To assess the clinical value and of metformin as mono-therapy versus other treatments for type 2 diabetes mellitus in children and adolescents. Major electronic databases, the reference lists of relevant articles and databases of ongoing trials were searched. Authors of reviews and metformin manufacturers were contacted in order to obtain more references and reports of unpublished trials. The methodological quality of these reports, included randomised controlled trials (RCTs) was assessed using the National Health System Centre for Reviews and Dissemination (NHS CRD) checklist. The search identified 1,825 studies. Three RCTs met the inclusion criteria. Two RCTs had been completed and one was still ongoing. In the metformin group there were significant reductions of mean change of HBA1c from baseline. It reduced by -0.71% (P = 0.0002) and in the other trial the result was reduced by -1.10 (95% CI: -1.19 to -1.01). In addition, more patients (48.1%) in the metformin group achieved good glycaemic control (<7%) at week 24. The mean changes in FPG from baseline were significantly (P < 0.05) different in the metformin group (-16.6%, for week 18 and week 24 20.6%. In the second trial there was a significant (P < 0.001) reduction in the adjusted mean of FPG from baseline in the metformin group, while there was an increase in the placebo group ( -42.9 mg/dl vs. +21.4mg/dl) with mean difference of -64.80 in favour of the metformin group. For BMI, significant (P < 0.001) differences were seen at week 12 and week 24 (0.07 and 0.55 kg2) for metformin and glimepiride respectively. There was no significant difference between the placebo and metformin in the other trials. For lipid value there was a significant decrease in LDL levels in the metformin group. No significant changes were found in the other lipid parameters after adjusting. There were more adverse events in the metformin group but they were not statistically significant. There was a limited but not convincing evidence to suggest that metformin can improve the glycaemic control in children and adolescent with type 2 diabetes compared with other interventions. This is may be the result of the limited number, poor quality and short duration of the included trials.
Adolescents; children; diabetes mellitus; meta-analysis; metformin; systematic review
Accreditation is usually a voluntary program, in which authorized external peer reviewers evaluate the compliance of a health care organization with pre-established performance standards. The aim of this study was to systematically review the literature of the attitude of health care professionals towards professional accreditation. A systematic search of four databases including Medline, Embase, Healthstar, and Cinhal presented seventeen studies that had evaluated the attitudes of health care professionals towards accreditation. Health care professionals had a skeptical attitude towards accreditation. Owners of hospitals indicated that accreditation had the potential of being used as a marketing tool. Health care professionals viewed accreditation programs as bureaucratic and demanding. There was consistent concern, especially in developing countries, about the cost of accreditation programs and their impact on the quality of health care services.
Accreditation; attitude; systematic review
Primary and secondary prevention of cardiovascular diseases (CVD) are markedly overlooked worldwide. The use of these kinds of preventive methods will greatly improve outcome of or even reverse major CVD, especially coronary atherosclerosis. Comprehensive lifestyle changes combined with aggressive medical therapy [lipid lowering agents “statins”, antiplatelet agents, beta-blockers and angiotensin-converting enzyme inhibitors] for patients suffering from coronary heart disease significantly reduce all major adverse cardiovascular events (MACE), especially in those with stable coronary artery disease (CAD), even if their coronary lesions are significant. The main mechanistic pathways for the significant reduction of MACE are: Stabilization of atheromatous plaques through endothelial function reparation, strengthening of the fibrous cap of the atheromatous plaque and reduction of atheroma burden, i.e., reversal of the process of coronary artery stenosis, the great dream of “medical angioplasty”. Despite the compelling data indicating the great beneficial effects of both primary and secondary prevention of coronary atherosclerosis, the US national survey data reveals that only a minority of patients eligible by guidelines for these therapies in fact receive them. Hence, we strongly believe that our main duties as cardiologists is to improve the up-to-date knowledge of the practicing physicians about utility of aggressive medical therapy for both prevention and reversal of CVD, and also to promote useful primary and secondary prevention programs among physicians and patients. Meanwhile, further improvement and refinement of the current therapeutic modalities and introduction of new modalities for the management of lipid parameters other than LDL-C, such as HDL-C, triglyceride, lipoprotein (a), LDL particle size and susceptibility to oxidation may add further favourable effects in prevention and reversal of atherosclerotic process. Cardiologists should be just as aggressive with prevention as many have been with intervention. This optimistic overview is a valley cry to all practicing physicians; please depart from usual methods of intervention to preventive strategies which are largely overlooked.
