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.
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).
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
Atrial fibrillation; clinical characteristics; central region; Saudi Arabia
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.
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.
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.
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.
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.
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.
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).
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.
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.
Critically ill; hypoglycemia; insulin; intensive care; mortality; sepsis
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.
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.
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).
. 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.
quality of life; skin disease; Saudi Arabia
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.
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.
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.
Asthma; Saudi Arabia; uncontrolled asthma; unconventional therapy
"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.
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.
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.
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.
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.
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.
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.
diabetic foot; prevention; complications; lower limb amputation
Informed consent is considered the most important step in clinical interventions. The aims of this study were (1) to assess the quality of informed consent for invasive procedures with regard to consent process and information given about risks and alternative treatments, and (2) to determine patients’ attitude toward informed consent at King Abdulaziz Medical City, Riyadh, Saudi Arabia.
A cross-sectional study was conducted of 162 adult patients in different wards after undergoing surgery or invasive procedures within 1–2 days of signing the informed consent, using a previously validated interview questionnaire. Data on patients’ characteristics, type of invasive procedure, and some informed consent-related issues were collected. Multiple linear regression analysis was used to identify the predictors of the percentage mean score of quality of informed consent, and significance was considered at P ≤ 0.05.
The quality of informed consent was generally poor (% mean score = 50.98 ± 17.49). About two-thirds of patients were told during the informed consent process that they have to sign merely as routine, 48% thought that if they refused the treatment plan they would lose the interest of the treating physician to help them, 42% thought that by saying no they would lose the good relationship with their physician, and 42.6% were not interested in having a copy of the informed consent document. Significantly higher quality was predicted when the physicians were the ones who explained the informed consent (t = 4.15, P < 0.001) and when informed consent was explained to younger patients (t = 2.754, P = 0.007). The overall attitude of the patients toward the process of informed consent was satisfactory (% mean score = 76.31 ± 7.63).
The results suggest either that patients are not aware of their rights or that physician paternalism is practiced in Saudi Arabia. Cultural barriers should not be an argument to diminish the role of informed consent. Further studies should focus on how the value of autonomy can be appreciated in the Saudi culture.
informed consent; quality; invasive procedure; Saudi Arabia
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.
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.
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.
Adult; Hepatic Wilson's disease; diagnosis; outcome; presentation
Infertility is a severely distressing experience for many couples. Depression is considered as one of the main psychological disorders associated with infertility and it may significantly affect the life of infertile individuals, their treatment, and follow-up.
The objective of the study was to determining the prevalence and predisposing factors of depressive disorders among the infertile compared to fertile women.
Rate of depression was explored by this cross-sectional study carried out among women attending In-Vitro Fertilization Clinic (91 infertile women) and Well Baby Clinic (94 fertile women) at King Abdulaziz Medical City (KAMC) in Riyadh, KSA.
Self administrated questionnaire including Beck Depression Inventory (BDI) was used. Mean BDI score was measured and its relation with different variables was explored, such as age, educational level, duration of infertility, pressure from family members, miscarriages and support from husband.
This study showed that 49 (53.8%) of the infertile women and 35 (37.2%) of the fertile women had depression. Mean BDI score between infertile and fertile women was significantly different (p <0.001). Infertile women were found to be more severely depressed (p =0.014). Among the infertile women, those who had pressure from family members for not getting pregnant were more depressed than those with no such pressure (P=0.001).
Depression is more common and severe in infertile women than fertile women. Pressure from family to get pregnant is a significant contributor to depression. Caregivers should routinely screen infertile women for depression during and after treatment for infertility and manage concomitantly.
Cardiovascular disease (CVD) is a leading cause of death worldwide. CVD-related mortality can be substantially reduced by modifying risk factors.
In this cross-sectional study conducted in King Abdulaziz Medical City, Riyadh, we estimated and compared prevalence of self-reported risk factors for CVD among physicians and a comparative group of non-physician health workers. We postulated that prevalence of CVD risk factors would be significantly lower in physicians. Participants filled in a structured self-administered questionnaire on CVD risk factors.
