The Saudi clinical practice guideline for the prophylaxis of venous thromboembolism in long-distance travelers

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a preventable disease. Long distant travelers are prone to variable degree to develop VTE. However, the low risk of developing VTE among long-distance travelers and which travelers should receive VTE prophylaxis, and what prophylactic measures should be used led us to develop these guidelines. These clinical practice guidelines are the result of an initiative of the Ministry of Health of the Kingdom of Saudi Arabia involving an expert panel led by the Saudi Association for Venous Thrombo Embolism (a subsidiary of the Saudi Thoracic Society). The McMaster University Guideline working group provided the methodological support. The expert panel identified 5 common questions related to the thromboprophylaxis in long-distance travelers. The corresponding recommendations were made following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.

The Saudi clinical practice guideline for the prophylaxis of venous thromboembolism in medical and critically ill patients

Venous thromboembolism (VTE) acquired during hospitalization is common, yet preventable by the proper implementation of thromboprophylaxis which remains to be underutilized worldwide. As a result of an initiative by the Saudi Ministry of Health to improve medical practices in the country, an expert panel led by the Saudi Association for Venous Thrombo Embolism (SAVTE; a subsidiary of the Saudi Thoracic Society) with the methodological guidance of the McMaster University Guideline working group, produced this clinical practice guideline to assist healthcare providers in VTE prevention. The expert part panel issued ten recommendations addressing 10 prioritized questions in the following areas: thromboprophylaxis in acutely ill medical patients (Recommendations 1-5), thromboprophylaxis in critically ill medical patients (Recommendations 6-9), and thromboprophylaxis in chronically ill patients (Recommendation 10). The corresponding recommendations were generated following the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach.

Chronic eosinophilic pneumonia presenting with recurrent massive bilateral pleural effusion : case report.

We describe a rare case of a 29-year-old woman with chronic eosinophilic pneumonia (CEP) presenting with massive bilateral pleural effusion leading to respiratory failure, a complication that was not reported before with CEP. The patient was successfully managed with ventilatory support and steroid therapy. On long-term follow-up, she remained well, receiving a low maintenance dose of prednisone without evidence of relapse of the disease.

Idiopathic hypereosinophilic syndrome: a report of four cases in Arabs, and a review of the literature.

We report four Arab patients with idiopathic hypereosinophilic syndrome (IHES). They presented with varied clinical pictures simulating chronic inflammatory bowel disease (IBD), pulmonary tuberculosis (TB), meningioma, peripheral neuropathy, and infective endocarditis (IE). All had significant peripheral and bone marrow eosinophilia, histological confirmation of eosinophilic infiltration of multiple organs, and clinical evidence of multi-organ dysfunction. Extensive laboratory investigations excluded other possible causes of eosinophilia. All were treated with steroids, with complete response in two. Two others were treated additionally with hydroxyurea, and one with methotrexate, cyclophosphamide, vincristine and alpha-interferon. The pathogenesis, varied clinical, laboratory, and histopathological features, and the management of IHES are reviewed.

Circadian rhythm of granulocyte-macrophage colony-stimulating factor in normal subjects and neutropenic hospitalised patients.

BACKGROUND: Granulocyte-macrophage colony-stimulating factor (GM-CSF), one of the haemopoietic growth factors, has rarely been detected in human serum. It has, therefore, been suggested that a paracrine model can explain its behaviour where the substance is produced and acts locally. An alternative explanation might be due to blood sampling time with GM-CSF concentrations undetectable at the nadir of secretion. HYPOTHESIS: We hypothesised that endogenous production of GM-CSF in humans is subject to diurnal rhythm. METHODS: Blood samples were obtained from 17 healthy individuals and 17 neutropenic hospitalised patients with haematological malignancies on myelosuppressive therapy at 6, 12, 18 and 24 hours. In the neutropenic patients, samples were collected at the nadir of the neutrophil count (ANC < 0.2 x 109/L). Serum was assayed for GM-CSF levels using an enzyme-linked immunosorbent assay method. RESULTS: There were significant differences in the mean levels of GM-CSF within the two groups (P < 0.001). In normal subjects, peak GM-CSF levels were reached at six hours (mean = 10.1 pg/ml). Peak levels were reached in hospitalised neutropenic patients at 18 hours (mean = 13.7 pg/ml). The difference between the peak GM-CSF levels in the two groups was not significant (P = 0.11). On factorial design analysis, there was a significant interaction between the time of blood collection and the subject groups (P < 0.001). CONCLUSIONS: Our data are consistent with a diurnal secretion pattern for GM-CSF in both normal and neutropenic patients. As this finding might have practical implications, including timing of administration of GM-CSF in neutropenic patients, further studies are suggested.