Atheromatous plaque; endothelial function; hypercholesterolemia; high density lipoprotein cholesterol; low density lipoprotein cholesterol; nitric oxide; percutaneous coronary intervention; statins
Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections among young people without healthcare-associated risk factors have emerged during the past decade. Reported prevalence rates of CA-MRSA vary widely among studies, largely because of the different definitions employed and different settings in which the studies have been performed. Although the majority of CA-MRSA infections are mild skin and soft tissue infections, severe life-threatening cases have been reported. CA-MRSA infections have mostly been associated with staphylococcal strains bearing the staphylococcal cassette chromosome mec type IV element and Panton-Valentine leukocidin genes. These strains are more frequently susceptible to a variety of non-beta-lactam antibiotics. Clinicians must be aware of the wide spectrum of disease caused by CA-MRSA. Continued emergence of MRSA in the community is a public health problem, and therefore warrants increased vigilance in the diagnosis and management of suspected and confirmed staphylococcal infections.
Clindamycin; methicillin; Saudi Arabia; Staphylococcus aureus
Anomalous origin of the left coronary artery from pulmonary artery is a rare congenital heart anomaly. It presents predominantly in infancy with clinical features of myocardial ischemia and/or congestive heart failure. It poses a clinical diagnostic challenge to family physicians and pediatricians as it may present in a way similar to common pediatric conditions such as infantile colic, food intolerance, gastroesophageal reflux, and bronchiolitis. Awareness of this condition is essential for prompt diagnosis and referral to a cardiac center for early surgical intervention and improved prognosis. This article reviews this rare but serious disease in children.
Anomalous left coronary artery arise from the pulmonary artery; anomalous origin of left coronary artery from pulmonary artery; Bland-White-Garland syndrome
Acute diarrhea remains a major cause of morbidity and mortality in children. Since the introduction of oral rehydration salts (ORS) mortality has dropped to less than 50% worldwide. Low osmolarity ORS improved the outcome and reduced the hospitalization further. Zinc difficiency has been found to be associated with severe episodes of acute diarrhea. Zinc supplement in developing countries did reduce the incidence and prevalence of diarrhea. In addition, Zinc supplement significantly reduced the severity of diarrhea and duration of the episode. In the Americas and Europe, Rota virus vaccine was 90% effective in preventing severe episodes of severe rotavirus gastroenteritis. This review concludes that low osmolarilty ORS, zinc supplementation and rotavirus vaccine are major factors in reducing the morbidity, mortality and hospitalization resulting from to acute gastroenteritis in childhood.
Diarrhea; childhood; oral rehydration salts; zinc; rota vaccine
The constellation of dyslipidemia (hypertriglyceridemia and low levels of high-density lipoprotein cholesterol), elevated blood pressure, impaired glucose tolerance, and central obesity is now classified as metabolic syndrome, also called syndrome X. In the past few years, several expert groups have attempted to set forth simple diagnostic criteria for use in clinical practice to identify patients who manifest the multiple components of the metabolic syndrome. These criteria have varied somewhat in specific elements, but in general, they include a combination of multiple and metabolic risk factors. The most widely recognized of the metabolic risk factors are atherogenic dyslipidemia, elevated blood pressure, and elevated plasma glucose. Individuals with these characteristics, commonly manifest a prothrombotic state as well as and a proinflammatory state. Atherogenic dyslipidemia consists of an aggregation of lipoprotein abnormalities including elevated serum triglyceride and apolipoprotein B (apoB), increased small LDL particles, and a reduced level of HDL cholesterol (HDL-C). The metabolic syndrome is often referred to as if it were a discrete entity with a single cause. Available data suggest that it truly is a syndrome, ie, a grouping of atherosclerotic cardiovascular disease (ASCVD) risk factors, that probably has more than one cause. Regardless of cause, the syndrome identifies individuals at an elevated risk for ASCVD. The magnitude of the increased risk can vary according to the components of the syndrome present as well as the other, non–metabolic syndrome risk factors in a particular person.
