatively low, while advanced glandular abnormalities prevalence was observed to be high.
doi:10.15537/smj.2015.1.9141
PMCID: PMC4362183  PMID: 25630016
4.  Cultural acceptance of robotic telestroke medicine among patients and healthcare providers in Saudi Arabia 
Neurosciences  2015;20(1):27-30.
Objectives:
To determine the degree of satisfaction and acceptance of stroke patients, their relatives, and healthcare providers toward using telestroke technology in Saudi Arabia.
Methods:
A cross-sectional study was conducted between October and December 2012 at King Abdulaziz Medical City, Ministry of National Guard Affairs, Riyadh, Saudi Arabia. The Remote Presence Robot (RPR), the RP-7i® (FDA- cleared) provided by InTouch Health was used in the study. Patients and their relatives were informed that the physician would appear through a screen on top of a robotic device, as part of their clinical care. Stroke patients admitted through the emergency department, and their relatives, as well as healthcare providers completed a self-administered satisfaction questionnaire following the telestroke consultation sessions.
Results:
Fifty participants completed the questionnaire. Most subjects agreed that the remote consultant interview was useful and that the audiovisual component of the intervention was of high quality; 98% agreed that they did not feel shy or embarrassed during the remote interview, were able to understand the instruction of the consultant, and recommended its use in stroke management. Furthermore, 92% agreed or strongly agreed that the use of this technology can efficiently replace the physical presence of a neurologist.
Conclusion:
Results suggest that the use of telestroke medicine is culturally acceptable among stroke patients and their families in Saudi Arabia and favorably received by healthcare providers.
PMCID: PMC4727601  PMID: 25630777
5.  Clinical characteristics of patients with atrial fibrillation at a tertiary care hospital in the central region of Saudi Arabia 
Objective:
To report on the clinical presentation, etiology, and laboratory features of acute and chronic atrial fibrillation (AF) in a tertiary hospital in Riyadh, Saudi Arabia.
Materials and Methods:
We retrospectively studied records of 720 patients with AF seen in outpatients and inpatients departments at King Abdulaziz Medical City, Riyadh, during the period of 1 January 2002 to 31 August 2008.
Results:
Documented acute and chronic AF was present in 157 (21.8%) and 563 (78.1%) patients, respectively. Palpitations, dizziness and syncope were the most frequent symptoms in acute AF, while dyspnea and palpitations were the most common symptoms in the chronic type. Acute respiratory problems and acute myocardial infarction were significantly more common in acute AF, while congestive heart failure and acute respiratory problems (chest infection, bronchial asthma, and pulmonary embolism) were significantly more common in chronic AF. The most common causes of both types of AF were diabetes mellitus (DM) in 68.8%, hypertension (HTN) in 59.3%, chronic lung diseases (bronchial asthma, chronic obstructive pulmonary disease and interstitial lung disease) in 31.8%, valvular heart disease in 23.6%, and ischemic heart disease (IHD) in 23.1%. In 9 (1.3%) patients, no cause was detected. The echocardiographic findings of left ventricular hypertrophy, valve lesions, and depressed left ventricular function were significantly more common in chronic AF (P<0.01).
Conclusions
Nowadays, DM, HTN, and IHD are becoming the most common predisposing factors for AF in the central region of Saudi Arabia and require prevention and control
doi:10.4103/2230-8229.83374
PMCID: PMC3159233  PMID: 21897916
Atrial fibrillation; clinical characteristics; central region; Saudi Arabia
6.  Prevalence and associated factors of polypharmacy among adult Saudi medical outpatients at a tertiary care center 
Objective:
The objective of this study was to assess the prevalence of polypharmacy (PP) and the associated factors in medical outpatients.
Materials and Methods:
A cross-sectional, observational, descriptive study was carried out in adult medical outpatients attending internal medicine clinics at King Abdulaziz Medical City, Riyadh, Saudi Arabia from 1 March 2009 to 31 December 2009. PP was defined as the concomitant use of ≥5 medications daily. The number of medications being currently taken by patient was recorded. Effect of patients’ age, gender, educational level, number of prescribers, disease load and disease type on PP was assessed by multivariate analysis using Statistical Package for Social Sciences Incorporated (SPSS Inc) Version 18.
Results:
Out of 766 patients included in the study, 683 (89%) had PP. The mean number of prescribed medications, oral pills and doses was 8.8, 9.6 and 12.1, respectively. Factors significantly associated with PP included age (≥61 years), disease load and the number of prescribers. Gender had no impact on PP while education beyond primary education significantly decreased PP. Hypertension, diabetes mellitus and dyslipidemia alone and as a cluster increased PP.
