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1.  Lower versus higher dose of enteral caloric intake in adult critically ill patients: a systematic review and meta-analysis 
Critical Care  2016;20:358.
There is conflicting evidence about the relationship between the dose of enteral caloric intake and survival in critically ill patients. The objective of this systematic review and meta-analysis is to compare the effect of lower versus higher dose of enteral caloric intake in adult critically ill patients on outcome.
We reviewed MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus from inception through November 2015. We included randomized and quasi-randomized studies in which there was a significant difference in the caloric intake in adult critically ill patients, including trials in which caloric restriction was the primary intervention (caloric restriction trials) and those with other interventions (non-caloric restriction trials). Two reviewers independently extracted data on study characteristics, caloric intake, and outcomes with hospital mortality being the primary outcome.
Twenty-one trials mostly with moderate bias risk were included (2365 patients in the lower caloric intake group and 2352 patients in the higher caloric group). Lower compared with higher caloric intake was not associated with difference in hospital mortality (risk ratio (RR) 0.953; 95 % confidence interval (CI) 0.838–1.083), ICU mortality (RR 0.885; 95 % CI 0.751–1.042), total nosocomial infections (RR 0.982; 95 % CI 0.878–1.077), mechanical ventilation duration, or length of ICU or hospital stay. Blood stream infections (11 trials; RR 0.718; 95 % CI 0.519–0.994) and incident renal replacement therapy (five trials; RR 0.711; 95 % CI 0.545–0.928) were lower with lower caloric intake. The associations between lower compared with higher caloric intake and primary and secondary outcomes, including pneumonia, were not different between caloric restriction and non-caloric restriction trials, except for the hospital stay which was longer with lower caloric intake in the caloric restriction trials.
We found no association between the dose of caloric intake in adult critically ill patients and hospital mortality. Lower caloric intake was associated with lower risk of blood stream infections and incident renal replacement therapy (five trials only). The heterogeneity in the design, feeding route and timing and caloric dose among the included trials could limit our interpretation. Further studies are needed to clarify our findings.
Electronic supplementary material
The online version of this article (doi:10.1186/s13054-016-1539-3) contains supplementary material, which is available to authorized users.
PMCID: PMC5097427  PMID: 27814776
Enteral feeding; Nutrition; Intensive care unit; Cross infection; Mortality
2.  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.
PMCID: PMC4363811  PMID: 25793169
Knee; Replacement; Arthroplasty; Implantation; Surgery; Orthopedics; Total knee arthroplasty; Total knee replacements
3.  Accuracy of urea breath test in Helicobacter pylori infection: Meta-analysis 
AIM: To quantitatively summarize and appraise the available evidence of urea breath test (UBT) use to diagnose Helicobacter pylori (H. pylori) infection in patients with dyspepsia and provide pooled diagnostic accuracy measures.
METHODS: We searched MEDLINE, EMBASE, Cochrane library and other databases for studies addressing the value of UBT in the diagnosis of H. pylori infection. We included cross-sectional studies that evaluated the diagnostic accuracy of UBT in adult patients with dyspeptic symptoms. Risk of bias was assessed using QUADAS (Quality Assessment of Diagnostic Accuracy Studies)-2 tool. Diagnostic accuracy measures were pooled using the random-effects model. Subgroup analysis was conducted by UBT type (13C vs 14C) and by measurement technique (Infrared spectrometry vs Isotope Ratio Mass Spectrometry).
RESULTS: Out of 1380 studies identified, only 23 met the eligibility criteria. Fourteen studies (61%) evaluated 13C UBT and 9 studies (39%) evaluated 14C UBT. There was significant variation in the type of reference standard tests used across studies.Pooled sensitivity was 0.96 (95%CI: 0.95-0.97) andpooled specificity was 0.93 (95%CI: 0.91-0.94). Likelihood ratio for a positive test was 12 and for a negative test was 0.05 with an area under thecurve of 0.985. Meta-analyses were associated with a significant statistical heterogeneity that remained unexplained after subgroup analysis. The included studies had a moderate risk of bias.
CONCLUSION: UBT has high diagnostic accuracy for detecting H. pylori infection in patients with dyspepsia. The reliability of diagnostic meta-analytic estimates however is limited by significant heterogeneity.
PMCID: PMC4306177  PMID: 25632206
Helicobacter pylori; Dyspepsia; Breath tests; Urea/analysis; Diagnosis; Sensitivity; Specificity; Gastritis; Positive predictive value; Negative predictive value
4.  SSRIs for Hot Flashes: A Systematic Review and Meta-Analysis of Randomized Trials 
Hot flashes are the most commonly reported vasomotor symptom during the peri- and early post-menopausal period.
To systematically review, appraise and summarize the evidence of the impact of different SSRIs on peri-menopausal hot flashes in healthy women in randomized, controlled trials.