Metabolic syndrome; risk; cardiovascular
Children with a history of recurrent, severe, or unusual infections present a diagnostic challenge. It is important to maintain a high index of suspicion for the diagnosis of immunodeficiency, for early diagnosis and treatment can improve outcome. Differentiation between infections caused by common risk factors, or immune dysfunction should be based on a detailed history and physical examination and, if indicated, followed by appropriate laboratory studies. This paper aims at providing guidelines for the evaluation of children with recurrent infections. It provides an overview of the diagnostic approach including important details required from the history, physical examination, and an appropriate choice of screening test to be ordered.
Antibody deficiency; Primary immunodeficiency; Recurrent infection; Severe combined immunodeficiency
Cutaneous leishmaniasis (CL) is still a major health problem in many countries including Saudi Arabia. Patients with CL are seen, not only by dermatologists, but also by pediatricians and community physicians. Knowledge of available treatment options is essential.
A literature review utilizing PubMed and Cochrane evidence-based library was undertaken in the last five years.
Several medications and therapeutic modalities are currently in use, though the gold standard remains systemic antimonials. Drug resistance and serious side effects preclude the use of available medications. Newer therapies like liposomal amphotericin B, miltefosine and pentamidine are being used; while it is hoped that other drugs like imiquimod, tamoxifen, PDT and pentamidine structural analogs being tested would offer better efficacy, easier administration and lower toxicity.
After decades of little advance in the treatment of leishmaniasis, there are now several options with newer compounds and combinations of these.
Leishmaniasis; Leishmaniasis treatment
Coronary heart disease (CHD) is the leading cause of death throughout the world. PHC doctors are in a unique position to prevent CHD and promote health in the population. However, the perception of PHC doctors on CHD prevention has not been well documented.
To explore and examine the perception of PHC doctors on the prevention of CHD. Subject and method: A questionnaire survey of all PHC doctors attending a continuing medical education (CME) activity in Riyadh city. The questionnaire was designed and piloted with local PHC doctors before being used in this survey.
All the 77 PHC doctors responded (100%) and almost all the them (97.4%) agreed that the primary prevention of CHD was an essential task. Fifty-two participants (67.53%) confirmed that little attention had been paid to the primary prevention of CHD. While the majority of respondents (71.43%) felt that the primary prevention of CHD was an easy task, a significant minority (23.37%) disagreed. Interestingly, 70 (90.91%) respondents were not aware of any local literature on how to achieve primary prevention of CHD and would like to have the literature made available to them. Finally, participants indicated that the percentage prevalence of CHD risk factors among their patients was high.
the findings of this survey confirm a general feeling that the primary prevention of CHD is not being given enough attention. Participants accepted that the primary prevention of CHD was an essential part of their work, but the lack of local literature and research on this vital area was a major concern.
Opinion of PHC doctors; Prevention and prevalence of CHD
Noise is recognized as a source of hazard to the patient's environment. Studies have also shown that it has a direct impact on mortality and morbidity as a result of sleep deprivation which affects the immunity of critically ill patients.
The aim of this study was to measure levels of environmental noise in a six- bed, open-plan general medical intensive care unit (MICU).
Levels of exposure to environmental noise were assessed in the intensive care unit of King Fahad Hospital of the University (KFHU) where measurements of environmental noise were taken using calibrated sound level meter during shifts of working days and weekends.
Statistical analysis revealed that there were no significant differences between noise levels in the morning, evening and night shifts of working days and weekends in the ICU of KFHU (p value =0.155, 0.53 and 0.711) respectively. There was no significant difference between overall level of exposure to noise in the working days and weekends as well (p-value=0.71). However, the assessed levels of exposures to noise were still higher than stipulated international standards.
Some sources of environmental noise, such as the use of oxygen, suction equipment or respirators are unavoidable. Nevertheless, hospital ICUs should have measures to minimize the level of exposure to noise in the ICU.
Further research in this area might focus on the noise level and other modifiable environmental stress factors in the ICU that affect patients as well as the staff.
