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author:("tamil, Hani")
1.  Increased cesarean section rate in Central Saudi Arabia: a change in practice or different maternal characteristics 
Cesarean section (CS) rate has shown an alarming increase. We aimed in this work to identify factors contributing to the increasing rate of CS in central Saudi Arabia.
A retrospective cohort study was conducted at King Abdulaziz Medical City. Two groups of women were included (G1 and G2). G1 had delivered by CS during the year 2002 (CS rate 12%), and G2 had delivered by CS during the year 2009 (CS rate 20%). We compared the included women’s characteristics, neonates, CS indications, and complications. Data were analyzed using SPSS version 15 program. Odds ratios and confidence intervals were calculated to report precision of categorical data results. A P-value of ≤0.05 was considered significant.
A total of 198 women were included in G1 and 200 in G2. Both groups had comparable maternal and fetal characteristics; however, absence of antenatal care has resulted in 70% increase in CS deliveries for G2, P=0.008, OR =0.30, CI 0.12–0.76. Previous vaginal surgeries have contributed to tenfold increase in CS deliveries for G2, P=0.006, OR =10.37, CI 1.32–81.78. G2 had eight times increased CS deliveries than G1 due to intrauterine growth restriction, P=0.02, OR =8.21, CI 1.02–66.25, and 80% increased risk of CS was based on maternal demand, P=0.02, OR =0.20, CI 0.02–1.71. Decision taken by less-experienced staff was associated with 2.5-fold increase in CS deliveries for G2, P=0.002, OR =2.62, CI 1.39–4.93. There was a significant increase in CS deliveries under regional analgesia and shorter duration of hospital stay for G2, P=0.0001 and P=0.001, respectively. G2 women had 2.75-fold increase in neonatal intensive care unit admission, P=0.03, OR =2.75, CI 1.06–7.15.
CS delivery rate significantly increased within the studied population. The increased rate of CS may be related to a change in physician’s practice rather than a change in maternal characteristics, and it appears to be reducible.
PMCID: PMC4506023  PMID: 26203285
cesarean section; maternal morbidity; neonatal morbidity; cesarean section rate
2.  Determinants of functional status among survivors of severe sepsis and septic shock: One-year follow-up 
Annals of Thoracic Medicine  2015;10(2):132-136.
Sepsis is a leading cause of intensive care unit (ICU) admissions worldwide and a major cause of morbidity and mortality. Limited data exist regarding the outcomes and functional status among survivors of severe sepsis and septic shock.
This study aimed to determine the functional status among survivors of severe sepsis and septic shock a year after hospital discharge.
Adult patients admitted between April 2007 and March 2010 to the medical-surgical ICU of a tertiary hospital in Saudi Arabia, were included in this study. The ICU database was investigated for patients with a diagnosis of severe sepsis or septic shock. Survival status was determined based on hospital discharge. Patients who required re-admission, stayed in ICU for less than 24 hours, had incomplete data were all excluded. Survivors were interviewed through phone calls to determine their functional status one-year post-hospital discharge using Karnofsky performance status scale.
A total of 209 patients met the eligibility criteria. We found that 38 (18.1%) patients had severe disability before admission, whereas 109 (52.2%) patients were with severe disability or died one-year post-hospital discharge. Only one-third of the survivors had good functional status one-year post-discharge (no/mild disability). After adjustment of baseline variables, age [adjusted odds ratio (aOR) = 1.03, 95% confidence interval (CI) = 1.01-1.04] and pre-sepsis functional status of severe disability (aOR = 50.9, 95% CI = 6.82-379.3) were found to be independent predictors of functional status of severe disability one-year post-hospital discharge among survivors.
We found that only one-third of the survivors of severe sepsis and septic shock had good functional status one-year post-discharge (no/mild disability). Age and pre-sepsis severe disability were the factors that highly predicted the level of functional status one-year post-hospital discharge.
PMCID: PMC4375742  PMID: 25829965
Disability; functional status; severe sepsis; septic shock
3.  Diet, physical activity and socio-economic disparities of obesity in Lebanese adults: findings from a national study 
BMC Public Health  2015;15:279.
The prevalence of obesity within countries varies by gender, age, lifestyle and socioeconomic factors. Identification of behavioural factors that are associated with obesity within the country’s context is critical for the development of effective public health programs which aim to prevent and manage obesity. The objective of this study was to assess age and gender differentials in the prevalence of obesity in Lebanon and examine correlates of obesity with a focus on socioeconomic disparities.
Following the WHO STEPwise guidelines, a national survey was conducted in Lebanon in 2008–2009. Households were selected randomly from all Governorates based on stratified cluster sampling method. One adult aged 20 years and over was randomly selected from each household for the interview. Anthropometric measurements and 24 hour recall dietary intake were obtained. The final sample included 1244 men and 1453 women. Descriptive statistics were computed for BMI, waist circumference, and percent body fat. Multivariate logistic regression analysis was carried out to assess the relationship between energy intake and obesity adjusted for relevant co-variables.