Conclusion:
We found an extremely high level of PP in medical outpatients at our tertiary care center. The impact of PP on medication compliance and control of underlying diseases in Saudi Arabia is unknown and needs to be studied at different levels of care.
doi:10.4103/2230-8229.121987
PMCID: PMC3957169  PMID: 24672273
Medical; medications; outpatients; polypharmacy
7.  Assessment of microalbuminuria and albumin creatinine ratio in patients with type 2 diabetes mellitus 
Aim:
We aimed to evaluate the levels of urine microalbumin, urine albumin creatinine ratio, plasma creatinine and glycosylated hemoglobin (HbA1c) among type 2 diabetic patients and assessed the correlation between microalbuminuria and plasma creatinine levels.
Materials and Methods:
A retrospective chart review study was conducted at Department of Clinical Chemistry, King Abdulaziz Medical City in Riyadh, Saudi Arabia, during August to December 2014. The study included 100 male and female patients diagnosed with type 2 diabetes mellitus (DM) and excluding patients with type 1 DM. Medical history and biochemical laboratory data were obtained from medical records and from biochemistry laboratory database.
Results:
Increase in mean level of plasma creatinine (138 μmol/L), urine microalbuminuria (240 mg/L), albumin creatinine ratio (82) and HbA1c (8.7%) was observed among type 2 DM patients. Moderate positive correlation was observed between microalbuminuria and urine albumin creatinine ratio (r = 0.509 P = 0.0006) and between urine albumin creatinine ratio and plasma creatinine (r = 0.553 P = 0.017).
Conclusion:
We concluded that type 2 DM patients who are at risk of developing renal impairment must be regularly monitored for microalbuminuria, urine albumin creatinine ratio, and HbA1c levels.
doi:10.4103/0976-9668.166095
PMCID: PMC4630772  PMID: 26604628
Albumin creatinine ratio; diabetes mellitus type 2; microalbuminuria
8.  Students' and teachers' perceptions of clinical assessment program: A qualitative study in a PBL curriculum 
BMC Research Notes  2009;2:263.
Background
"Examinations drive students' learning." This statement refers to what is assumed to be one of the strongest relationships in education. We explored in this research how and why students differ in their approaches to learning, how assessment affects deep learning, and which barriers stand in the way of good assessment and learning in the clinical years of a Problem Based Learning (PBL) graduate entry medical curriculum.
Findings
Method: We conducted a qualitative, phenomenological study using semi-structured group interviews with students and semi-structured individual interviews with teachers and students. The transcripts were analyzed, and themes were identified.
Setting: The research was conducted at the King Saud bin Abdulaziz University for Health Sciences, College of Medicine, Riyadh, Saudi Arabia from November 2007 to March 2008.
Results: A total of 28 students participated in 7 focus group interviews. Semi-structured individual interviews were conducted with 12 teachers and 12 students. The analysis yielded four themes: summative assessment, formative assessment, continuous assessment of clinical attachments, and learning objectives.
Conclusions
The results of this study confirm that assessment affects students' perceptions of learning and how they learn. These effects are not uniformly positive. According to the students, the predominantly summative assessment program offers little inducement to engage in deep learning. They express a clear preference for formative assessment, which may foster a deeper approach to learning. Efforts to achieve more clinically relevant assessment with adequate balance between the various types of assessment are required. Research is needed to decide this balance.
doi:10.1186/1756-0500-2-263
PMCID: PMC2804577  PMID: 20030842
9.  User acceptance of a picture archiving and communication system (PACS) in a Saudi Arabian hospital radiology department 
Background
Compared with the increasingly widespread use of picture archiving and communication systems (PACSs), knowledge concerning users’ acceptance of such systems is limited. Knowledge of acceptance is needed given the large (and growing) financial investment associated with the implementation of PACSs, and because the level of user acceptance influences the degree to which the benefits of the systems for healthcare can be realized.
Methods
A Technology Acceptance Model (TAM) was used to assess the level of acceptance of the host PACS by staff in the radiology department at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia. A questionnaire survey of 89 PACS users was employed to obtain data regarding user characteristics, perceived usefulness (PU) (6 items), perceived ease of use (PEU) (4 items), a change construct (4 items), and a behavior (acceptance) construct (9 items). Respondents graded each item in each construct using five-point likert scales.
Results
Surveyed users reported high levels of PU (4.33/5), PEU (4.15/5), change (4.26/5), and acceptance (3.86/5). The three constructs of PU, PEU, and change explained 41 % of the variation in PACS user acceptance. PU was the most important predictor, explaining 38 % of the variation on its own. The most important single item in the explanatory constructs was that users found PACS to have improved the quality of their work in providing better patient care. Technologists had lower acceptance ratings than did clinicians/radiologists, but no influence on acceptance level was found due to gender, age, or length of experience using the PACS. Although not directly measured, there appeared to be no cultural influence on either the level of acceptance or its determinants.