Hepatitis C virus genotyping by polymerase chain reaction and DNA enzyme immunoassay among Saudi patients in the Western Province, Saudi Arabia.

BACKGROUND: The distribution of hepatitis C virus (HCV) genotypes in the Western Province of Saudi Arabia is unknown. The purpose of our study was to determine the prevalent HCV genotypes among HCV seropositive Saudi patients in the Western Province, and to study the relationship between types/subtypes, clinical status and liver histology. PATIENTS AND METHODS: Serum samples were collected from 140 consecutive patients attending the Hepatology Clinic with varying grades of liver diseases, high alanine transferase (ALT) for >6 months, positive HCV, qualitative PCR, and who had had liver biopsy. HCV genotyping was determined on patients who had tested positive by both HCV enzyme immunoassay (EIA) and recombinant immunoblot assay (RIBA). RESULTS: Of the 140 patients, 97 (69.2%) had genotype 4, 18 (12.8%) had genotype 1a, and 16 (11.4%) had genotype 1b. Genotypes 2b and 5 were found in two patients (1.4%) each, while 5 patients (3.6%) had mixed infections with genotypes 4 and 5. Of the 97 patients infected with genotype 4, 84 (86.6%) had chronic active hepatitis (CAH), two (2.1%) had CAH with active cirrhosis, 9 (9.3%) had cirrhosis and two (2.1%) had normal liver histology (NLH). CONCLUSION: The most prevalent HCV genotype in the Western Province of Saudi Arabia was genotype 4 (69.2%). Genotype 1b was encountered in 16 (11.4%) patients. For the first time, genotype 5 was identified in the Western Province of Saudi Arabia. Genotypes 1b and 4 were associated with different histological grades of liver disease.

Mutations in CUBN, encoding the intrinsic factor-vitamin B12 receptor, cubilin, cause hereditary megaloblastic anaemia 1.

Megaloblastic anaemia 1 (MGA1, OMIM 261100) is a rare, autosomal recessive disorder characterized by juvenile megaloblastic anaemia, as well as neurological symptoms that may be the only manifestations. At the cellular level, MGA1 is characterized by selective intestinal vitamin B12 (B12, cobalamin) malabsorption. MGA1 occurs worldwide, but its prevalence is higher in several Middle Eastern countries and Norway, and highest in Finland (0.8/100,000). We previously mapped the MGA1 locus by linkage analysis in Finnish and Norwegian families to a 6-cM region on chromosome 10p12.1 (ref. 8). A functional candidate gene encoding the intrinsic factor (IF)-B12 receptor, cubilin, was recently cloned; the human homologue, CUBN, was mapped to the same region. We have now refined the MGA1 region by linkage disequilibrium (LD) mapping, fine-mapped CUBN and identified two independent disease-specific CUBN mutations in 17 Finnish MGA1 families. Our genetic and molecular data indicate that mutations in CUBN cause MGA1.

Blood group phenotype distribution in Saudi Arabs.

The distribution of eight blood phenotypes (ABO, Rh, MNSs Lutheran, Kell, Duffy, Kidd and Lewis) was determined in Saudi Arabs and compared with corresponding published information for Caucasians and Negroes of United States of America, Saudi Arabs manifest ABO phenotype distribution similar to Negroes; rhesus phenotypes similar to Caucasians but an MNSs pattern largely distinct. Heterozygous Kell phenotype, Kk, was much more frequent in Saudi Arabs than in either Caucasians, or Negroes. The Kidd system null allete, JKa-b- was not seen in the studied group. However, increased frequencies of null alleles of the Duff (Fya-b-) and Lewis (Le(a-b-)) systems were observed in Saudi Arabs.

Comparative study of Amplicor polymerase chain reaction and ligase chain reaction for direct detection of M.tuberculosis in clinical specimens.

Full text is available as a scanned copy of the original print version.

Frequency of red cell-specific antibodies in patient population attending a general hospital.

Full text is available as a scanned copy of the original print version.