The prevalence of obesity among Lebanese adults was 26.1%. Gender differences in obesity estimates were observed across age groups and the three obesity classes, with men showing higher prevalence rates at the younger age groups (20–49 years), and women showing higher prevalence rates in older age groups (50 years and above). Obesity showed significant associations with socio-economic status in women; it decreased with higher educational attainment (OR = 0.54, 95% CI: 0.32, 0.91), greater household assets (OR = 0.26; 95% CI: 0.10, 0.72) and lower crowding index (OR = 0.62; 95% CI: 0.39, 0.98), net of the effect of other co-variates. There was a significant positive association between obesity and energy intake in both genders, and a negative association between obesity and physical activity, significantly among women.
Lifestyle and socioeconomic determinants of obesity are identified in this Lebanese population. Policy makers and service providers need to tailor public health strategies to tackle obesity accordingly.
PMCID: PMC4373105  PMID: 25880751
Obesity; Prevalence; Diet; Physical activity; Socioeconomic status; Adults; Gender; Lebanon
4.  Characteristics, management and outcomes of critically ill patients who are 80 years and older: a retrospective comparative cohort study 
BMC Anesthesiology  2014;14:126.
Older age is associated with chronic illnesses and disability, which contribute to increased admission to the intensive care unit (ICU). Our primary objective was to compare the characteristics, ICU management and outcomes of critically ill patients ≥ 80 year-old with those of younger patients.
This was a retrospective cohort study of patients admitted to a tertiary-care ICU from 1999 to 2011. The characteristics, ICU management and outcomes of patients ≥ 80 year-old were compared with those 50–64.9 and 65–79.9 year-old. Multivariate analysis was performed to determine the adjusted risk of Do-Not-Resuscitate orders and hospital mortality in patients ≥ 80 year-old compared with the younger groups.
During the study period, patients aged ≥ 80 years (N = 748) represented 7.9% of all ICU admissions and 12.8% of patients aged ≥ 50 years. Chronic cardiac (32.2%) and respiratory (21.8%) diseases were more prevalent in them than the younger groups (p < 0.0001). The most common reasons for their ICU admission were cardiovascular (30.9%) and respiratory (40.4%) conditions. Sepsis was commonly present in them on admission (32.9%). Mechanical ventilation and renal replacement therapy were commonly provided (76.9% and 16.0%, respectively). During ICU stay, Do-Not-Resuscitate orders were more frequently written for patients aged ≥ 80 years (35.0%) compared with 21.9% for 50–64.9 year-old group, p < 0.0001, and 25.4% for the 60–79.9 year-old group, p < 0.0001. On multivariate analysis, patients aged ≥ 80 years were more likely to receive these order compared with the 50–64.9 year-old patients (adjusted OR, 1.83; 95% CI, 1.45-2.31) and the 65–80 year-old patients (adjusted OR, 1.64; 95% CI, 1.32-2.04). The hospital mortality increased gradually with age and was highest (54.6%) in patients ≥ 80 year-old (p < 0.0001). Patients ≥ 80 year-old had higher risk of hospital mortality compared with patients aged 50–64.9 years (adjusted OR, 2.16; 95% CI, 1.73-2.69) and with those aged 65–79.9 years (adjusted OR, 1.51; 95% CI, 1.23-1.86).
Patients ≥ 80 year-old represented a significant proportion of ICU admissions. Although they received life sustaining measures similar to younger groups, they had higher adjusted mortality risk compared with the younger groups.
PMCID: PMC4289550  PMID: 25580090
Aged 80 and over; Critical illness; Health outcome; Mortality
5.  Carbon monoxide poisoning in Beirut, Lebanon: Patient's characteristics and exposure sources 
Carbon monoxide (CO) poisoning is a preventable disease. Patients present with nonspecific symptoms post CO exposure. Causal factors are well described in developed countries, but less in developing countries.
This study examined the characteristics of patients with CO poisoning treated at a tertiary care center in Beirut, Lebanon, and their association with the CO poisoning source.
Materials and Methods:
A retrospective chart review of all patients who presented to the Emergency Department (ED) of the American University of Beirut Medical Center (AUBMC) over 4-year period and for whom a carboxyhemoglobin (CO-Hb) level was available. Patients with CO poisoning diagnosis were included in the study. Patients’ characteristics and their association with CO poisoning source were described.
Twenty-seven patients were treated for CO poisoning during the study period, 55% of whom were males. Headache was the most common presenting symptom (51.9%). Burning charcoal indoors was the most common causal factor (44.4%), whereas fire-related smoke was another causal factor. The median arterial CO-Hb level on presentation for all cases was 12.0% (interquartile range (IQR) 7.3–20.2). All patients received normobaric oxygen therapy. No complications were documented in the ED. All patients were discharged from the ED with a median ED length of stay of 255 min (IQR 210-270). Young females were more likely to present with CO poisoning from burning charcoal indoors than from another cause.
CO poisoning in Beirut, Lebanon is mainly due to charcoal burning grills used indoors and to fire-related smoke. A clinically significant association was present between gender and CO poisoning source. An opportunity for prevention is present in terms of education and increased awareness regarding CO emission sources.