Conclusions
User acceptance must be considered when an organization implements a PACS, in order to enhance its successful adoption. Health organizations should adopt a PACS that offers all required functions and which is likely to generate high PU on the part of its users, rather than a system that is easy to use. Training/familiarization programs should aim at establishing high levels of PU in all users, particularly technologists. Health organizations are advised to measure all the factors that influence the acceptance of a PACS by their staff, in order to optimize the productivity of the system and realize the potential benefits to the greatest extent possible.
doi:10.1186/1472-6947-12-44
PMCID: PMC3423046  PMID: 22640490
10.  Maternal Serum Lipids in Women with Pre-eclampsia 
Background:
Evidence of increased oxidative stress due to endothelial dysfunction in pre-eclampsia has been well-established. Increase in the oxidative stress is associated with abnormal lipid profile.
Aim:
The aim of the study is to compare serum lipids in pre-eclamptic women and healthy pregnant women.
Subjects and Methods:
In this case-control study, blood samples were collected from 40 pregnant females diagnosed as pre-eclampsia and 80 normal pregnant females at the Department of Obstetrics and Gynecology at King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia between February 2009 and January 2010. We evaluated serum levels of total cholesterol, low-density lipoprotein and high-density lipoprotein cholesterol and triglyceride in women with pre-eclampsia and those of women with normal pregnancies. Data was analyzed using SPSS for Windows (version 17.0, SPSS Inc., Chicago, Illinois, USA). The data is presented descriptively and test for significance was done using the student t-test for continous data.
Results:
Women with pre-eclampsia exhibited higher serum triglyceride levels compared with normal pregnant women (P < 0.01). Other measured serum lipids did not differ significantly in the two groups.
Conclusion:
We recommend that any pregnant female with higher serum triglyceride concentrations may be further investigated for pre-eclampsia. Further large scale multicenter studies are required to establish the use of measuring serum triglyceride levels to screen the pregnant females for pre-eclampsia.
doi:10.4103/2141-9248.139358
PMCID: PMC4160696  PMID: 25221720
Lipids; Pre-eclampsia; Triglycerides
11.  Relation between glycosylated hemoglobin and lipid and thyroid hormone among patients with type 2 diabetes mellitus at King Abdulaziz Medical City, Riyadh 
Background:
The main objectives of this study were to: (1) Evaluate the levels of thyroid hormones and glycosylated hemoglobin (HbA1c) among patients, (2) correlate between thyroid hormones and HbA1c and different types of lipids and HbA1c among diabetic patients.
Materials and Methods:
A retrospective chart review study was conducted at Department of Clinical Chemistry, King Abdulaziz Medical City (KAMC) in Riyadh, Saudi Arabia, during the period from August 2014 to December 2014, including 100 male and female patients diagnosed with diabetes mellitus (DM) type 2 and excluding patients with DM type 1. These patients were admitted to the hospital in 2013. Biochemical laboratory results were retrieved from biochemistry laboratory database while age and sex of patients were retrieved from patient files. Statistical analysis was performed using SPSS software conducting frequency analysis and correlation test.
Results:
The result showed increased mean levels of HbA1c (8.4%) and normal level of thyroid stimulating hormone (TSH) (4.5 mlU/L) and T4 (14.1 pmol/L). The results also showed a weak positive correlation between HbA1c and TSH (r = 0.212, P = 0.034) and insignificant correlation with thyroxin T4 (r = −0.018, P = 0.855). There was a weak positive correlation between HbA1c and total cholesterol and low density lipoprotein (r = 0.258, P = 0.001), (r = 0.297, P = 0.003), respectively.
Conclusion:
It is concluded that increased blood glucose could trigger anterior pituitary gland to increase secretion of TSH, whereas there was no direct correlation between increased glycemic index and the rate of thyroxine secretion. Furthermore, it is concluded that there is an association between blood glucose and some lipid markers.
doi:10.4103/0976-9668.166091
PMCID: PMC4630769  PMID: 26604625
Correlation; glycosylated hemoglobin; thyroid hormones; types of lipids
12.  Unconventional therapy use among asthma patients in a tertiary care center in Riyadh, Saudi Arabia 
Annals of Thoracic Medicine  2008;3(2):48-51.
OBJECTIVES:
Unconventional therapy (UT) is a therapeutic practice of alternative and complementary medicine that is not currently considered an integral part of modern medical practice. The aim of this article is to investigate the experience of Saudi patients with UT modalities in the treatment of asthma.
MATERIALS AND METHODS:
We carried out a cross-sectional study of asthma patients referred to King Abdulaziz Medical City, Riyadh, Saudi Arabia, during the year 2004. Information was collected using a pre-designed questionnaire administered through interviews.
RESULTS:
Two hundred consecutive patients with a mean age of 52.3 years (±18.7) were included in this study. Sixty-nine (34.5%) of those patients used some form of UT in the previous year. There was a tendency to use UT among the older age group (P = 0.029) and among those with longer duration of disease (P = 0.009). However, there was no significant correlation observed between the use of UT and gender, FEV1, or disease control. The most commonly used form of UT was recitation of Holy Quran (9%), honey (24.5%), herbs (23.5%), cautery (12%), and blackseed (10%). There was no significant correlation between disease control and the use of modalities.