The study included 200 participants (100 respondents each group). Participants in the two groups were of similar age (P = 0.46) and Body Mass Index (BMI) P = 0.11. There was no statistical difference in smoking, frequency and length of physical exercise per week (P = 0.53, 0.57, 0.47 respectively). Diet habits showed daily intake of more protein, less fat and highly processed food, and similar vegetables, fruit and carbohydrate among physicians. Health status (presence of hypertension, diabetes, or dyslipidemia, or other diseases) didn’t differ between the two groups. Physicians showed a significantly higher familial cardiovascular risk, with mothers and siblings having more dyslipidemia, but there was no significant difference in parental dyslipidemia, diabetes or hypertension.
These findings indicate that high awareness of CVD and associated risk factors alone is not enough to prevent their occurrence. Programs to routinely screen these risk factors and improve the lifestyle of physicians are needed.
Cardiovascular disease; risk factors; physicians; Saudi Arabia
Vitamin D plays an important role in diverse physiological functions in addition to its role in bone health. Vitamin D deficiency is very common in elderly people, but there are few reports on its prevalence in young adults.
A cross-sectional study was carried out on a total of 465 young adult Saudi females aged 19 to 40 years old who were selected from primary health care centers of King Abdulaziz medical city, Riyadh, KSA. A questionnaire was used to identify socio-demographic characteristics and risk factors such as sunlight exposure and dietary intake. 25-hydroxy vitamin D [25(OH)D], Parathyroid hormone (PTH) and bone biochemical parameter were measured. The cutoff values for Vitamin D were defined as follows: deficient (<25nmol/L), insufficient (25–75 nmol/L) and normal (≥ 75 nmol/L).
Overall, hypovitaminosis D were identified in all participants, with a mean level of 18.34 ±8.2 nmol/L. Of all the participants, 79.1% exhibited severe vitamin D deficiency (serum 25(OH) D < 25 nmol/L), while 20.9% exhibited vitamin D insufficiency (serum 25(OH) D between 25–50 nmol/L). There was a significant inverse correlation between serum 25 (OH) D concentrations and PTH, where secondary hyperparathyroidism was evident in 61.4% of participants with deficient vitamin D compared to 39.2% of participants with insufficient vitamin D.
Despite the abundant sunlight in Saudi Arabia, the prevalence of hypovitaminosis D among young healthy Saudi females is 100%. This finding should be considered a public health problem. Case identification, health education and prevention should be encouraged.
Vitamin D; prevalence; women; Saudi; secondary hyperparathyroidism; sunlight; dietary supplement
The emergency medical services program at the College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia, was adapted from the integrated problem-based learning curriculum of Flinders University, Adelaide, South Australia.
The purpose of this article is to discuss the major adaptations required for adoption of the full-fledged PBL curriculum, use of sequential blocks, and multilayer alignment of the curriculum.
A logical model and step-by-step approach were used to design the curriculum. Several studies using Delphi methods, focus group interviews, and expert opinions were performed to identify the priority health problems; related competencies, learning objectives, and learning strategies; the web-based curriculum for delivery; student assessment; and program evaluation.
Sixty priority health problems were identified for inclusion in different blocks of the curriculum. Identified competencies matched the satisfaction of different stakeholders, and ascertained learning objectives and strategies were aligned with the competencies. A full-fledged web-based curriculum was designed and an assessment was created that aligned with a blueprint of the objectives and the mode of delivery.
Step-by-step design ensures the multilayer alignment of the curriculum, including priority health problems, competencies, objectives, student assessment, and program evaluation.
emergency medical services; problem-based learning; logical model; step-by-step approach; multilayer alignment
The aim of this study is to explore the effects of clinical supervision, and assessment characteristics on the study strategies used by undergraduate medical students during their clinical rotations. We conducted a qualitative phenomenological study at King Saud Bin Abdulaziz University for Health Sciences, College of Medicine, Riyadh, Saudi Arabia during the period from November 2007 to December 2008. We conducted semi-structured focus groups interviews with students and conducted individual interviews with teachers and students to explore students’ and clinical teachers’ perceptions and interpretations of factors influencing students’ study strategies. Data collection was continued until saturation was reached. We used Atlas-ti Computer Software (Version 5.2) to analyse the data, apply the obtained themes to the whole dataset and rearrange the data according to the themes and sub-themes. Analysis of data from interviews with twenty-eight students and thirteen clinical supervisors yielded three major themes relating to factors affecting students’ study strategies: “clinical supervisors and supervision”, “stress and anxiety” and “assessment”. The three themes we identified played a role in students’ adoption of different study strategies in the “community of clinical practice”. It appeared that teachers played a key role, particularly as assessors, clinical supervisors and as a source of stress to students.