PMCID: PMC4231264  PMID: 25400389
Carbon monoxide poisoning; charcoal; developing countries; fire; Lebanon
6.  Axillary and rectal thermometry in the newborn: do they agree? 
BMC Research Notes  2014;7:584.
Accurate measurement of body temperature is critical for the assessment of a newborn’s general well-being. In nursery settings, the gold standard rectal thermometry has been replaced by the axillary method. However, evidence pertaining to the agreement between axillary and rectal thermometry in the newborn is controversial. In this cross-sectional study, the agreement between axillary and rectal temperature in newborns, as well as the effects of neonatal, maternal and environmental factors on this agreement were investigated.
The mean difference between axillary and rectal temperatures was compared in stable term and preterm newborns using paired t-test for the means of differences, Pearson correlation coefficient (r), and the Bland-Altman plot. Stepwise multivariate regression assessed predictors of this difference in the overall group and by gestational age categories.
The study included 118 newborns with gestational ages ranging from 29 to 41 weeks, median birth weight of 2980 grams (IQR: 2321.3-3363.8). Axillary and rectal temperatures correlated significantly (r = 0.5, p = 0.000) and had similar overall means but differed in 34–36 weeks gestation newborns (p = 0.01). Correlation between both methods increased with advancing gestational age being highest in term newborns (r = 0.6, p = 0.000). Bland-Altman plots revealed good agreement in gestational ages above 29 weeks. The difference between measurements increased with Cesarean delivery (ß = 0.2; 95% CI: 0.02, 0.38), but decreased with advancing chronological age (ß = -0.01; 95% CI: -0.02,-0.01), and with gestational age (ß = -0.05; 95% CI: -0.08,-0.01).
In clinically stable term and preterm infants, axillary thermometry is as reliable as rectal measurement. Predictors of agreement between the two methods include gestational age, chronological age and mode of delivery. Further studies are needed to confirm this agreement in sick newborns and in extremely premature infants.
PMCID: PMC4156607  PMID: 25176563
Axillary temperature; Diagnostic accuracy; Newborn; Rectal temperature; Thermometry methods
7.  Acute Stroke Care and Thrombolytic Therapy Use in a Tertiary Care Center in Lebanon 
Background. Thrombolytic therapy (rt-PA) is approved for ischemic stroke presenting within 4.5 hours of symptoms onset. The rate of utilization of rt-PA is not well described in developing countries. Objectives. Our study examined patient characteristics and outcomes in addition to barriers to rt-PA utilization in a tertiary care center in Beirut, Lebanon. Methods. A retrospective chart review of all adult patients admitted to the emergency department during a one-year period (June 1st, 2009, to June 1st, 2010) with a final discharge diagnosis of ischemic stroke was completed. Descriptive analysis was done followed by a comparison of two groups (IV rt-PA and no IV rt-PA). Results. During the study period, 87 patients met the inclusion criteria and thus were included in the study. The mean age was found to be 71.9 years (SD = 11.8). Most patients arrived by private transport (85.1%). Weakness and loss of speech were the most common presenting signs (56.3%). Thirty-three patients (37.9%) presented within 4.5 hours of symptom onset. Nine patients (10.3%, 95% CI (5.5–18.5)) received rt-PA. The two groups (rt-PA versus non rt-PA) had similar outcomes (mortality, symptomatic intracerebral hemorrhage, modified Rankin scale scores, and residual deficit at hospital discharge). Conclusion. In our setting, rt-PA utilization was higher than expected. Delayed presentation was the main barrier to rt-PA administration. Public education regarding stroke is needed to decrease time from symptoms onset to ED presentation and potentially improve outcomes further.
PMCID: PMC4124754  PMID: 25140255
8.  Will any future increase in cigarette price reduce smoking in Saudi Arabia? 
Annals of Thoracic Medicine  2014;9(3):154-157.
In Saudi Arabia, no studies have been conducted on the correlation between any possible cigarette's price increase and its effects on cigarette consumption.
The aim of this study was to determine the prevalence of cigarette smoking in Saudi Arabia and to predict the effect of price increase on cigarette consumption.
A cross-sectional study was conducted in April and May 2013.
We developed an Arabic questionnaire with information on demographic and socioeconomic factors, smoking history, and personal opinion on the effect of price increase on cigarette consumption. The questionnaire was distributed in public places such as malls and posted on famous Saudi athlete media's twitter accounts.
Among the 2057 included responses, 802 (39%) were current smokers. The smokers’ population constituted of 746 (92%) males, of which 546 (68%) had a monthly income equal or greater to 800 US dollars, and 446 (55%) were aged between 21 and 30 years. Multivariate analyses of the risk factors for smoking showed that male gender and older age were associated with greater risk. Despite the current low prices of 2.67 US dollars, 454 smokers (56%) thought that cigarette prices are expensive. When asked about the price of cigarettes that will lead to smoking cessation, 443 smokers (55%) expected that a price of 8.27 US dollars and more per pack will make them quit.