CONCLUSION:
Unconventional therapy is frequently practiced by asthma patients in Saudi Arabia, who commonly believe that UT will lead to improvement. The lack of evidence necessitates the fostering of a national project to address the practice of UT.
doi:10.4103/1817-1737.39636
PMCID: PMC2700461  PMID: 19561905
Asthma; Saudi Arabia; uncontrolled asthma; unconventional therapy
13.  Nosocomial infections in ambulances and effectiveness of ambulance fumigation techniques in Saudi Arabia 
Saudi Medical Journal  2014;35(11):1354-1360.
Objectives:
To evaluate infection control and the incidence of bacterial pathogens in Emergency Medical Service (EMS) ambulances in Riyadh, Saudi Arabia. The effectiveness of fumigation techniques used for these ambulances to minimize the spread of infection to transported patients and pre-hospital care providers was also assessed.
Methods:
Based on previous literature review indicating a higher propensity of microbial load, 3 areas within the ambulance, such as, stretcher handle, oxygen flow meter knob, and interior handle of the rear door were selected for specimen collection. Swab samples were collected both in the day and night shift, after the intended disinfection and cleaning (before and after fumigation). Micro-organisms were identified using standard procedures. This phase-I study was conducted at the Emergency Medical Services Department, Prince Sultan Bin Abdulaziz College of Emergency Medical Services, Al Malaz, King Saud University, Riyadh, Saudi Arabia between October and November 2013, wherein a total of 10 ambulances from the Saudi Red Crescent Authority in Riyadh were selected for inclusion in the study.
Results:
The specimens from all 10 ambulances showed similar results. In post disinfection and before fumigation, swab samples showed positive cultures that grew moderate to large quantities of environmental and skin flora. However, almost all organisms were susceptible to the fumigation technique.
Conclusion:
This study confirms the importance of evaluating the frequency and efficiency of various fumigation techniques as an ambulance is a potential reservoir for microbial transmission to patients and staff.
PMCID: PMC4362147  PMID: 25399212
14.  Breast cancer in women younger than 30 years: prevalence rate and imaging findings in a symptomatic population 
Introduction
To identify the prevalence rate of primary breast cancer in women younger than 30 years of age in a symptomatic population in Riyadh, Kingdom of Saudi Arabia. To analyze the imaging pattern and possible risk factors in cases with cancer. Breast cancer in this age group is generally rare and not clearly understood.
Methods
At King Abdulaziz Medical City for National Guard, Riyadh, a retrospective 5-year (January 2006 to December 2010) data was collected from the Medical Imaging departmental records on breast imaging. Patients younger than 30 years of age were identified including those with breast cancer. The clinical presentation, risk factors, imaging findings and final outcomes were analyzed in a descriptive way. The total number of patients diagnosed with primary breast cancer was recorded.
Results
Seventeen out of a total of 4873 patients younger than 30 years examined had primary breast cancer constituting a rate of 3.5 per 1000 symptomatic patients. The age range was 17 to 29 with mean of 27. The total number of patients with primary breast cancer diagnosed during that period was 413 making a percentage of 4.1% (17 out of 413) in those younger than 30 years. First presentation with a palpable mass and imaging findings of unequivocal category 5 of Breast Imaging Reporting and Data System (BI-RADS) occurred in all. Eight patients had stage I and II while nine had stage III and IV cancers. Only 2 of the 17 had first-degree family history. The youngest was 17 years old.
Conclusion
A prevalence rate of 3.5 per 1000 primary cancer occurred in the symptomatic population studied and 4 in every 100 primary cancer diagnosed in the unit occurred in women younger than 30 years. First presentation, low family trait and typical imaging features of malignancy was found in all cases.
doi:10.11604/pamj.2014.19.35.2849
PMCID: PMC4314149  PMID: 25667697
Breast cancer; prevalence; imaging; Arab women younger than 30 years
15.  Improving the care of sepsis: Between system redesign and professional responsibility: A roundtable discussion in the world sepsis day, September 25, 2013, Riyadh, Saudi Arabia 
Annals of Thoracic Medicine  2014;9(3):134-137.
This paper summarizes the roundtable discussion in September 25, 2013, Riyadh, Saudi Arabia as part of the World Sepsis Day held in King Abdulaziz Medical City, Riyadh. The objectives of the roundtable discussion were to (1) review the chasm between the current management of sepsis and best practice, (2) discuss system redesign and role of the microsystem in sepsis management, (3) emphasize the multidisciplinary nature of the care of sepsis and that improvement of the care of sepsis is the responsibility of all, (4) discuss the bundle concept in sepsis management, and (5) reflect on the individual responsibility of the health care team toward sepsis with a focus on accountability and the moral agent.
doi:10.4103/1817-1737.134066
PMCID: PMC4073568  PMID: 24987470
Accountability; moral responsibility; sepsis bundle; World Sepsis Day
16.  Improving venous thromboembolism risk assessment compliance using the electronic tool in admitted medical patients 
BMJ Quality Improvement Reports  2015;4(1):u209593.w3965.