Study strategy; Assessment; Clinical supervisor; Clinical attachment; Anxiety
Evidence-based medicine (EBM) involves approaching a clinical problem using a four-step method: (1) formulate a clear clinical question from a patient’s problem, (2) search the literature for relevant clinical articles, (3) evaluate (critically appraise) the evidence for its validity and usefulness, (4) implement useful findings into clinical practice. EBM has now been incorporated as an integral part of the medical curriculum in many faculties of medicine around the world. The Faculty of Medicine, King Abdulaziz University, started its process of curriculum reform and introduction of the new curriculum 4 years ago. One of the most characteristic aspects of this curriculum is the introduction of special study modules and electives as a student-selected component in the fourth year of study; the Introduction to Evidence-Based Medicine course was included as one of these special study modules. The purpose of this article is to evaluate the EBM skills of medical students after completing the course and their perceptions of the faculty member delivering the course and organization of the course.
Materials and methods
The EBM course was held for the first time as a special study module for fourth-year medical students in the first semester of the academic year 2009–2010. Fifteen students were enrolled in this course. At the end of the course, students anonymously evaluated aspects of the course regarding their EBM skills and course organization using a five- point Likert scale in response to an online course evaluation questionnaire. In addition, students’ achievement was evaluated with regard to the skills and competencies taught in the course.
Medical students generally gave high scores to all aspects of the EBM course, including course organization, course delivery, methods of assessment, and overall. Scores were also high for students’ self-evaluation of skill level and EBM experience. The results of a faculty member’s evaluation of the students’ achievement showed an average total percentage (92.2%) for all EBM steps.
The EBM course at the Faculty of Medicine, King Abdulaziz University, is useful for familiarizing medical students with the basic principles of EBM and to help them in answering routine questions of clinical interest in a systematic way. In light of the results obtained from implementing this course with a small number of students, and as a student-selected component, the author believes integrating EBM longitudinally throughout the curriculum would be beneficial for King Abdulaziz University medical students. It would provide a foundation of knowledge, offer easy access to resources, promote point-of-care and team learning, help students to develop applicable skills for lifelong learning, and help the faculty to achieve its goals of becoming more student-centered and encouraging students to employ more self-directed learning strategies.
student-selected component; evidence-based medicine; learning; curriculum
The direct involvement of clinical pharmacists in patient care is an ever-evolving role in the pharmacy profession. Studies have demonstrated that discharge counseling performed by a clinical pharmacist improves patients’ knowledge of their medications. The aim of this article is to evaluate the effect of patients’ educational level and previous counseling on medication knowledge among patients visiting King Abdulaziz Medical City, a tertiary care center.
The effect of the education level and previous counseling on medication knowledge was assessed in 90 patients in both inpatient and outpatient settings at King Abdul Aziz Medical City during a 5-week period using a questionnaire that contains items to assess patients’ medication knowledge and the pharmacists’ performance during counseling.
The average age of the participants was 52.9 ± 17.6 years. The participants’ education level was not significantly associated with gender; however, it was significantly associated with age, P < 0.05. A higher educational level was found to positively affect the aspects of medication knowledge that were assessed in this study (P < 0.05): 35.8-56.9% of the non-educated patients showed good to excellent recognition of medications, knowledge of their indications, and knowledge of dosage schedule compared to 76.2-90.5% for the more educated participants. Furthermore, 13.6%, 38.1%, and 70.0% of the non-educated group, the below high school group and high school education or above group, respectively, demonstrated good to excellent knowledge of their medications’ side effects. Previous counseling was also positively linked to medication knowledge (P < 0.05). Here, 87.8-97.6% of the patients who received previous counseling showed good to excellent recognition of medications, knowledge of their indications, and better knowledge of dosage schedule compared to 37.2-43.2% for those who did not. Finally, 52.9% of the patients who received previous counseling showed good to excellent knowledge of medication side effects compared to only 12.5% for those who did not.