Increasing the price of popular cigarettes pack from 2.67 US dollars to 8.27 US dollars is expected to lead to smoking cessation in a large number of smokers in the Saudi population.
PMCID: PMC4073572  PMID: 24987474
Cessation; cigarette; price increase; Saudi Arabia; smokers; smoking; tobacco
9.  Spectral domain optical coherence tomography in children: normative data and biometric correlations 
BMC Ophthalmology  2014;14:53.
The aim was to report normative values of retinal nerve fiber layer (RNFL) and macular parameters in children using spectral domain optical coherence tomography (OCT) and to perform correlations with age, refractive error and axial length.
This was an observational cross-sectional study recruiting 113 healthy children aged 6 to 17 years with no ocular abnormality except refractive error. After a comprehensive eye examination and axial length measurement, RNFL and macular thickness measurements were performed using the Cirrus OCT machine. Main outcome measures were macular volume, macular thickness and RNFL thickness values as well as their correlations with age, refractive error and axial length. Right eyes of all subjects were selected for analysis.
One hundred and eight children were included in the study, 65 females and 43 males. Mean age was 10.7+/−3.1 years, average spherical equivalent refraction (SE) was −0.02+/−1.77(−4.25 to +5.00) diopters and average axial length was 23.5+/−1.0 (21.5 to 25.8)mm. Mean RNFL thickness was 95.6+/−8.7 μm, average macular thickness was 279.6+/−12.5 μm, central macular thickness was 249.1+/−20.2 μm, and mean macular volume was 10.1+/−0.5 mm3. Central macular thickness values were significantly higher in males (p < 0.001). RNFL measurements did not correlate with age but did show a positive correlation with SE. All macular parameters were consistently positively correlated with age and most of them were positively correlated with SE. When controlling for axial length, only the macular inner circle thickness was positively correlated with age.
Using Cirrus OCT, normative RNFL and macular parameters in healthy children below 18 years of age were established; measurements varied by age and gender.
PMCID: PMC4008392  PMID: 24755354
Optical coherence tomography; Pediatric; Retinal nerve fiber layer; Macular thickness; Biometric correlations
10.  Tertiary care availability and adolescent pregnancy characteristics in Saudi Arabia 
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.
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.
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).
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.
PMCID: PMC3979779  PMID: 24729733
adolescent pregnancy; maternal mortality; maternal morbidity; neonatal mortality; neonatal morbidity
11.  Effect of education and clinical assessment on the accuracy of post partum blood loss estimation 
This research aimed to assess the effect of health care provider education on the accuracy of post partum blood loss estimation.
A non-randomized observational study that was conducted at King Abdulaziz Medical City, Riyadh, Saudi Arabia between January 1, 2011 and June 30, 2011. Hundred and twenty three health care providers who are involved in the estimation of post partum blood loss were eligible to participate. The participants were subjected to three research phases and an educational intervention. They have assessed a total of 30 different simulated blood loss stations, with 10 stations in each of the research phases. These phases took place before and after educational sessions on how to visually estimate blood loss and how to best utilize patient data in clinical scenarios. We have assessed the differences between the estimated blood loss and the actual measure. P-values were calculated to assess the differences between the three research phases estimations.
The participants significantly under-estimated post partum blood loss. The accuracy was improved after training (p-value < 0.0001) and after analysing each patient’s clinical information (p-value = 0.042). The overall results were not affected by the participants’ clinical backgrounds or their years of experience. Under-estimation was more prominent in cases where more than average-excessive blood losses were simulated while over-estimations or accurate estimations were more prominent in less than average blood loss incidents.
Simple education programmes can improve traditional findings related to under-estimation of blood loss. More sophisticated clinical education programmes may provide additional improvements.
PMCID: PMC3994970  PMID: 24646156
Post partum blood loss; Visual estimation; Maternal mortality; Maternal morbidity; Education
12.  Vitamin D status among patients visiting a tertiary care center in Riyadh, Saudi Arabia: a retrospective review of 3475 cases 
BMC Public Health  2014;14:159.
Vitamin D deficiency has been implicated in several chronic, non-communicable diseases independent of its conventional role in bone and calcium homeostasis. In this retrospective study, we determined the prevalence of vitamin D deficiency and its association to several cardiometabolic indices among patients visiting King Abdulaziz Medical City (KAMC), a tertiary hospital in Riyadh, Saudi Arabia.
A total of 3475 charts of out-patient subjects who visited KAMC from September 2009 until December 2010 were reviewed and included. Variables of interest included measurements of vitamin D status, glycemic and renal profile, as well as trace elements (calcium and phosphorous).
The over-all prevalence of vitamin D deficiency in the cohort studied was 78.1% in females and 72.4% in males. 25(OH) vitamin D was significantly associated with increasing age and weight (p-values < 0.0001 and 0.005, respectively). It was also positively associated with albumin, calcium and phosphorous (p-values < 0.0001, < 0.0001 and 0.0007, respectively) and negatively associated with alkaline phosphatase as well as circulating levels of PTH (p-values 0.0002 and 0.0007, respectively).