Sheikh Khalifa Medical City (SKMC) in Abu Dhabi is the main tertiary care referral hospital in the United Arab Emirates (UAE) with 560 bed capacity that is fully occupied most of the time.
SKMC senior management has made a commitment to make quality and patient safety a top priority. Venous thromboembolism (VTE) risk assessment has been identified as a critical patient safety measure and key performance indicator. The electronic VTE risk assessment form a computerized decision support tool was introduced to improve adherence with deep venous thrombosis (DVT) prophylaxis recommendations. A multidisciplinary task force team was formed and led this quality improvement project. The purpose of this publication is to indicate the quality improvement interventions implemented to enhance compliance with VTE risk assessment and the outcomes of those interventions.
We chose to conduct the pilot study in General Medicine as it is the busiest department in the hospital. The study period was from April 2014 till August 2015.The lessons learned were disseminated throughout the hospital. Our aim was to improve VTE risk assessment compliance by using the electronic form in order to ensure patient safety and reduce preventable harm. VTE risk assessment compliance improved in general medicine from 4% to 98%, and overall SKMC compliance from 21% to above 90%.
doi:10.1136/bmjquality.u209593.w3965
PMCID: PMC4693050  PMID: 26734399
17.  Tertiary care availability and adolescent pregnancy characteristics in Saudi Arabia 
Background
In this study, we aimed to assess the rate of adolescent delivery in a Saudi tertiary health care center and to investigate the association between maternal age and fetal, neonatal, and maternal complications where a professional tertiary medical care service is provided.
Methods
A cross-sectional study was performed between 2005 and 2010 at King Abdulaziz Medical City, Riyadh, Saudi Arabia. All primigravid Saudi women ≥24 weeks gestation, carrying a singleton pregnancy, aged <35 years, and with no chronic medical problems were eligible. Women were divided into three groups based on their age, ie, group 1 (G1) <16 years, group 2 (G2) ≥16 up to 19 years, and group 3 (G3) ≥19 up to 35 years. Data were collected from maternal and neonatal medical records. We calculated the association between the different age groups and maternal characteristics, as well as events and complications during the antenatal period, labor, and delivery.
Results
The rates of adolescent delivery were 20.0 and 16.3 per 1,000 births in 2009 and 2010, respectively. Compared with G1 and G2 women, G3 women tended to have a higher body mass index, a longer first and second stage of labor, more blood loss at delivery, and a longer hospital stay. Compared with G1 and G2 women, respectively, G3 women had a 42% and a 67% increased risk of cesarean section, and had a 52% increased risk of instrumental delivery. G3 women were more likely to develop gestational diabetes or anemia, G2 women had a three-fold increased risk of premature delivery (odds ratio 2.81), and G3 neonates had a 50% increased overall risk of neonatal complications (odds ratio 0.51).
Conclusion
The adolescent birth rate appears to be low in central Saudi Arabia compared with other parts of the world. Excluding preterm delivery, adolescent delivery cared for in a tertiary health care center is not associated with a significantly increased medical risk to the mother, fetus, or neonate. The psychosocial effect of adolescent pregnancy and delivery needs to be assessed.
doi:10.2147/IJWH.S57743
PMCID: PMC3979779  PMID: 24729733
adolescent pregnancy; maternal mortality; maternal morbidity; neonatal mortality; neonatal morbidity
18.  Presentation, Diagnosis and Outcome of Predominantly Hepatic Wilson's Disease in Adult Saudi Patients: A Single Centre Experience 
Background/Aim:
To evaluate the clinical manifestations, diagnostic features, disease course and response to treatment among Saudi adults with predominantly hepatic Wilson's disease. A retrospective cohort study of 40 adult patients diagnosed with predominantly hepatic Wilson's disease between 1994 and 2008 at King Abdulaziz Medical City, Riyadh was carried out.
Patients and Methods:
The diagnosis was based on varying combinations of clinical and laboratory evidence of liver disease, presence of Kayser Fleisher rings, low serum ceruloplasmin levels, elevated 24 hour urinary copper excretion and histopathological findings on liver biopsy.
Results:
The most frequent clinical presentation was decompensated chronic liver disease in 19 (47.5%), followed by chronic hepatitis in 15 (37.5%) and fulminant hepatic failure (FHF) in 5 (12.5%) patients. Eight (20%) patients with end-stage liver disease had liver transplantation, while 24 (60%) patients followed up on medical treatment for a variable period of 1-12 years showed clinical and laboratory improvement. One patient was lost early in follow up. Eight (20%) patients died during the study period, 5 with FHF, and 2 with advanced hepatic and neurological disease and one seven years after liver transplantation. Mortality rate was 100% in FHF without liver transplantation.
