Undergraduate curriculum reform in Saudi medical schools. Which direction to go?

Curriculum reform in undergraduate medical education is quite essential for the success of the educational process. Saudi medical schools have been involved in curriculum reform over the past 2 decades. Review of the existing literature identifies the following as problems with today's curriculum including: Overcrowding of the curriculum, over presentation of some subjects, presence of relatively non-relevant subjects, dissociation between basic and clinical sciences, repetition of lectures and exams, need for new subjects of clinical relevance, predominantly hospital based medical education with minimal community-based practice, as well as non-optimal use of resources. The authors put forth suggestions for reform of the current curriculum to meet today's problems and future demands.

The pattern of lower gastrointestinal disease in the eastern region of Saudi Arabia: a retrospective analysis of 1590 consecutive patients.

To determine the pattern of lower gastrointestinal disease in the Eastern region of Saudi Arabia we analysed 1907 colorectal biopsies obtained from 1590 consecutive patients (1256 males & 334 females), evaluated during a 13 year period (1983-1996) in a tertiary care teaching hospital. The age range was 6-81 years with a mean of 37 + 15. During the same period 6874 new patients were seen in the Gastroenterology Clinics. Saudi Arabs constituted 970 (61 %) of all patients. The remaining 620 (39%) were non-Saudi, mostly of Arab origin from neighbouring countries. The most common presenting symptom for referral was abdominal pain (1193 patients, 75%) followed by diarrhea (636 patients, 40%). The most frequent histologic diagnosis was a normal mucosa followed by non specific proctocolitis accounting respectively for 37.9% and 37.4% of all cases. These were followed by schistosomiasis, 113 (7.1%), adenocarcinoma, 91 (5.7%) and ulcerative colitis, 91 cases with a relative frequency of 5.7% and a calculated prevalence of 1.3%. Of significance was the encounter of 14 cases of Crohn's disease amounting to 0.9% of all cases with a calculated prevalence of 0.2%. A minority of 83 patients (5.2%) were cases of either a benign polyp, diverticular disease, tuberculosis, ischaemia, lymphoma, pseudomembranous colitis (PMC), eosinophilic gastroenteritis or malacoplakia. These data show that although a "normal mucosa" and "nonspecific proctocolitis" were the dominant diagnoses, significantly, ulcerative colitis and Crohn's disease exist and should be considered in the differential diagnosis of lower GI disease.

Crohn's disease in Saudi Arabia: a clinicopathological study of 12 cases.

In this report we present our experience with 12 cases of Crohn's disease out of 1279 consecutive colorectal biopsies (0.9%), seen during an l 1 years period (1983-1994) in a tertiary care teaching hospital. During the period 76 cases (6%) of Ulcerative Colitis (UC) were seen. Of the 12 patients with Crohn's disease, seven were males and five were females, all Saudi nationals aged 16-39 with a median of 23 years, relatively younger than those with UC seen during the same period. Recurrent colicky abdominal pain was the striking presenting symptoms in all patients, commonly associated with weight loss. The disease involved both small and large bowel in eight patients (67%) and the colon alone in one patient. Granulomas were seen in seven patients (58%). Surgery was offered for two patients and most of the remaining patients were symptomatic on follow up.

Inflammatory bowel disease: medical management.

Various papers have been published on inflammatory bowel disease in the Kingdom of Saudi Arabia and other Gulf States during last decade. Apparently, the published data contradict previous belief and indicate that, we might deal here with a medical problem. However, data on the magnitude of this disease in our community remains uncertain. Could we attribute this possible change to the improvement in diagnostic procedure or to the change in life style? Unfortunately, the literature does not provide us with a convicting answer to this question yet. However, at this stage a review of the medical management in inflammatory bowel disease seems to be justified. Hence currently used drugs in the management in inflammatory bowel disease are reviewed in this paper. Some of the potentially effective drugs for the future are also summarized.

Abdominal tuberculosis in Saudi Arabia: a clinicopathological study of 65 cases.