A comprehensive literature search was conducted of MEDLINE™, EMBASE, the Cochrane Central Register of Controlled Trials, Web of Science and Scopus through March 2013. Two independent reviewers selected studies and extracted data. Random effects meta-analysis was used to pool outcomes across studies, and Bayesian mixed treatment methods were used to rank SSRIs in terms of effectiveness.
We included a total of 11 randomized controlled trials with good methodological quality enrolling 2,069 menopausal and post-menopausal women (follow-up 1–9 months, mean age 36–76 years, mean time since menopause 2.3–6.6 years). Compared with placebo, SSRIs were associated with a statistically significant decrease in hot flash frequency (difference in means −0.93; 95 % CI −1.46 to −0.37; I2 = 21 %) and severity assessed by various scales (standardized difference in means −0.34; 95 % CI −0.59 to −0.10; I2 = 47 %). Adverse events did not differ from placebo. Mixed treatment comparison analysis demonstrated the superiority of escitalopram compared to other SSRIs in terms of efficacy.
SSRI use is associated with modest improvement in the severity and frequency of hot flashes but can also be associated with the typical profile of SSRI adverse effects.
PMCID: PMC3889979  PMID: 23888328
SSRI; hot flashes; menopause
5.  Adult depression screening in Saudi primary care: prevalence, instrument and cost 
BMC Psychiatry  2014;14:190.
By the year 2020 depression would be the second major cause of disability adjusted life years lost, as reported by the World Health Organization. Depression is a mental illness which causes persistent low mood, a sense of despair, and has multiple risk factors. Its prevalence in primary care varies between 15.3-22%, with global prevalence up to 13% and between 17-46% in Saudi Arabia. Despite several studies that have shown benefit of early diagnosis and cost-savings of up to 80%, physicians in primary care setting continue to miss out on 30-50% of depressed patients in their practices.
A cross sectional study was conducted at three large primary care centers in Riyadh, Saudi Arabia aiming at estimating point prevalence of depression and screening cost among primary care adult patients, and comparing Patient Health Questionnaires PHQ-2 with PHQ-9. Adult individuals were screened using Arabic version of PHQ-2 and PHQ-9. PHQ-2 scores were correlated with PHQ-9 scores using linear regression. A limited cost-analysis and cost saving estimates of depression screening was done using the Human Capital approach.
Patients included in the survey analysis were 477, of whom 66.2% were females, 77.4% were married, and nearly 20% were illiterate. Patients exhibiting depressive symptoms on the basis of PHQ9 were 49.9%, of which 31% were mild, 13.4% moderate, 4.4% moderate-severe and 1.0% severe cases. Depression scores were significantly associated with female gender (p-value 0.049), and higher educational level (p-value 0.002). Regression analysis showed that PHQ-2 & PHQ-9 were strongly correlated R = 0.79, and R2 = 0.62. The cost-analysis showed savings of up to 500 SAR ($133) per adult patient screened once a year.
The point prevalence of screened depression is high in primary care visitors in Saudi Arabia. Gender and higher level of education were found to be significantly associated with screened depression. Majority of cases were mild to moderate, PHQ-2 was equivocal to PHQ 9 in utility and that screening for depression in primary care setting is cost saving.
PMCID: PMC4227058  PMID: 24992932
Screened depression; PHQ-9; Cost-analysis; Primary health care; Saudi Arabia
6.  Erlotinib in wild type epidermal growth factor receptor non-small cell lung cancer: A systematic review 
Annals of Thoracic Medicine  2013;8(4):204-208.
Targeting epidermal growth factor receptors (EGFR) is an innovative approach to managing non-small cell lung cancer (NSCLC) which harbors EGFR mutation. However, the efficacy of these agents like erlotinib in patients without the mutation is not known.
This systematic review included Phase III randomized clinical trials that compared single agent erlotinib to other management options in the setting of NSCLC with reported outcome data on patients with EGFR wild type (EGFRWT) tumors. Outcome data include overall survival (OS), progression free survival (PFS) and response rate (RR). Random effects meta-analysis was used to pool outcomes across studies.
Three studies met the inclusion criteria. These studies included a total of 2044 patients with outcome data on 674 patients with EGFRWT tumors (33%). Meta-analysis revealed a statistically significant improvement in OS with erlotinib (hazard ratio of 0.780; 95% confidence interval: 0.654-0.930, P = 0.006). Data were not available to perform PFS or RR analysis. The quality of this evidence is considered to be moderate to high.
Our study revealed a significant benefit of erlotinib in patient with EGFRWT tumors compared with other approaches. These findings add another therapeutic option to patients generally considered difficult to treat.
