impact of onset time on the isolated pathogens and outcomes in ventilator associated pneumonia

Several guidelines base the empirical therapy of ventilator-associated pneumonia [VAP] on the time of onset. However, there is emerging evidence that the isolated microorganisms may be similar regardless of onset time. This study evaluated the characteristics and outcomes of VAP with different onset times. All of the mechanically ventilated patients admitted to the ICU of a 900-bed tertiary-care hospital between 01/08/2003 and 31/12/2010 were prospectively followed for VAP development according to the National Healthcare Safety Network criteria. The patients were categorized into four groups: EO if VAP occurred within 4 days of intubation and hospital admission; LO if VAP occurred after 4 days of admission; EL if VAP occurred within 4 days of intubation, but after the fourth hospitalization day; and LL if VAP occurred after the fourth day of intubation and hospitalization. Out of the 394 VAP episodes, 63 [16%] were EO episodes, 331 [84.0%] were LO episodes, 40 [10.1%] were EL episodes and 291 [73.1%] were LL episodes. The isolated microorganisms were comparable among the four groups, with a similar rate of potentially multidrug resistant organisms in the EO-VAP [31.7%], LO-VAP [40.8%], EL-VAP [37.5%] and LL-VAP [43.3%] samples. The hospital mortality was 24% for EO-VAP cases, 28% for LO-VAP cases, 40% for EL-VAP cases and 49% for LL-VAP cases. However, in the adjusted multivariate analysis, neither LO-VAP, EL-VAP nor LL-VAP was associated with an increased risk of hospital mortality compared with EO-VAP [OR, 0.86 95% CI, 0.34-2.19; 1.22; 95% CI, 0.41-3.68, and 0.95; 95% CI, 0.43-2.10, respectively]. In this study, the occurrence of potential multidrug resistant pathogens and the mortality risk were similar regardless of VAP timing from hospital admission and intubation. The bacterial isolates obtained from the VAP cases did not follow an early vs. late-onset pattern, and thus, these terms may not be clinically helpful

Determinants of functional status among survivors of severe sepsis and septic shock: one-year follow-up

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

Will any future increase in cigarette price reduce smoking in Saudi Arabia?

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

Risk factors, management and outcomes of patients admitted with near fatal asthma to a tertiary care hospital in Riyadh

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 32-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 [Cl], 0.92-0.99, P= 0.015] and the number of ED visits in the preceding year [OR, 1.25; 95% Cl, 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% Cl, 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

Quality of life of patients with chronic obstructive pulmonary disease in the gulf cooperation council countries

To assess the health-related quality of life [HRQL] of patients with chronic obstructive pulmonary disease [COPD] in 4 Gulf Council Cooperation countries. We conducted a cross-sectional survey between December 2011 and March 2012 in the following countries: Kingdom of Saudi Arabia [Riyadh, Dammam, and Jeddah], Kuwait, Bahrain, and the United Arab Emirates. The HRQL was measured using the COPD Assessment Test [CAT] and the Chronic Respiratory Disease Questionnaire-Self-Administered Standardized questionnaire [CRQ-SAS]. We recruited 120 patients from 6 centers in 4 countries. Their average forced expiratory volume [FEV][1] was 49.3% [+/- 13.4] of predicted, and the ratio of FEV[1] to forced vital capacity was 0.58 [+/- 0.11]. The average COPD Assessment Test [CAT] score was 20.4 +/- 7.6; CAT scores were highest for Riyadh [24.1 +/- 7.7]; and lowest for Kuwait [18.5 +/- 9.2], with no significant difference between the centers. For the CRQ-SAS, the dyspnea domain score was 4.6 +/- 1.6, the fatigue domain score was 4.3 +/- 1.3, the emotional domain was 4.6 +/- 1.2, and the mastery domain was 4.8 +/- 1.4. The correlation coefficients of the association between the CAT score and the 4 domains of the CRQ-SAS for all of the centers combined was statistically significant. The CAT and CRQ-SAS revealed that the patients with COPD experienced a moderate to severe impact from the disease, and a considerably compromised quality of life in the GCC countries

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

reliability of an Arabic translation of the chronic obstructive pulmonary disease assessment test

To produce a conceptually equivalent Arabic version of the Chronic Obstructive Pulmonary Disease [COPD] Assessment Test [CAT], and to assess its reliability. A prospective observational study was carried out from June 2010 to September 2010 at King Abdulaziz Medical City and King Khalid University Hospital, Riyadh, Saudi Arabia. We conducted this study in 2 phases. Phase 1: the translation of the CAT from English to Arabic, through forward and backward translation, as well as pilot testing. Phase 2: assessment of the test-retest reliability of the CAT for 45 patients with COPD who received optimal care by their pulmonologist. This study was conducted on 45 participants. The CAT mean total [ +/- SD] score at the test session was 10.7 +/- 5.8, and 9.2 +/- 4.5 at the re-test session. The interclass correlation of the total score was 0.9 [p=0.000076]. The strongest correlation was for the item of confidence in leaving home with a value of 0.92 [p=0.000082], whereas the weakest was for the item related to sleep with a value of 0.53 [p=0.007]. The Arabic version of the CAT was found to be easy to administer, reliable, and had a strong interclass correlation reflecting stability over time and across the items