Chloroquine-resistant Plasmodium falciparum malaria: report of two locally acquired infections in Saudi Arabia.

We report here two cases of Saudi patients who acquired chloroquine-resistant Plasmodium falciparum locally, without any history of foreign travel, blood transfusion, or drug abuse. Both were satisfactorily treated, the first with quinine and a pyrimethamine-sulfadoxine combination, and the other with quinine and tetracycline. These two cases suggest either the possible establishment of chloroquine-resistant P. falciparum in Saudi Arabia, or the beginning of the spread of resistant strains from countries with established resistance to this country. Diligent notification of cases by attending physicians to the Ministry of Health will help to achieve effective control.

Childhood lymphoma in Saudi Arabia: experience at the King Khalid National Guard Hospital.

A review of twenty two cases of childhood non-Hodgkin's lymphomas (NHLs) seen at the King Khalid National Guard Hospital, Jeddah, Saudi Arabia, between January 1985 and June 1993 was done. The mean age of occurrence was 7.2 years with a male to female ratio of 2.7:1. The commonly seen NHLs were the high grade tumours (95%), mainly lymphoblastic and Burkitt's type lymphomas. Most cases (45.5%) presented with lymph node enlargement of the head and neck region. All cases of Burkitt's lymphoma presented as abdominal masses with either intestinal, ovarian or mesenteric involvement. Most of the lymphomas (61%) were of B-cell phenotype and 22% were of T-cell type.

Malignant lymphoma in western province of Saudi Arabia.

A review of all malignant lymphomas seen at the King Khalid National Guard Hospital, Jeddah, Saudi Arabia between January 1985 and June 1993 was done. There were 106 cases of non-Hodgkin's lymphoma with a male: female ratio of 2.1:1. Low grade, intermediate grade and high grade lymphomas constituted 17.9%, 36.8% and 28.7% respectively. A comparatively lower frequency of follicular lymphomas (5.6%) was noted, compared to the Western literature. Of the few cases immunophenotyped, T-cell and B-cell tumours make up 29% and 71%, respectively.

The prevalence of hepatitis C virus antibodies among hemodialysis patients in jeddah area, saudi arabia.

The prevalence of antibody to hepatitis C virus (HCV) in hemodialysis (HD) patients is high and variable. One hundred and thirty nine patients undergoing maintenance HD at three different renal units in Jeddah, Kingdom of Saudi Arabia, were studied for prevalence of anti-HCV antibody. The overall prevalence in the group examined was 52.5% (73/139). There was a significant correlation between prevalence of anti-HCV and duration of HD; 53/ 74 (71.6%) in patients on HD for > 3 years as against 20/65 (30.8%) for patients on HD for < 3 years (P< 0.05). We were unable to demonstrate a correlation of anti-HCV positivity with history of blood transfusions, previous exposure to hepatitis-B virus, sex, age, or ethnic group. The very high prevalence of anti-HCV found in patients on maintenance HD and the positive correlation between anti-HCV reactivity and duration on dialysis suggest that factors within the dialysis unit might contribute to the spread of the virus.

The value of serum interleukin-6 measurement in the investigation of patients suspected of myocardial infarction.

Interleukin-6 (IL-6) is one of the cytokine mediators of the acute phase response. The value of IL-6 determination in the investigation of patients suspected of acute myocardial infarction and unstable angina is not fully established. In 26 patients being investigated for AMI and UA, IL-6, Creatine Kinase (CK) and Troponin T (TnT) were elevated with peak values at 12 hours (for IL-6 and CK) and at 0 and 24 hours (for TnT) following admission. CK values in AMI were significantly different from UA patients at 0, 6, 12, and 25 hours following admission, whereas, IL-6 values showed significant difference only at 24 hours. TnT showed a significant difference between the groups at 0 and 24 hours following admission. There was poor negative correlation between IL-6 and CK levels and percentage left ventricular ejection fraction. This study showed that, although IL-6 was elevated in AMI and UA patients, the spread of the data indicated that its measurement is of limited value in the diagnosis of AMI.

Case report: spinal extradural haematoma in haemophilia-A--a diagnosis not to be missed.

A child with severe haemophilia-A is reported who developed an extensive spinal extradural haematoma. He was successfully treated with intensive replacement therapy after attempted surgical decompression failed. The importance of early diagnosis is stressed and the potential value of magnetic resonance imaging for monitoring haematoma maturity is discussed.