Conclusion:
A predominantly hepatic Wilson's disease has varied clinical presentations with decompensated chronic liver disease being the most common among adult patients. Majority of the patients show stabilization of the disease on medical treatment. FHF in Wilson's disease has a grave prognosis without liver transplantation, the later remains a definitive treatment option for decompensated cirrhotics and patients with FHF.
doi:10.4103/1319-3767.101135
PMCID: PMC3500023  PMID: 23006462
Adult; Hepatic Wilson's disease; diagnosis; outcome; presentation
19.  Prospective study of incidence and predictors of peripheral intravenous catheter-induced complications 
Background
Although intravenous therapy is one of the most commonly performed procedures in hospitalized patients, it remains susceptible to infectious and noninfectious complications. Previous studies investigated peripheral intravenous catheter (PIVC) complications mainly in pediatrics, but apparently none were investigated among Saudi adult populations. The aim of this study was to assess the pattern and complications of PIVCs at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia.
Methods
An observational prospective cohort study investigated PIVCs pattern and complications among adults with PIVCs, admitted to various wards at KAMC. PIVCs-related clinical outcomes (pain, phlebitis, leaking, and others) were recorded in 12-hour intervals, using the Visual Inspection Phlebitis scale. Density incidence (DI) and cumulative incidence (CI) of complications and their relative risks (RRs) were calculated. Regression analyses were applied and significance limits were set at P<0.05.
Results
During the study period, 359 adults were included, mounting to 842 PIVCs and 2,505 catheter days. The majority of patients, 276 (76.9%), had medical, chief admission complaints, whereas 83 (23.1%) were trauma/surgical and infectious cases. Complicated catheters were found in 141 (39.3%) patients, with 273 complications (32.4/100 catheters), in 190 complicated catheters (CI =22.56/100 catheters and DI =75.84/1,000 catheter days). Phlebitis ranked first among complications, 148 (CI =17.6%), followed by pain 64 (CI =7.6%), leaking 33 (CI =3.9%), dislodgement 20 (CI =2.4%), and extravasations and occlusion 4 (CI =0.5% each). Phlebitis was predicted with female sex (P<0.001), insertion in fore/upper arm (P=0.024), and infusion of medication (P=0.02). Removal time for PIVCs insertion was not a significant predictor of phlebitis (RR =1.46, P=0.08).
Conclusion
Incidence of complications in this study was significantly higher than rates in previous studies. Better insertion techniques may be sought to lower the incidences of PIVC complications, thus extending their onset beyond day 3. Changing catheters is recommended when clinically indicated rather than routinely post-72 hours.
doi:10.2147/TCRM.S74685
PMCID: PMC4266329  PMID: 25525365
catheter-induced complications; peripheral venous catheter; phlebitis; thrombo-phlebitis; incidence; prospective study
20.  Impact of lipid disorders on mortality among Saudi patients with heart failure 
Background
Dyslipidemia, a known cardiovascular risk factor, is extremely common among Saudis, both adults and children. The impact, however, of dyslipidemia and several other lipid disorders in patients with congestive heart failure in this particular population has not been documented. This study aims to fill the gap.
Methods
This retrospective, single center study was conducted at King Abdulaziz Medical City, Riyadh, Saudi Arabia. Of the 500 cases seen during the period between 2002 and 2008, 392 were included in the study. Charts were reviewed and information on medical history, medications, and lipid status were documented.
Results
Low HDL-cholesterol level was the most common lipid disorder with 82.9%, followed by hypertriglyceridemia (35.2%), atherogenic dyslipidemia (27.8%), and hypercholesterolemia (9.2%). Diabetes mellitus was the single most significant predictor of mortality (p = 0.001). Among the lipid disorders, only low levels of HDL-cholesterol contributed to significant mortality risk [OR 1.29 (Confidence Interval 1.04–1.59) (p-value < 0.01)] adjusted for age, gender and statin use.
Conclusion
The results of this study suggest that emphasis should be on the elevation of HDL-cholesterol levels among subjects with congestive heart failure, without compromising any ongoing management of LDL-lowering drugs. Management should not be limited to conventional statin use and should promote other treatments to elevate HDL-cholesterol levels.
doi:10.1016/j.jsha.2014.12.003
PMCID: PMC4392377  PMID: 25870502
Congestive heart failure; Lipid disorders; Saudi Arabia
21.  Reliability of Canadian Emergency Department Triage and Acuity Scale (CTAS) in Saudi Arabia 
Background
The Canadian Emergency Department Triage and Acuity Scale (CTAS) is an integral part of the Canadian emergency medicine triaging system. There is growing interest and implementation of CTAS worldwide. However, little is known about its reliability outside Canada. The aim of this study was to determine the reliability agreement of CTAS in a tertiary care emergency center in Saudi Arabia.