In conclusion, vitamin D deficiency is overwhelmingly common among patients seen at KAMC regardless of the medical condition, and it is significantly associated with increasing age, weight and markers of calcium homeostasis. Findings of the present study further stress the spotlight on vitamin D deficiency epidemic in the country and region in general.
PMCID: PMC3942273  PMID: 24524260
Vitamin D; Vitamin D deficiency; Saudi
13.  A complex breastfeeding promotion and support intervention in a developing country: study protocol for a randomized clinical trial 
BMC Public Health  2014;14:36.
Breastfeeding has countless benefits to mothers, children and community at large, especially in developing countries. Studies from Lebanon report disappointingly low breastfeeding exclusivity and continuation rates. Evidence reveals that antenatal breastfeeding education, professional lactation support, and peer lay support are individually effective at increasing breastfeeding duration and exclusivity, particularly in low-income settings. Given the complex nature of the breastfeeding ecosystem and its barriers in Lebanon, we hypothesize that a complex breastfeeding support intervention, which is centered on the three components mentioned above, would significantly increase breastfeeding rates.
A multi-center randomized controlled trial. Study population: 443 healthy pregnant women in their first trimester will be randomized to control or intervention group. Intervention: A “prenatal/postnatal” professional and peer breastfeeding support package continuing till 6 months postpartum, guided by the Social Network and Social Support Theory. Control group will receive standard prenatal and postnatal care. Mothers will be followed up from early pregnancy till five years after delivery. Outcome measures: Total and exclusive breastfeeding rates, quality of life at 1, 3 and 6 months postpartum, maternal breastfeeding knowledge and attitudes at 6 months postpartum, maternal exclusive breastfeeding rates of future infants up to five years from baseline, cost-benefit and cost-effectiveness analyses of the intervention. Statistical analysis: Descriptive and regression analysis will be conducted under the intention to treat basis using the most recent version of SPSS.
Exclusive breastfeeding is a cost-effective public health measure that has a significant impact on infant morbidity and mortality. In a country with limited healthcare resources like Lebanon, developing an effective breastfeeding promotion and support intervention that is easily replicated across various settings becomes a priority. If positive, the results of this study would provide a generalizable model to bolster breastfeeding promotion efforts and contribute to improved child health in Lebanon and the Middle East and North Africa (MENA) region.
Trial registration
Current Controlled Trials ISRCTN17875591
PMCID: PMC3898488  PMID: 24428951
Breastfeeding; Lay support; Cost analysis; Lactation support; Knowledge; Attitudes; Social network; Social support theory
14.  Risk factors, management and outcomes of patients admitted with near fatal asthma to a tertiary care hospital in Riyadh 
Annals of Thoracic Medicine  2014;9(1):33-38.
Near-fatal asthma (NFA) has not been well studied in Saudi Arabia. We evaluated NFA risk factors in asthmatics admitted to a tertiary-care hospital and described NFA management and outcomes.
This was a retrospective study of NFA patients admitted to an ICU in Riyadh (2006-2010). NFA was defined as a severe asthma attack requiring intubation. To evaluate NFA risk factors, randomly selected patients admitted to the ward for asthma exacerbation were used as controls. Collected data included demographics, information on prior asthma control and various NFA treatments and outcomes.
Thirty NFA cases were admitted to the ICU in the five-year period. Compared to controls (N = 120), NFA patients were younger (37.5 ± 19.9 vs. 50.3 ± 23.1 years, P = 0.004) and predominantly males (70.0% vs. 41.7%, P = 0.005) and used less inhaled steroids/long-acting ß2-agonists combination (13.6% vs. 38.7% P = 0.024. Most (73.3%) NFA cases presented in the cool months (October-March). On multivariate analysis, age (odds ratio [OR] 0.96; 95% confidence interval [CI], 0.92-0.99, P = 0.015) and the number of ED visits in the preceding year (OR, 1.25; 95% CI, 1.00-1.55) were associated with NFA. Rescue NFA management included ketamine (50%) and theophylline (19%) infusions. NFA outcomes included: neuromyopathy (23%), mechanical ventilation duration = 6.4 ± 4.7 days, tracheostomy (13%) and mortality (0%). Neuromuscular blockade duration was associated with neuromyopathy (OR, 3.16 per one day increment; 95% CI, 1.27-7.83).
In our study, NFA risk factors were younger age and higher number of ED visits. NFA had significant morbidity. Reducing neuromuscular blockade duration during ventilator management may decrease neuromyopathy risk.
PMCID: PMC3912685  PMID: 24551016
Asthma; critical illness; mechanical ventilation; neuromyopathy
15.  Venous Thromboembolism in Critically Ill Cirrhotic Patients: Practices of Prophylaxis and Incidence 
Thrombosis  2013;2013:807526.