Inpatients' care experience and satisfaction study

Measures to promote patient satisfaction are important components of the assessment of outcome and strategies for the delivery of health care. In this article, we assess satisfaction among inpatients and the impact of demographics on satisfaction levels. This cross-sectional survey adapted from previously used survey tools and validated in our patient group included questions on demographics, communication skills, hospital environment, and the patients' overall evaluation of the hospital. Inpatients from acute wards of five different specialties who stayed for at least 2 days were enrolled. There were 988 respondents with a mean age of 39.1 years [25.9%] and the mean length of stay [LOS] of 10.0 days [24.1%]. Illiteracy rate was 42.4%, and 43.1% were male. The overall satisfaction scores-out of five-were 4.3 [0.6%] for communication with nurses, 4.4 [0.4%] for communication with doctors, and 4.1 [0.3%] for hospital environment; 98.9% of the patients would recommend the hospital to their family and friends. The lowest score was for the "room environment" [3.99, 0.8%] and the highest for "overall services of the hospital" [4.7, 0.5%]. Satisfaction levels drop significantly with LOS of more than 4 days [P < 0.006]. The satisfaction was higher in females than males across all the three domains of care assessed [P < 0.005]. The highest satisfaction seen in the obstetrics service could be explained by the nature of the condition normally seen in this department and the normally good outcome. There was higher satisfaction in the medical than surgical services but this reached a significant level for the overall center score domain only [4.1, 0.3% versus 4.0, 0.3%; P < 0.0001]. The factors with positive impact on satisfaction were the female gender and shorter LOS. There was higher satisfaction in the medical than surgical services for all three domains reaching significant levels for center score only

Intensive insulin therapy versus conventional insulin therapy for critically ill trauma patients admitted to ICU

The objective of our study was to evaluate the beneficial effect of IIT in reducing mortality and morbidity in critically ill trauma patients admitted to ICU. Nested cohort study within a Randomized Controlled Trial. All trauma patients with GCS

Risk factors for postpartum hemorrhage among Saudi women

To identify health-related risk factors for the development of post partum hemorrhage [PPH] in Saudi women and to estimate the incidence of primary PPH. A case-control study was conducted between July 1, 2007 and June 30, 2008 at King Abdulaziz Medical City, Riyadh, Saudi Arabia. One hundred and one patients with PPH and 209 control patients were included. Bivariate associations between the different risk factors for the development of PPH were studied. Multivariate logistic regression analysis to identify significant risk factors for the occurrence of this obstetrics complication was carried out. High parity was associated with a 17% increased risk of PPH. Risk factors in preeclampsia was associated with >6-fold increase. History of antepartum hemorrhage [APH] increased the risk for PPH by >8-fold. Other factors were: multiple pregnancy, vaginal delivery, prolonged third stage of labor, and presence of cardiotocograph [CTG] abnormalities. Risk factors for developing PPH among Saudi women are comparable to other reported studies with a greater influence of parity, presence of APH, multiple gestation, CTG abnormalities and prolonged third stage of labor. There is a need for patient education on family planning and antenatal care, physician education on active management of the third stage, and correct estimation of blood loss

Patterns of breastfeeding practice during the fist 6 months of life in Saudi Arabia

To assess the breastfeeding practices in the first 6 months of infants at King Abdulaziz Medical City KAMC, Riyadh, Kingdom of Saudi Arabia. A cross-sectional study was carried out at KAMC in 2005. Infants who attended the primary care centers and well-baby clinic of the hospital for the 6-month's vaccine were included. Mothers were interviewed to collect information on the mothers, infants, and their breastfeeding practice. World Health Organization definitions were used for classification of infant nutrition patterns. Five hundred seventy eight infants were included in this study. The breastfeeding initiation among the sample was 95%. Most mothers supplemented the infants with milk formula 83.4% or fluids 94% during the first 6 months. The percent of exclusive breastfeeding was 1.7% and the partial breastfeeding breast milk with formula was the most common type of feeding 78.8%. Lactation duration dropped to 50% at 6 months of age. Factors favoring the milk formula use were introduction of the formula in the first day of life and maternal reasons of inadequate milk. Lactation duration and formula introduction were found to be significantly associated with mothers' parity, working status, and combined contraceptive pill use. Prevalence of exclusive breastfeeding was extremely low in our population. Partial breastfeeding was the trend for feeding in the first 6 months of life, which was accompanied with rapid decline in lactation duration