The education level of the patient and previous counseling are positively linked to medication knowledge. Knowledge of the medications’ side effects proved to be the most difficult task for the participants in this study, requiring the highest level of education, and was improved by previous counseling.
Discharge counseling; educational level; medication knowledge; patient counseling
The aim of the present study was to study the etiologies and patterns of maxillofacial fractures in patients treated in Riyadh City, Saudi Arabia, between 2007 and 2011.
Patients and methods
Data were obtained through a retrospective review of 237 patients admitted to the King Saud Medical City Dental Department with a diagnosis of maxillofacial trauma. After excluding patient files with incomplete or unclear records, and cases in which computed tomography showed no evidence of fracture, the files of 200 patients with a diagnosis of maxillofacial fracture were included in the study. For each case, patient’s sex and age, pattern of facial fractures, and cause of injury were recorded on a data sheet. The data were transferred to an SPSS (ver. 16.0; SPSS Inc., Chicago, IL, USA) spreadsheet for statistical analysis. The chi-square test was used to test the association between two categorical variables or factors (age group, cause) with p value set at p<0.05, and t-test value at <0.05 and independent.
Motor vehicle accidents were the most common cause of maxillofacial fractures in most age groups, especially in males. Within the study sample, mandibular fractures were significantly more common than middle-third facial fractures (56.4% vs. 43.6%; p=0.006). Among mandibular fractures, parasymphyseal fractures were most common (47%), followed by condylar fractures (35.3%). Most (77.2%) middle-third facial fractures involved the zygomatic complex, and the incidence of such fractures differed significantly between male and female patients. p=0.72, not significant.
Males were more prone to maxillofacial fractures, perhaps as a result of the conservative nature of Saudi society, as the rules of Saudi Arabia do not allow the females to drive. Motor vehicle accidents were the most common cause of maxillofacial fractures in patients aged 10–29 years, indicating the high demand for the application of stricter traffic rules to reduce the rate of such accidents.
Maxillofacial trauma; Pattern of facial fractures; Etiology of maxillofacial fractures
The College of Medicine at King Saud bin Abdulaziz University for Health Sciences (KSAU-HS) was established in January 2004. The four-year curriculum was based on the Problem Based Learning (PBL) format and involved the web-based graduate medical program adopted from the University of Sydney, Australia. At KSAU-HS, one additional semester was added to the beginning of this curriculum to prepare the students in English language skills, PBL, Information Technology and Evidence Based Medicine (EBM). EBM is part of the Personal and Professional Development (PPD) theme of the medical curriculum and is integrated into each stage of the medical curriculum. These modifications of the University of Sydney curriculum are presented here as a model of EBM integration into a college of medicine curriculum.
Evidence based medicine (EBM); medical education; medical curriculum; epidemiology
Teaching Evidence Based Medicine (EBM) helps medical students to develop their decision making skills based on current best evidence, especially when it is taught in a clinical context. Few medical schools integrate Evidence Based Medicine into undergraduate curriculum, and those who do so, do it at the academic years only as a standalone (classroom) teaching but not at the clinical years. The College of Medicine at King Saud bin Abdulaziz University for Health Sciences was established in January 2004. The college adopted a four-year Problem Based Learning web-based curriculum. The objective of this paper is to present our experience in the integration of the EBM in the clinical phase of the medical curriculum. We teach EBM in 3 steps: first step is teaching EBM concepts and principles, second is teaching the appraisal and search skills, and the last step is teaching it in clinical rotations. Teaching EBM at clinical years consists of 4 student-centered tutorials. In conclusion, EBM may be taught in a systematic, patient centered approach at clinical rounds. This paper could serve as a model of Evidence Based Medicine integration into the clinical phase of a medical curriculum.