Objectives. We compared venous thromboembolism (VTE) prophylaxis practices and incidence in critically ill cirrhotic versus noncirrhotic patients and evaluated cirrhosis as a VTE risk factor. Methods. A cohort of 798 critically ill patients followed for the development of clinically detected VTE were categorized according to the diagnosis of cirrhosis. VTE prophylaxis practices and incidence were compared. Results. Seventy-five (9.4%) patients had cirrhosis with significantly higher INR (2.2 ± 0.9 versus 1.3 ± 0.6, P < 0.0001), lower platelet counts (115,000 ± 90,000 versus 258,000 ± 155,000/μL, P < 0.0001), and higher creatinine compared to noncirrhotic patients. Among cirrhotics, 31 patients received only mechanical prophylaxis, 24 received pharmacologic prophylaxis, and 20 did not have any prophylaxis. Cirrhotic patients were less likely to receive pharmacologic prophylaxis (odds ratio, 0.08; 95% confidence interval (CI), 0.04–0.14). VTE occurred in only two (2.7%) cirrhotic patients compared to 7.6% in noncirrhotic patients (P = 0.11). The incidence rate was 2.2 events per 1000 patient-ICU days for cirrhotic patients and 3.6 events per 1000 patient-ICU days for noncirrhotics (incidence rate ratio, 0.61; 95% CI, 0.15–2.52). On multivariate Cox regression analysis, cirrhosis was not associated with VTE risk (hazard ratio, 0.40; 95% CI, 0.10–1.67). Conclusions. In critically ill cirrhotic patients, VTE incidence did not statistically differ from that in noncirrhotic patients.
PMCID: PMC3872442  PMID: 24386564
16.  Maternal and neonatal risk factors for early-onset group B streptococcal disease: a case control study 
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.
Neonatal unit at King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia.
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.
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).
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.
PMCID: PMC3814928  PMID: 24194650
group B streptococcus; neonatal morbidity; maternal morbidity; antenatal screening
17.  Even Mild Hyperlactatemia Is Associated with Increased Mortality in Critically Ill Patients 
Critical Care  2013;17(5):R197.
The clinical significance of elevation of lactate levels within the reference range is not well studied. The objective of this study was to determine the best cutoff threshold for serum lactate within the reference range (0.01 to 2.00 mM) that best discriminated between survivors and nonsurvivors of critical illness and to examine the association between relative hyperlactatemia (lactate above the identified threshold) and mortality.
This was a retrospective cohort study of adult patients admitted to the medical-surgical intensive care unit (ICU) of a tertiary care academic center. Youden index was calculated to identify the best lactate cutoff threshold that discriminated between survivors and nonsurvivors. Patients with lactate above the identified threshold were defined as having relative hyperlactatemia. Multivariate logistic regression, adjusting for baseline variables, was performed to determine the relationship between the above two ranges of lactate levels and mortality. In addition, a test of interaction was performed to assess the effect of selected subgroups on the association between relative hyperlactatemia and hospital mortality.
During the study period, 2,157 patients were included in the study with mean lactate of 1.3 ± 0.4 mM, age of 55.1 ± 20.3 years, and acute physiology and chronic health evaluation (APACHE) II score of 22.1 ± 8.2. Vasopressors were required in 42.4%. Lactate of 1.35 mM was found to be the best cutoff threshold for the whole cohort. Relative hyperlactatemia was associated with increased hospital mortality (adjusted odds ratio (aOR), 1.60, 95% confidence interval (CI) 1.29 to 1.98), and ICU mortality (aOR, 1.66; 95% CI, 1.26 to 2.17) compared with a lactate level of 0.01 to 1.35 mM. This association was consistent among all examined subgroups.
Relative hyperlactatemia (lactate of 1.36 to 2.00 mM) within the first 24 hours of ICU admission is an independent predictor of hospital and ICU mortality in critically ill patients.
PMCID: PMC4056896  PMID: 24025259
18.  Discrepancies between two lipid-lowering guidelines for CVD prevention in seemingly healthy individuals—case study Lebanon 
In deciding on optimal interventions for cardiovascular disease (CVD) prevention, more than one set of guidelines are available.
The aim of the study was to assess the agreement between the European Society of Cardiology (ESC) 2011 Guidelines for CVD Prevention and the Canadian Cardiovascular Society (CCS) 2009 Guidelines in recommending lipid lowering interventions in a seemingly healthy cohort of Lebanese persons.
A nationally representative cohort of Lebanon was identified according to the World Health Organization (WHO) Steps Criteria. From this cohort, a group of 283 adult individuals not known to have chronic illnesses was selected. Using the algorithms present in each guideline, lipid lowering recommendations for each individual were determined. Agreement between the two guideline recommendations was determined using the Kappa test.
As per ESC, 3.9% of the participants required immediate drug therapy, 15.5% should be considered for drug therapy, and 80.1% required lifestyle intervention. As per the CCS, however, 19.4% required drug therapy. The overall level of agreement between the ESC and CCS for recommending lipid lowering was moderate (Kappa 0.77), and better in males (Kappa 0.82). In contrast, 37.5% of females recommended drug therapy as per the CCS guidelines would not be per the ESC guidelines (Kappa 0.63).