Noise; Intensive Care Unit; decibel; alarm; sleep
This paper takes a public health approach to briefly examine: (i) the concept of community health care need assessment; (ii) the roles of academic institutions in health needs assessment; (iii) Jazan study to address the health care needs in Jazan region, Saudi Arabia. The methods included an analysis of the literature, distillation of experience from the recently Jazan Health Need Assessment Survey, and WHO reports. The most important perceived health problems in Jazan region are shortage of health care providers, increased prevalence of communicable diseases and poor environmental health. The academic institutions, Ministry of Health and other health care institutions need to work together to look for innovative approaches, especially to increase the awareness of the society on public health issues, and give more support to increase national and regional funding for community based studies.
The findings of the assessment of the health needs of Jazan presented in this review could be utilized as a baseline and reference information for policy formulation, subsequent planning and cost effective intervention programs. It could also be utilized for the curriculum development or review for a community oriented medical schools.
Health Needs; Assessment; Jazan
The consumption of the stimulant leaf Khat (Catha edulis Forsk) is widespread in several countries of East Africa and the Arabian Peninsula. The leaf comes from a small evergreen shrub that can grow to the size of a tree. Young buds and tender leaves are chewed to attain a state of euphoria and stimulation. Khat leaves contain cathinones, an active brain stimulant that is similar in structure and pharmacological activity to amphetamines. Like amphetamines, Khat ingestion in low doses results in decreased appetite, euphoria, increased intellectual efficiency, and hyperalertness.
High doses and chronic use of Khat can cause more serious adverse neurological, psychiatric, cardiovascular, dental, gastrointestinal and genitourinary effects. Besides damaging health, Khat has adverse socio-economic consequences effects on many other aspects of life including the loss of thousands of acres of arable land and billions of hours of work.
The purpose of this review is to describe briefly the adverse consequences of habitual chewing of Khat on health, and help educate the general public. The study is based on literature review that includes internet search and journals.
Khat; Health; Social; economy; Saudi Arabia
Acute episodes of bronchial asthma are associated with specific etiological factors such as air pollutants and meteorological conditions including thunderstorms. Evidence suggests that thunderstorm-associated asthma (TAA) may be a distinct subset of asthmatics, and, epidemics have been reported, but none from Saudi Arabia.
The trigger for this review was the TAA epidemic in November 2002, Eastern Saudi Arabia. The bulk of patients were seen in the King Fahd Hospital of the University, Al-Khobar. The steady influx of acute cases were managed effectively and involved all neighboring hospitals, without evoking any “Major Incident Plan”.
Three groups of factors are implicated as causes of TAA: pollutants (aerobiologic or chemical) and meteorological conditions. Aerobiological pollutants include air-borne allergens: pollen and spores of molds. Their asthma-inducing effect is augmented during thunderstorms.
Chemical pollutants include greenhouse gases, heavy metals, ozone, nitrogen dioxide, sulfur dioxide, fumes from engines and particulate matter. Their relation to rain-associated asthma is mediated by sulfuric and nitric acid.
Outbreaks of non-epidemic asthma are associated with high rainfall, drop in maximum air temperature and pressure, lightning strikes and increased humidity. Thunderstorm can cause all of these and it seems to be related to the onset of asthma epidemic.
Patients in epidemics of TAA are usually young atopic adults not on prophylaxis steroid inhalers. The epidemic is usually their first known attack. These features are consistent with the hypothesis that TAA is related to both aero-allergens and weather effects. Subjects allergic to pollen who are in the path of thunderstorm can inhale air loaded with pollen allergen and so have acute asthmatic response. TAA runs a benign course
Doctors should be aware of this phenomenon and the potential outbreak of asthma during heavy rains. A & E departments and ICU should be alert for possible rush of asthmatic admissions and reinforce ventilators and requirements of cardio-pulmonary resuscitation. Scientific approach should be adopted to investigate such outbreaks in the future and must include meteorological, bio-aerosole pollutants and chemical pollutant assessment. Regional team work is mandatory.
Thunderstorm-associated asthma; epidemic
Normal Hemostasis requires the interaction of platelets and the clotting cascade with normal blood vessels and supporting tissues. Bleeding problems and easy bruising are commonly encountered clinical problems. Assessment of these patients is a multistep evaluation process that involves a complete detailed history, thorough physical examination and relevant laboratory evaluation. Many disorders are usually relatively straight forward to diagnose, but in other disorders, patients may have “hidden” signs and symptoms making diagnosis more difficult. A meticulous approach must be used to plan the first steps of management.