Clinical years; evidence based medicine; medical curriculum; medical education
BACKGROUND AND OBJECTIVES:
The most frequent procedures performed on women with abnormal uterine bleeding are 2D and 3D ultrasound. The most common accepted approach for the management of abnormal uterine bleeding is 2D TV scan followed by therapeutic hysteroscopy. The purpose of this prospective study was to assess whether 3D saline infusion sonohysterography (3D SIS) could replace diagnostic hysteroscopy (DH) for the diagnosis of endometrial pathology, in patients with abnormal uterine bleeding.
DESIGN AND SETTING:
A prospective study in the ultrasound department of the Women's Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia from January 2008 to February 2010.
PATIENTS AND METHODS:
0One hundred and one patients with abnormal uterine bleeding, suspected to have endometrial abnormality by 2D and 3D transvaginal scan, were prospectively studied. Of these, 55 patients had undergone both 3D SIS and DH, followed by verification of results with histopathology.
Upon comparison of 3D SIS and DH individually with histopathology, specificity and sensitivity for 3D SIS were 67% and 100%, respectively, and for hysteroscopy 67% and 98%, respectively. In addition, the positive predictive value and negative predictive value were 98% and 100%, respectively, for 3D SIS, while for DH they were 98% and 67%, respectively.
3D SIS is a safe alternative to hysteroscopy. However, larger randomized controlled trials should be conducted to ascertain the validity and reliability of this advantageous, less-invasive procedure, for women with abnormal uterine bleeding, who require evaluation of the endometrial cavity.
OBJECTIVE--To determine the efficacy of antiplatelet therapy as prophylaxis against deep venous thrombosis or pulmonary embolism in surgical and high risk medical patients. DESIGN--Overviews of all randomised trials of antiplatelet therapy that could have been available by March 1990 and in which deep venous thrombosis was assessed systematically. SETTING--53 trials (total 8400 patients) of an average of two weeks of antiplatelet therapy versus control in general or orthopaedic surgery; nine trials (600 patients) of antiplatelet therapy versus control in other types of immobility; 18 trials (1000 patients) of one antiplatelet regimen versus another. RESULTS--Overall, a few weeks of antiplatelet therapy produced a highly significant (2P < 0.00001) reduction in deep venous thrombosis. 25% of patients allocated antiplatelet therapy versus 34% of appropriately adjusted controls had deep venous thrombosis detected by systematic fibrinogen scanning or venography, representing prevention in about 90 patients per 1000 allocated antiplatelet therapy. There was an even greater proportional reduction in pulmonary embolism: such emboli were detected among 47 (1.0%) antiplatelet allocated patients versus an adjusted control total of 129 (2.7%), representing prevention among about 17 patients per 1000 treated (2P < 0.00001). In analyses confined to surgical trials, the proportional reductions were similar and separately significant for nonfatal pulmonary embolism (0.7% antiplatelet therapy v 1.8% control; 2P < 0.00001) and for deaths attributed to pulmonary embolism (0.2% v 0.9%; 2P = 0.0001). There was a slight but non-significant excess of deaths from other causes (1.0% v 0.7%), which made the difference in total mortality nonsignificant, though still favourable (1.2% v 1.5%). Information on adding antiplatelet therapy to heparin was limited but, at least for pulmonary embolism, suggested more protection from the combination than from heparin alone. The proportional reduction in the odds of suffering a deep venous thrombosis was roughly the same in patients having general surgery, traumatic orthopaedic surgery, and elective orthopaedic surgery (and in medical patients who were at increased risk of thromboembolism). For pulmonary embolism the numbers affected were smaller, but again the reductions were highly significant both in general surgery (16 (0.5%) v 58 (1.7%) pulmonary emboli; 2P < 0.0001) and in orthopaedic surgery (28 (2.7%) v 63 (6.1%) pulmonary emboli; 2P < 0.0002). CONCLUSION--It had previously been supposed that antiplatelet therapy did not influence venous thromboembolism, and many surgeons and physicians do not use it routinely for thromboprophylaxis, even for patients who are at substantial risk of deep venous thrombosis or pulmonary embolism. These results indicate that antiplatelet therapy--either alone or, for greater effect, in addition to other proved forms of thromboprophylaxis (such as subcutaneous heparin)--should be considered.