Methods
Ten triage nurses (five senior and five junior nurses) utilized CTAS guidelines to independently assign a triage level for 160 real case-based scenarios. Quadratic weighted kappa statistics were used to measure raters’ agreements.
Results
Raters provided 1600 triage category assignments to case scenarios for analysis. Intra-rater agreement was similar for both senior and junior nurses; for senior nurses (SN1) kappa 0.871 95 % CI (0.840–0.897), and for junior nurses (SN2) kappa 0.871 95 % CI (0.839–0.898). Inter-rater agreement for the SN1 versus SN2 nurses had statistically meaningful agreement across different triage levels (weighted kappa = 0.770) 95 % CI (0.742–0.797).
Conclusions
CTAS has good reliability among emergency department (ED) triage nurses in King Abdulaziz Medical City (KAMC), Saudi Arabia. The findings suggest that CTAS might be a reliable instrument when applied in countries outside Canada.
doi:10.1186/s12245-015-0080-5
PMCID: PMC4527972  PMID: 26251308
Canadian triage and acuity scale (CTAS); Triage; Agreement; Reliability
22.  Impact of a diabetic foot care education program on lower limb amputation rate 
Background
Diabetic foot complications are a leading cause of lower extremity amputation. With the increasing incidence of diabetes mellitus in the Arab world, specifically in the Kingdom of Saudi Arabia, the rate of amputation will rise significantly. A diabetic foot care program was implemented at King Abdulaziz Medical City in Riyadh, Saudi Arabia, in 2002. The program was directed at health care staff and patients to increase their awareness about diabetic foot care and prevention of complications. The purpose of this study was to perform a primary evaluation of the program’s impact on the rate of lower extremity amputation due to diabetic foot complications.
Method
This pilot study was the first analysis of the diabetic foot care program and examined two groups of participants for comparison, ie, a “before” group having had diabetic foot ulcers managed between 1983, when the hospital was first established, and 2002 when the program began and an “after group” having had foot ulcers managed between 2002 and 2004, in the program’s initial phase. A total of 41 charts were randomly chosen retrospectively. A data sheet containing age, gender, medical data, and the presentation, management, and outcome of diabetic foot cases was used for the analysis.
Results
The before group contained 20 patients (17 males) and the after group contained 21 patients (16 males). There was no difference between the two groups with regard to age and comorbidities. The rate of amputation was 70% in the before group and 61.9% in the after group. There was a decrease in the percentage of toe amputation in the after group and an increase in the percentage of below-knee amputation in the before group. However, these changes were not significant.
Conclusion
The program, although evaluated at an early stage, has increased the awareness of both patients and health care staff about the prevention and management of diabetic foot disease, and decreased the rate of lower extremity amputation. We believe that the statistical proof of its impact will be evident in the final evaluation.
doi:10.2147/VHRM.S13569
PMCID: PMC2964945  PMID: 21057577
diabetic foot; prevention; complications; lower limb amputation
23.  What is the optimal blood glucose target in critically ill patients? A nested cohort study 
Annals of Thoracic Medicine  2011;6(4):207-211.
AIMS:
There is an uncertainty about what constitutes an optimal level of blood glucose (BG) in critically ill patients. The objective of this study is to identify the optimal BG target for glycemic control in critically ill patients that is associated with survival benefit with the least hypoglycemia risk.
SETTING AND DESIGN:
This is a nested cohort study within a randomized control trial conducted in a tertiary care center in King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia.
METHODS:
The study was carried out in a single center to assess the effect of intensive insulin therapy [IIT; target BG 4.4-6.1 mmol/L (80-110 mg/dL)] versus conventional insulin therapy [CIT; target BG 10-11.1 mmol/L (180-200 mg/dL)] in a medical/surgical ICU. All patients were divided into six groups based on the mean daily BG levels. A logistic regression model was used to determine the association of BG and ICU mortality. We compared different outcomes below and above different BG thresholds of 0.1 mmol/L (2 mg/dL) increments using multivariate analyses.
STATISTICAL ANALYSIS:
Data are presented as mean ± SD or median with interquartile ranges, unless otherwise indicated. Differences between the six groups were assessed using the χ2 test. A P-value equal or less than 0.05 was considered to indicate statistical significance. The results were expressed as adjusted odds ratio (aOR) and 95% confidence intervals (CI). Statistical analyses were carried out using the Statistical Analysis Software (SAS, release 8, SAS Institute Inc., Cary, NC, USA).
RESULTS:
Among six groups, the ICU mortality was least in patients with BG <8.7 mmol/L (<157 mg/dL) compared with patients with BG ≥8.7 mmol/L (≥157 mg/dL) [11.5% vs. 21.5%, P = 0.002]. When analyzed using 0.1 mmol increments in average BG, we found that mortality remained unchanged by increasing thresholds of BG up to 8.0 mmol/L (144 mg/dL) and started to rise with thresholds of BG of 8.1 mmol/L (146 mg/dL) and above. The risk of hypoglycemia was the highest with a BG threshold of 6.1 mmol/L (110 mg/dL) and gradually decreased with increasing BG levels to plateau with a BG level of 7.2 mmol/L (130 mg/dL) and higher.