Bleeding disorder; clinical history; laboratory tests
The main objective of the medical curriculum is to provide medical students with knowledge, skills and attitudes required for their practice. A decade ago, the UK Medical Council issued a report called “Tomorrow's Doctors”1 which called for the reduction in the factual content of the medical course with the promotion of problem-based and self-dedicated learning. This report was the basis for a move toward an extensive reform of the medical and nursing curricula. The new reformed curricula enhanced the integrated medical teaching and emphasized the teaching and learning of clinical skills. However, there were still concerns about the standards and appropriateness of the skills of new medical graduates.2
The changes in the teaching and learning methods, the radical changes in the health care delivery and the rapid growth of technology challenged the traditional way of clinical skills development and led to the emergence of clinical skills laboratories (CSLs) in the medical education of many medical and nursing schools. With the proliferation of the CSLs, it is important to evaluate and introduce the reader to their applications, bearing in mind the paucity of information on this subject particularly over the last couple of years. This article is based on literature review.
Clinical; Skills; Laboratories; Centers; Units
Diabetes mellitus is a common, serious, and treatable disease. Good control is associated with fewer complications. The impact of the disease on the patient, family and the community psychologically and physically is staggering. This paper aims to update the reader on certain issues related to the management of diabetes. Recent criteria for the diagnosis are presented followed by non-pharmacological and pharmacological management, glycemic monitoring, prevention, continuity of diabetes care and the control of co-morbidities. Throughout, as far as possible, the best available evidence was used.
Type 2 Diabetes; Diabetes Management; Guideline and Out-Patients
Advances in the biomedical and the behavioral sciences have paved the way for the integration of medical practice towards the biopsychosocial approach. Therefore, dealing with health and illness overtakes looking for the presence or absence of the disease and infirmity (the biomedical paradigm) to the biopsychosocial paradigm in which health means a state of complete physical, psychological and social well-being. Psychology as a behavioral health discipline is the key to the biopsychosocial practice, and plays a major role in understanding the concept of health and illness. The clinical role of psychologists as health providers is diverse with the varying areas of care giving (primary, secondary and tertiary care) and a variety of subspecialties. Overall, psychologists assess, diagnose, and treat the psychological problems and the behavioral dysfunctions resulting from, or related to physical and mental health. In addition, they play a major role in the promotion of healthy behavior, preventing diseases and improving patients’ quality of life. They perform their clinical roles according to rigorous ethical principles and code of conduct. This article describes and discusses the significant role of clinical health psychology in the provision of health care, following a biopsychosocial perspective of health and illness. Professional and educational issues have also been discussed.
Psychology; health psychology; biopsychosocial; and behavioral medicine
The best therapy for cancer is prevention. Primary prevention involves health promotion and risk reduction in the general population so that invasive cancers do not develop. These primary preventive measures include the cessation of smoking, lifestyle and diet modification, vitamins and micronutrients supplementation. Identification of genetic risk, understanding of carcinogenesis, development of effective screening tools, avoiding risk factors and effective chemoprevention can lead to decreased morbidity and mortality of cancers in general and more importantly breast cancer. Secondary prevention is the identification and treatment of premalignant or subclinical cancers. Screening by means of mammography is a typical example of secondary prevention. Tertiary prevention is defined as symptoms control and rehabilitation. These definitions may become less useful in the future as they do not account for the new incoming data such as molecular data.
Prevention; Cancer; Breast
The management of patients with low back pain (LBP) problems by primary care physicians or even spine specialists differ significantly and little is known about treatment strategy.
This review is to present the clinical profile and to assess the most common treatment modalities of patients with low-back pain in order to improve the clinical judgment of the treating physician.
Data were obtained from a midline literature search of articles in English. A manual revision of original articles was done and demonstrative figures from patients at our institute were added.
LBP is an extremely common problem. It is characterized by attacks, remissions and exacerbations. It is best managed by a multidisciplinary team. Primary coordination of treatment may depend on the patient's need and the awareness of the treating physician of the importance of history and physical examinations. The following suggested protocol may help to identify red flags that denote more serious conditions.