Medication errors (MEs) are among the most common types of medical errors and one of the most common and preventable causes of iatrogenic injuries. The aims of the present study were; (i) to determine the incidence and types of medication prescribing errors (MPEs), and (ii) to identify some potential risk factors in a pediatric inpatient tertiary care setting in Saudi Arabia.
A five-week retrospective cohort study identified medication errors in the general pediatric ward and pediatric intensive care unit (PICU) at King Abdulaziz Medical City (KAMC) through the physical inspection of physician medication orders and reviews of patients' files. Out of the 2,380 orders examined, the overall error rate was 56 per 100 medication orders (95% CI: 54.2%, 57.8%). Dose errors were the most prevalent (22.1%). These were followed by route errors (12.0%), errors in clarity (11.4%) and frequency errors (5.4%). Other types of errors were incompatibility (1.9%), incorrect drug selection (1.7%) and duplicate therapy (1%). The majority of orders (81.8%) had one or more abbreviations. Error rates were highest in prescriptions for electrolytes (17.17%), antibiotics (13.72%) and bronchodilators (12.97%). Medication prescription errors occurred more frequently in males (64.5%), infants (44.5%) and for medications with an intravenous route of administration (50.2%). Approximately one third of the errors occurred in the PICU (33.9%).
The incidence of MPEs was significantly high. Large-scale prospective studies are recommended to determine the extent and outcome of medication errors in pediatric hospitals in Saudi Arabia.
medication errors; prescriptions; pediatric; in-patient; Saudi Arabia
This study was aimed to determine plasma levels of total (TFPI-T) and free (TFPI-F) tissue factor pathway inhibitor, plasminogen activator inhibitor-1 (PAI-1), and tissue plasminogen activator (t-PA) in a cohort of Saudi patients with chronic stable angiographically defined coronary artery disease (CAD) and to determine its correlation with its severity.
This cross sectional study was conducted in the department of physiology and department of cardiology, College of Medicine, and King Khalid University Hospital and King Saud University, Riyadh. Sixty known cases of CAD who had undergone angiography (35 males and 25 females) were selected. A control group included 39 (20 males and 19 females) healthy subjects. Fasting venous blood samples were analyzed for total (TFPI-T) and free (TFPI-F) tissue factor pathway inhibitor, plasminogen activator inhibitor-1 (PAI-1), and tissue plasminogen activator (t-PA). Gensini scores and vessel scores were determined for assessing CAD severity.
There were non-significant differences between age, body mass index (BMI) and Blood pressure between the controls and CAD subjects. A comparison of hemostatic markers between control and CAD patients showed significantly higher levels of Fibrinogen, PAI-1, TFPI-T and TFPI-F in CAD patients compared to control subjects. But there was no difference in plasma t-PA levels. TFPI-T had a significant positive correlation with severity of disease determined by Gensini Scores (r=0.344; p=0.006) and vessel scores (r=0.338; p=0.015).
Plasma levels of total tissue factor pathway inhibitor are significantly related with the presence and severity of CAD. Elevated levels of TFPI-T may be considered as useful diagnostic and prognostic markers in patients with CAD.
Coronary artery disease; Hemostasis; Gensini score; Angiography total tissue factor pathway inhibitor; Free tissue factor pathway inhibitor; Plasminogen activator inhibitor-1; Tissue plasminogen activator
To study the anatomical and visual outcomes and prognostic factors that may predict the outcomes of rhegmatogenous retinal detachment (RRD) in children.
A retrospective chart review was performed for patients 16 years of age or younger who underwent retinal reattachment surgery for RRD at the King Abdulaziz University Hospital from 1996 to 2005 and the King Khalid Eye Specialist Hospital from 2002 to 2006, Riyadh, Saudi Arabia. Good visual outcome was defined as ≥20/200. The association between two categorical variables was evaluated with the Chi-squared test or the exact test, as appropriate. Predictors for RRD and good final visual acuity were identified by conducting stepwise logistic regression analysis. P < 0.05 was statistically significant.