CONCLUSION:
Our study suggests that a BG level of 8.1 mmol/L (146 mg/dL) and below represents an optimal level in critically ill patients.
doi:10.4103/1817-1737.84774
PMCID: PMC3183637  PMID: 21977065
Critically ill; hypoglycemia; insulin; intensive care; mortality; sepsis
24.  Quality of life in patients with skin diseases in central Saudi Arabia 
Background
Previous national and international studies of quality of life (QoL) in patients with skin diseases have revealed different levels of QoL impairment. The aims of this study were to assess QoL in patients with skin diseases in central Saudi Arabia using the newly validated Skindex-16 instrument and to determine the association between QoL in patients with skin disease, sociodemographic data, and disease characteristics.
Methods
A cross-sectional study was conducted in 283 adult patients who visited the outpatient dermatology clinics of King Abdulaziz Medical City, Riyadh, Saudi Arabia, over 3 months. The patients were interviewed using a pretested Arabic version of the Skindex-16 to measure the effect of skin disorders on their QoL during the previous 7 days. Patient characteristics, medical history, and clinical findings were collected. Multiple linear regression analyses were used to relate the demographic and clinical characteristics to the percentage mean QoL score, and P ≤ 0.05 was considered to be statistically significant.
Results
QoL was good in 69% of the respondents, with a total percent mean score of 31.80 ± 20.16. The emotional domain was the most affected (mean percentage score 44.27 ± 27.06), followed by symptoms (31.45 ± 28.40) and functioning (14.61 ± 22.75). After adjustment for potential confounders, poorer QoL was significantly associated with female gender (P = 0.03), older age (P = 0.003), rural origin (P = 0.03), positive family history of the same lesion(s) (P = 0.01), shorter duration of ≤6 months (P = 0.02), generalized spread (P ≤ 0.02), and lack of isotretinoin treatment (P = 0.02).
Conclusion
. The QoL results in this study were generally more optimistic than those of many previous studies. This discrepancy may be due to biases in questionnaire responses or to cultural differences in experience of skin disease and perception of disability. Significant predictors of QoL were not the same for the three domains of the Skindex scale. Further studies of specific diseases and educational programs targeting patients at higher risk for QoL impairments are recommended.
doi:10.2147/IJGM.S33276
PMCID: PMC3410718  PMID: 22866015
quality of life; skin disease; Saudi Arabia
25.  Maternal and neonatal risk factors for early-onset group B streptococcal disease: a case control study 
Objectives
To identify the prominent maternal and neonatal risk factors associated with early-onset group B streptococcus (EOGBS) disease in neonates and to determine their importance by comparing them with a control group.
Setting
Neonatal unit at King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia.
Patients
Cases were infants <7 days of age with invasive group B streptococcus (GBS) disease diagnosed between January 1, 2000 and December 31, 2009. Controls were healthy infants born in the same hospital during the same period having the same birth weight and gestational age category.
Main outcome measures
Maternal risk factors for developing EOGBS disease, feto–maternal and neonatal clinical data, their morbidities, mortalities, and length of hospital stay.
Results
A total of 99 cases and 200 controls were included. The majority of cases presented in the first 72 hours of life (62/99 [63.9%]), of which 87/99 (89.7%) had at least one clinical risk factor for the development of EOGBS disease. Mothers of neonates with EOGBS disease were more likely to have GBS bacteriuria (odds ratio [OR] 10.76, 95% confidence interval [CI] 1.24–93.42), infection in the peripartum period (OR 8.92, CI 2.87–27.68), and temperature ≥38°C (OR 7.10, CI 2.50–20.17). GBS disease was associated with premature rupture of membranes and fetal tachycardia (P<0.01 for both). Neonates with EOGBS disease were more likely to have respiratory distress disease and convulsions, require tube feeding, and have longer hospital stays compared with the controls (P<0.01 for all). Stepwise multiple logistic regression has identified three risk factors that were associated with the highest tendency for the development of EOGBS disease. These were lack of antenatal attendance (OR =0.30 and CI 0.98–0.88), rupture of membranes (OR =9.62 and CI 3.1–29.4), and antibiotic use in labor (OR =0.16 and CI 0.38–0.67).
Conclusion
A number of maternal risk factors were significantly associated with EOGBS disease. Taking these factors into consideration may result in preventing the occurrence of EOGBS disease, improve maternal and neonatal medical care, decrease their hospital stay, and reduce unnecessary hospital resource utilization.
doi:10.2147/IJWH.S52206
PMCID: PMC3814928  PMID: 24194650
group B streptococcus; neonatal morbidity; maternal morbidity; antenatal screening

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