Low back pain; red flags; treatment modalities
Because of the enormous changes in the lifestyle of Saudis in the last three decades, the risk factors of coronary heart disease (CHD), including physical inactivity, are increasingly becoming prevalent in the society. This paper provides an overview of the importance of physical activity in health promotion and disease prevention, and discusses the public health burden of physical inactivity in Saudi Arabia. Available evidence clearly indicates that physical inactivity is extremely prevalent in the different ages and sex of the Saudi population. This high prevalence of inactivity in Saudi society presents a major public health burden, as evidenced by the high risk in the Saudi population as a risk of physical inactivity compared with the populations of United States and the United Kingdom. Unless concrete steps are taken to reduce physical inactivity in the Saudi population, the future public health cost would be enormous. It is well known that physical activity is associated with numerous health benefits and plays a major role in modifying many other CHD risk factors. Finally, several recommendations for reducing physical inactivity and promoting active life in the Saudi population have been discussed.
Physical inactivity; coronary risk factors; health promotion; public health burden; population attributable risk; Saudi Arabia
Evidence based medicine (EBM) considered one of the most important developments in the practice of medicine in recent years, has evolved as a tool for improving the quality of health care. Several studies have shown EBM to be safe and cost-effective. Physicians have welcomed EBM and shown a positive attitude toward it and have expressed desire to learn more about it. This is consistent in most studies done in different countries. However, some studies found considerable misunderstanding about terms and websites used in EBM. The major barriers to the practice of EBM perceived by physician in different studies include insufficient time and evidence, patients’ preference and financial constraints. Training has been found to be conducive to the implementation and promotion of EBM. Some Arab countries are already implementing EBM and plan to include it in the undergraduate curriculum. In Saudi Arabia EBM was introduced in the late 90's and a National EBM Advisory Board was formed.
Evidence based medicine; Physician; Practice; Attitude; Barriers
Health services in Saudi Arabia have developed enormously over the last two decades, as evidenced by the availability of health facilities throughout all parts of the vast Kingdom. The Saudi Ministry of Health (MOH) provides over 60% of these services while the rest are shared among other government agencies and the private sector. A series of development plans in Saudi Arabia have established the infra-structure for the expansion of curative services all over the country. Rapid development in medical education and the training of future Saudi health manpower have also taken place. Future challenges facing the Saudi health system are to be addressed in order to achieve the ambitious goals set by the most recent health development plan. These include the optimum utilization of current health resources with competent health managerial skills, the search for alternative means of financing these services, the maintenance of a balance between curative and preventive services, the expansion of training Saudi health manpower to meet the increasing demand, and the implementation of a comprehensive primary health care program.
Health system; health statistics; primary health care; Saudi Arabia
Induced Abortion for social reasons is spreading all over the world. It is estimated that globally 50 million unborn babies are killed annually, resulting in the deaths of 200,000 pregnant women and the suffering of millions. The complications of illegal abortion are very serious. Abortion is still used in many countries as a means of family planning. The medical reasons for abortion are limited and con-sti-tute a small proportion of all abortion cases. This paper discusses the different views on abortion, its history, its evolution over time, and the present legal circumstances. The emphasis is on the situation in Islamic countries and the effect of Islamic Fatwas on abortion.
Induced abortion; illegal abortion; family planning; Islam
Abdominal pain is perhaps the most challenging of all the presenting complaints in the emergency department. It is estimated that it accounts for 5%-10% of all visits. Causes of abdominal pain range from the inconsequential to the life threatening. In addition, it nearly always poses a greater degree of diagnostic uncertainty in women of child-bearing age as compared to males. Such difficulties become more pronounced in pregnant women where the unwritten policy seems to be: If she is pregnant blame the pregnancy. This policy is justified by the favorable clinical outcomes. However, in a small but significant number of patients, this policy has the potential of creating delays and increasing the risk of unwarranted complications. Delays in management may lead to emotional trauma, loss to the society, and the potential for serious liability.
This review was undertaken at King Fahd hospital of the University, Eastern Province of Saudi Arabia, with a literature search covering a period of over twenty years. It mainly highlights the diagnostic difficulties in young women presenting with acute onset abdominal pain, and possible solutions.
It also suggests a policy which includes a careful clinical approach with liberal consults between the surgeon and the gynecologist reinforced by a judicious use of the available diagnostic aids leading to potentially favorable outcomes.
Pregnancy; acute abdomen; acute appendicitis; intestinal obstruction