Significant discrepancies exist in recommendations for lipid-lowering therapy between CCS and ESC guidelines when applied to Lebanese individuals, particularly for women. Local healthcare authorities and the WHO should attend to this issue in order to unify treatment approaches and limit disparities in care.
PMCID: PMC3839203  PMID: 24282761
Applicability; guidelines; cardiovascular disease; prevention; statins
19.  Prevalence and associated factors of polypharmacy among adult Saudi medical outpatients at a tertiary care center 
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.
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.
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.
PMCID: PMC3957169  PMID: 24672273
Medical; medications; outpatients; polypharmacy
20.  Demographics and outcomes of critically ill patients transferred from other hospitals to a tertiary care academic referral center in Saudi Arabia 
The objective of this study was to examine the outcomes of critically ill patients who were transferred from other hospitals to a tertiary care center in Saudi Arabia as a quality improvement project.
This was a retrospective study of adult patients admitted to the medical-surgical intensive care unit (ICU) of a tertiary care hospital. Patients were divided according to the source of referral into three groups: transfers from other hospitals, and direct admissions from emergency department (ED) and from hospital wards. Standardized mortality ratio (SMR) was calculated. Multivariate analysis was performed to determine the independent predictors of mortality.
Of the 7,654 patients admitted to the ICU, 611 patients (8%) were transferred from other hospitals, 2,703 (35.3%) were direct admissions from ED and 4,340 (56.7%) from hospital wards. Hospital mortality for patients transferred from other hospitals was not significantly different from those who were directly admitted from ED (35% vs. 33.1%, p = 0.37) but was lower than those who were directly admitted from hospital wards (35% vs. 51.2%, p < 0.0001). SMRs did not differ significantly across the three groups.
Critically ill patients who were transferred from other hospitals constituted 8% of all ICU admissions. Mortality of these patients was similar to patients with direct admission from the ED and lower than that of patients with direct admission from hospital wards. However, risk-adjusted mortality was not different from the other two groups.
PMCID: PMC3751539  PMID: 23937989
Emergency department; Hospital mortality; Hospital wards; Intensive care unit; Mortality; Ambulance; Trauma
21.  Clinical characteristics, sepsis interventions and outcomes in the obese patients with septic shock: an international multicenter cohort study 
Critical Care  2013;17(2):R72.
Data are sparse as to whether obesity influences the risk of death in critically ill patients with septic shock. We sought to examine the possible impact of obesity, as assessed by body mass index (BMI), on hospital mortality in septic shock patients.
We performed a nested cohort study within a retrospective database of patients with septic shock conducted in 28 medical centers in Canada, United States and Saudi Arabia between 1996 and 2008. Patients were classified according to the World Health Organization criteria for BMI. Multivariate logistic regression analysis was performed to evaluate the association between obesity and hospital mortality.
Of the 8,670 patients with septic shock, 2,882 (33.2%) had height and weight data recorded at ICU admission and constituted the study group. Obese patients were more likely to have skin and soft tissue infections and less likely to have pneumonia with predominantly Gram-positive microorganisms. Crystalloid and colloid resuscitation fluids in the first six hours were given at significantly lower volumes per kg in the obese and very obese patients compared to underweight and normal weight patients (for crystalloids: 55.0 ± 40.1 ml/kg for underweight, 43.2 ± 33.4 for normal BMI, 37.1 ± 30.8 for obese and 27.7 ± 22.0 for very obese). Antimicrobial doses per kg were also different among BMI groups. Crude analysis showed that obese and very obese patients had lower hospital mortality compared to normal weight patients (odds ratio (OR) 0.80, 95% confidence interval (CI) 0.66 to 0.97 for obese and OR 0.61, 95% CI 0.44 to 0.85 for very obese patients). After adjusting for baseline characteristics and sepsis interventions, the association became non-significant (OR 0.80, 95% CI 0.62 to 1.02 for obese and OR 0.69, 95% CI 0.45 to 1.04 for very obese).
The obesity paradox (lower mortality in the obese) documented in other populations is also observed in septic shock. This may be related in part to differences in patient characteristics. However, the true paradox may lie in the variations in the sepsis interventions, such as the administration of resuscitation fluids and antimicrobial therapy. Considering the obesity epidemic and its impact on critical care, further studies are warranted to examine whether a weight-based approach to common therapeutic interventions in septic shock influences outcome.