PMCID: PMC3821279  PMID: 24250733
Epidermal growth factor; erlotinib; non-small cell lung cancer
7.  Socio-demographic and Racial Differences in Acute Coronary Syndrome: Comparison between Saudi and South Asian Patients 
Acute coronary syndrome (ACS) is the leading cause of death in Saudi Arabia as elsewhere. Although, many studies found that South Asians had increased rates of ACS, others did not. The aim of the study is to explore the extent of difference between South Asians and Saudi presentation and risk factors of ACS patients.
Materials and Methods:
All patients who were diagnosed as having acute myocardial infarction (AMI) based on World Health Organization (WHO) criteria in 6 month period were included in the study.
A total of 190 patients confirmed ACS were included; 121 (63.70%) were Saudi, 50 (26.3%) were South Asians, and 19 (10.0%) were other Arab nationalities. The mean age was 53.9 (SD 14.6). Out of the total South Asians 82% had normal body mass index (BMI) (P = 0.000). Saudi patients were the lowest of the three groups who smoked cigarette and/or shisha (26.6%; P = 0.000). 52.9% of Saudi patients were diabetics and 41.3% were hypertensive (P = 0.004). More South Asians were presented with chest pain (94% vs 76%).
South Asians had a double rate of ACS incidence; they were younger, lower socio-economic status, more cigarette smokers, and less diabetics and hypertensive than other patients. An association between the apolipoprotein E (apoE) genotype with the incidence of ACS in young South Asian is proposed.
South Asians had double rate of ACS incidence; they were younger, lower socio-economic status, more cigarette smokers, and less diabetics and hypertensive than other patients.
PMCID: PMC3893997  PMID: 24479047
Acute coronary syndrome; acute myocardial infarction; Indians; myocardial infarction; racial differences
8.  Undergraduate medical students’ perceptions, attitudes, and competencies in evidence-based medicine (EBM), and their understanding of EBM reality in Syria 
BMC Research Notes  2012;5:431.
Teaching evidence-based medicine (EBM) should be evaluated and guided by evidence of its own effectiveness. However, no data are available on adoption of EBM by Syrian undergraduate, postgraduate, or practicing physicians. In fact, the teaching of EBM in Syria is not yet a part of undergraduate medical curricula. The authors evaluated education of evidence-based medicine through a two-day intensive training course.
The authors evaluated education of evidence-based medicine through a two-day intensive training course that took place in 2011. The course included didactic lectures as well as interactive hands-on workshops on all topics of EBM. A comprehensive questionnaire, that included the Berlin questionnaire, was used to inspect medical students’ awareness of, attitudes toward, and competencies’ in EBM.
According to students, problems facing proper EBM practice in Syria were the absence of the following: an EBM teaching module in medical school curriculum (94%), role models among professors and instructors (92%), a librarian (70%), institutional subscription to medical journals (94%), and sufficient IT hardware (58%). After the course, there was a statistically significant increase in medical students' perceived ability to go through steps of EBM, namely: formulating PICO questions (56.9%), searching for evidence (39.8%), appraising the evidence (27.3%), understanding statistics (48%), and applying evidence at point of care (34.1%). However, mean increase in Berlin scores after the course was 2.68, a non-statistically significant increase of 17.86%.
The road to a better EBM reality in Syria starts with teaching EBM in medical school and developing the proper environment to facilitate transforming current medical education and practice to an evidence-based standard in Syria.
PMCID: PMC3520748  PMID: 22882872
9.  Age and BMI Adjusted Comparison of Reproductive Hormones in PCOS 
Objective and Background:
Polycystic ovary syndrome (PCOS) is a complex condition and has been described in women who have polycystic ovaries as the underlying cause of hirsutism and chronic anovulation. Studies on PCOS in the Saudi population are very few. The aim of this study was to investigate the reproductive hormones levels in patients with PCOS. Effect of age and body mass index (BMI) on the hormonal findings was eliminated through a multivariate analysis.
Materials and Methods:
A comparative study was conducted on Saudi subjects attending the outpatient clinic of National Guard Hospital in Riyadh. A total of 62 cases with PCOS and 40 healthy Saudi women were included in this study. Physical evaluation and laboratory investigations were carried out. Blood luteinizing hormone (LH), follicle stimulating hormone (FSH), estradiol (E2), dehydroepiandrosterone sulfate (DHEA-SO4), sex hormone-binding globulin (SHBG), total testosterone, prolactin, and progesterone were determined. To adjust for the potentially confounding effect of age and BMI, we carried out multivariate linear regression analyses for the association between each of the reproductive hormones and PCOS.
Serum levels of FSH, SHBG, and progesterone were significantly lower in PCOS compared to controls (respective P values 0.001, 0.001, and 0.002), while LH/FSH and testosterone levels were higher in PCOS cases than in controls (P = 0.008 and 0.003, respectively). When multivariate linear regression analyses were carried out, LH/FSH and total testosterone were positively correlated with the disease [95% confidence interval (CI) = 0.02–0.35 and 0.02–0.17, respectively], whereas FSH, SHBG, and progesterone were negatively correlated with the disease (95% CI = –0.06 to 0.001, –0.01 to 0.001, and –0.17 to –0.03, respectively), independent of age and BMI.