The study population comprised 148 patients (166 eyes). There were 104 (70%) males and 44 (30%) females. Mean age at presentation was 8.33 ± 3.26 years (range 1.5–16 years). The retina was reattached after one surgical procedure in 106 (63.8%) eyes and reattached in 130 (78.3%) eyes after multiple surgeries. Factors predicting recurrence after the first surgery were myopia (P = 0.028), proliferative vitreoretinopathy (PVR) at presentation (P = 0.024), and total retinal detachment (P = 0.032). Good final visual outcome was achieved in 60 (44.4%) eyes. Predictors of good visual acuity were: good visual acuity at presentation (P < 0.001); absence of PVR at presentation (P < 0.001); one quadrant of retinal detachment (P = 0.0024); macula on (P = 0.0107); absence of primary repair of a ruptured globe (P = 0.0059); no pars plana vitrectomy (PPV) (P = 0.0123); clear phakic lens at follow-up (P < 0.001); absence of postoperative complications (P < 0.001); absence of recurrence of RRD (P < 0.001); and absence of epiretinal membrane (P = 0.0088). Logistic regression analysis indicated that recurrence of RRD was associated with myopia and previous congenital cataract surgery; good final visual outcome was associated with macula on detachment and poor visual outcome was associated with recurrence of RRD and occurrence of postoperative complications and previous repair of a ruptured globe.
RRD in children is usually associated with a predisposing factor, a high rate of PVR, and total retinal detachment. Despite late diagnosis and the presence of PVR, favorable anatomical and visual outcomes can be achieved.
children; rhegmatogenous; retinal detachment; predisposing factors; outcome
Hepatitis C virus (HCV) infection is a worldwide health issue with about 3% of the world’s population having HCV. In Saudi Arabia, prevalence ranges from 1.0% to 5.87%. Cutaneous diseases can indicate the presence of HCV infection.
The research project aims to identify prospectively the prevalence of HCV infection in 200 patients with various types of skin disorders and 50 healthy blood donors, and to quantify this association through clinical and laboratory investigations.
Two hundred patients with cutaneous manifestations who presented at the Dermatology outpatient clinics of King Khalid University Hospital (KKUH) and King Abdulaziz University Hospital (KAUH), Riyadh, and 50 healthy blood donors were prospectively studied. Patients were examined by a team of dermatologists and clinical data were collected through a standard questionnaire. Ten milliliters of venous blood were collected from fully consented, 8–10 h fasting patients and serum was analyzed for AST, ALT, double infection with HBsAg, anti-HCV antibodies, and screened for HCV-RNA-PCR.
Patients from the study (n = 200) consisted of 25 (12.5%) males and 175 (87.5%) females, with a mean age of 42.9 ± 15.06 years. Clinical examinations revealed that (35%) had urticaria, followed by pruritus (28%), lichen planus (25.5%), prurigo (10%), and palpable purpura (1.5%). The main serum levels of ALT and AST were within the normal reference ranges. Twenty-four patients (12%) tested positive for anti-HCV antibodies, with 15 (62.5%) being positive for the presence of HCV-RNA by PCR and 9 (37.5%) resulting negative for the viral RNA. Of the 24 anti-HCV positive patients, pruritus 12 (50%), urticaria 5 (20.8%), lichen planus 5(20.8%), and palpable purpura 2(8.3%). Five (2.5%) patients were positive for HBsAg, with 3 (60%) having pruritus and 2 (40%) presenting with urticaria. Of the 50 healthy blood donors, only one (2%) tested positive for the presence of anti-HCV antibodies, and all the donors tested negative for HBsAg.
Results clearly indicate the prevalence of anti-HCV antibodies in 24 out of 200 patients (12%) with skin manifestations seen at the dermatology outpatient clinics and documented with HCV-RNA-PCR positivity of 15/24 (62.5%). A p-value of <0.05 was considered significant, therefore, it is suggested that patients presenting with urticaria, pruritus and LP be investigated to exclude the possibility of HCV infection.
HCV; Skin disease; Prevalence