PMCID: PMC3672731  PMID: 23594407
22.  Age- and Gender-Specific Reference Intervals for Fasting Blood Glucose and Lipid Levels in School Children Measured With Abbott Architect c8000 Chemistry Analyzer 
Reference intervals for pubertal characteristics are influenced by genetic, geographic, dietary and socioeconomic factors. Therefore, the aim of this study was to establish age-specific reference intervals of glucose and lipid levels among local school children. This was cross-sectional study, conducted among Saudi school children. Fasting blood samples were collected from 2149 children, 1138 (53%) boys and 1011 (47%) girls, aged 6 to 18 years old. Samples were analyzed on the Architect c8000 Chemistry System (Abbott Diagnostics, USA) for glucose, cholesterol, triglycerides, HDL and LDL. Reference intervals were established by nonparametric methods between the 2.5th and 97.5th percentiles. Significant differences were observed between boys and girls for cholesterol and triglycerides levels in all age groups (P < 0.02). Only at age 6–7 years and at adolescents, HDL and LDL levels were found to be significant (P < 0.001). No significant differences were seen in glucose levels except at age 12 to 13 years. Saudi children have comparable serum cholesterol levels than their Western counterparts. This may reflect changing dietary habits and increasing affluence in Saudi Arabia. Increased lipid screening is anticipated, and these reference intervals will aid in the early assessment of cardiovascular and diabetes risk in Saudi pediatric populations.
PMCID: PMC3358380  PMID: 23542765
Glucose; Lipids; Reference intervals; Children
23.  Prevalence of Self-reported Cardiovascular Risk Factors among Saudi Physicians: A Comparative Study 
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.
PMCID: PMC3612413  PMID: 23559900
Cardiovascular disease; risk factors; physicians; Saudi Arabia
24.  HURT (Headache Under-Response to Treatment) questionnaire in the management of primary headache disorders: reliability, validity and clinical utility of the Arabic version 
To support better headache management in primary care, the Global Campaign against Headache developed an 8-question outcome measure, the Headache Under-Response to Treatment (HURT) questionnaire. HURT was designed by an expert consensus group with patient-input. It assesses the need for and response to treatment, and provides guidance on actions to optimize therapy. It has proven content validity.
We aim to evaluate the Arabic version of HURT for clinical utility in primary care in Saudi Arabia.
HURT was translated according to the Global Campaign’s translation protocol. We assessed test-retest reliability in consecutive patients of four primary-care centres, who completed HURT at two visits 4-6 weeks apart while receiving usual care. We then provided training in headache management to the GPs practising in these centres, which were randomized in pairs to control (standard care) or intervention (care guided by implementation of HURT). We assessed responsiveness of HURT to clinical change by comparing base-line responses to HURT questions 1-6 with those at follow up. We assessed clinical utility by comparing outcomes between control and intervention pairs after 3 months, using locally-developed 5-point verbal-rating scales: the patient-satisfaction scale (PSS) and doctor-satisfaction scale (DSS).
For test-retest reliability in 40 patients, intra-class correlation coefficients were 0.66-0.78 for questions 1-4 and 0.90-0.93 for questions 5-7 (all P ≤ 0.001). For the dichotomous response to question 8, Kappa coefficient = 1 (P < 0.0001). Internal consistency was good (Cronbach’s alpha = 0.74). In 342 patients, HURT signalled clinical improvement over 3 months through statistically significant changes in responses to questions 1-6. PSS scores were higher among those in whom HURT recorded improvement, and also higher among those with less severe headache at baseline. Patients treated with guidance from HURT (n = 207) were more satisfied than controls (n = 135), but this did not quite reach statistical significance (P = 0.06).
The Arabic HURT Questionnaire is reliable and responsive to clinical change in Arabic-speaking headache patients in primary care. HURT showed clinical utility in this first assessment, conducted in parallel with studies elsewhere in other languages, but this needs further study. Other Arabic instruments are not available as standards for comparison.
PMCID: PMC3620405  PMID: 23565801
Headache; Management; HURT questionnaire; Primary care; Reliability; Validation; Global campaign against headache
25.  Constructing a question bank based on script concordance approach as a novel assessment methodology in surgical education 
BMC Medical Education  2012;12:100.
Script Concordance Test (SCT) is a new assessment tool that reliably assesses clinical reasoning skills. Previous descriptions of developing SCT-question banks were merely subjective. This study addresses two gaps in the literature: 1) conducting the first phase of a multistep validation process of SCT in Plastic Surgery, and 2) providing an objective methodology to construct a question bank based on SCT.
After developing a test blueprint, 52 test items were written. Five validation questions were developed and a validation survey was established online. Seven reviewers were asked to answer this survey. They were recruited from two countries, Saudi Arabia and Canada, to improve the test’s external validity. Their ratings were transformed into percentages. Analysis was performed to compare reviewers’ ratings by looking at correlations, ranges, means, medians, and overall scores.
Scores of reviewers’ ratings were between 76% and 95% (mean 86% ± 5). We found poor correlations between reviewers (Pearson’s: +0.38 to −0.22). Ratings of individual validation questions ranged between 0 and 4 (on a scale 1–5). Means and medians of these ranges were computed for each test item (mean: 0.8 to 2.4; median: 1 to 3). A subset of test items comprising 27 items was generated based on a set of inclusion and exclusion criteria.
This study proposes an objective methodology for validation of SCT-question bank. Analysis of validation survey is done from all angles, i.e., reviewers, validation questions, and test items. Finally, a subset of test items is generated based on a set of criteria.
PMCID: PMC3533982  PMID: 23095569
Plastic surgery; Script concordance approach; Question bank; Surgical education

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