Our study suggests that regardless of the age and weight factors, Saudi patients with PCOS have higher levels of LH/FSH and total testosterone; but have lower levels of FSH, SHBG, and progesterone compared to controls.
PMCID: PMC3893977  PMID: 24479022
Age; body mass index; polycystic ovary syndrome; reproductive hormones; Saudi Arabia
10.  Integration of evidence based medicine into the clinical years of a medical curriculum 
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.
PMCID: PMC3410178  PMID: 22870419
Clinical years; evidence based medicine; medical curriculum; medical education
11.  Prevalence of mental disorders among high school students in National Guard Housing, Riyadh, Saudi Arabia 
Adolescents experience rapid biological, psychological, and social transitions that can be associated with mental health problems. During the high school period there are also more academic stressors.
(1) To study the prevalence of mental disorders in high school (grade 12) students. (2) To study some related sociodemographic data.
Materials and Methods:
A cross-sectional study, using GHQ-28, that included 354 students randomly selected from grade 12 in four high schools – two male and two female high schools – in the National Guard Housing (Iskan), in Kashmalaan (suburb of Riyadh).
The overall prevalence of mental disorders was found to be 48% (41% in males and 51% in females); more than 80% of these cases were mild to moderate. Females showed significantly more severe disorders than males (P = 0.017) and students with excellent performance degrees showed a significantly lower rate of mental disorders than others (P = 0.021). However, our study did not show a significant association between psychiatric disorders and other social variables (family size, birth order, and polygamous family) or smoking.
The adolescent age groups in our community had high rates of mental disorders, which required more attention from the family, as well as the educational and health institutes in our country.
PMCID: PMC3326771  PMID: 22518359
Adolescents; GHQ-28; high school students; mental disorder; prevalence; Saudi Arabia
12.  Nephrotic syndrome after treatment of Crohn's disease with mesalamine: Case report and literature review 
Inflammatory bowel disease and its various treatments may affect the kidney in several ways. Recently, case reports have been published documenting the development of nephrotic syndrome after the treatment for inflammatory bowel disease with 5-aminosalicylic acid derivatives. We report a 50-year-old patient who was diagnosed with Crohn's disease and was treated with mesalamine. The patient subsequently developed nephrotic syndrome and a renal biopsy showed minimal change disease. He was treated with losartan and rosuvastatin and showed improvement in his renal function and serum cholesterol level. This is the first reported case in Crohn's disease although there have been six previous case reports of nephrotic syndrome following salicylic acid derivatives for ulcerative colitis.
PMCID: PMC3507066  PMID: 23210014
Aminosalicylic acid; Crohn's disease; inflammatory bowel disease; mesalamine; minimal change disease; nephrotic syndrome
13.  Tissue plasminogen activator versus heparin for locking dialysis catheters: A systematic review 
Avicenna Journal of Medicine  2011;1(2):29-34.
Background and Objectives:
Hemodialysis catheters are commonly used when renal replacement therapy is initiated. These catheters have significant complications. Among “locking” solutions used in an attempt to decrease these complications is recombinant tissue plasminogen activator (rt-PA). This systematic review is to determine the efficacy of rt-PA versus heparin, the standard of care.
Materials and Methods:
A systematic review of randomized controlled trials studying rt-PA alone or rt-PA plus heparin versus heparin alone as locking agents for hemodialysis catheters, which included patients needed a temporary hemodialysis catheter for hemodialysis. We identified relevant trials through electronic databases and correspondence with experts. Two investigators independently reviewed potentially eligible trials and extracted data.
Three trials met the inclusion criteria. One trial reported an improved catheter malfunctioning in patients using rt-PA plus heparin to lock catheters (20.0%) versus heparin alone (34.8%). Another trial reported higher blood flow rate in hemodialysis catheters in patients who received rt-PA (231.6 ± 12.4 mL/min) compared with those who received heparin (206.9 mL/min). The third trial reported formation and weight of clots which were decreased by half in rt-PA group versus heparin group.
In the few randomized trials that met our inclusion criteria, the use of rt-PA as a locking solution for hemodialysis catheters seems to be associated with fewer adverse events and catheter malfunctioning as compared with heparin. Our systematic review is limited by the few randomized trials addressing our question and the wide variety of outcome measures. Further prospective randomized trials are needed to confirm this conclusion.
PMCID: PMC3507063  PMID: 23210006
Anticoagulants; catheter; dialysis; hemodialysis; heparin; prophylaxis; tissue plasminogen activator

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