The clinical and pathological features of 65 patients with abdominal tuberculosis obtained during a 7-yr period were analyzed and the diagnostic procedures critically evaluated. The diagnosis was histologically confirmed in 59 patients. In two more patients, the diagnosis was based solely on a positive ascitic fluid culture for tubercle bacilli. The remaining four patients responded dramatically to anti-tuberculous chemotherapy given on suspected laparoscopic findings in cases in which no biopsy was taken. Laparoscopy was found to be safer and superior to laparatomy and is recommended as an initial investigation in the diagnostic work-up of patients in whom tuberculous peritonitis is suspected. Furthermore, the finding of granulomatous inflammation in peritoneal biopsy is a justification for immediate therapy in such patients. This is particularly valid in endemic areas if one considers the risks of delaying treatment of these patients.

Hepatic encephalopathy in Saudi Arabia: retrospective analysis of 51 patients.

The clinical features, prognostic factors, and outcome of 51 patients with hepatic encephalopathy (HE), were retrospectively reviewed. The mean (+/- SD) age of patients was 47.2 (+/- 14.8) years. Seventy-five percent of patients were males and 73% were Saudi. All identified episodes of hepatic encephalopathy were associated with chronic underlying liver disease and no episode occurred as a result of acute fulminant hepatic failure. Most patients presented in advanced stage of hepatic dysfunction and had one or more precipitating factors. In-hospital mortality rate was 41% (21 out of 51 patients). Gastrointestinal tract bleeding, electrolytes imbalance and alkalosis were associated with significantly higher mortality rate. However, unadjusted analysis failed to identify certain base-line independent prognostic factors.

Tuberculous peritonitis: the value of laparoscopy.

The laparoscopic and pathological diagnoses of 43 patients who underwent abdominal laparoscopy for various indications are presented. Major indications for the laparoscopy included hepatomegaly in 32 patients, ascites in 28, and pyrexia of unknown origin (PUO) in 18 patients. A combination of two or more of these indications was a more common feature. The most frequently encountered laparoscopic diagnoses were tuberculosis and chronic liver disease (16 patients each), followed by cancer (9 patients). However, on pathological examination of peritoneal or liver biopsy tissue and on follow-up, tuberculosis was confirmed in 12 patients, chronic liver disease in 14 patients and hepatocellular carcinoma in 11 patients. No complications were encountered during the laparoscopy. Our findings indicate that abdominal laparoscopy is a safe, quick and inexpensive diagnostic tool, particularly when appropriate and adequate tissue is taken for pathological examination. In such instances, laparoscopy would save an unnecessary laparotomy, especially where tuberculosis and cancer are considered in the differential diagnosis.

Evaluation of students' performance and examination procedures in final certifying examinations in internal medicine (1982-1988).

We conducted a retrospective analysis to evaluate the performance of 459 students on their final certifying examination in internal medicine. These examinations were taken during 1982 through 1988, and the failure rate was 17.6%. Two hundred and five students (44.6%) received grade D (60-69% of the total marks) and 139 (30.1%) grade C (70-79% of total marks). Only 7.7% of the students scored higher (80% or more). A temporal trend has been observed in that a higher percentage of lower grades and lower percentage of higher grades has been observed in recent (1986-1988) compared with earlier (1982-1984) years. Female students generally performed on a par with males, though males students performed better on multiple choice questions (MCQs). The analysis also showed lower mean scores for the essay, oral, and clinical components in recent (1986-1988) than in earlier (1982-1984) years. In studying the interrelationships between different examination components, the MCQs were found to have the highest correlation with other procedures. A lower correlation was observed for clinical examination. Factor analysis also showed that MCQs had the highest and clinical examinations the lowest factor loading. Low correlation and factor loading were also noted for the essay portion. While in the newly implemented curriculum the essay paper has been wisely eliminated, our data suggest that the traditional clinical examination should be replaced by a more objective and structural method. Our analysis may serve as a guide for formulation of final certifying examinations in medical schools throughout the Kingdom.

A single nocturnal dose of famotidine for the treatment of duodenal ulcer: evaluation of efficacy and safety.

The efficacy and safety of a single nocturnal dose of famotidine (40 mg) was evaluated in 30 consecutive patients of duodenal ulcer (DU). Three patients were lost for follow-up and therefore were excluded. The mean age of remaining 27 patients was 34.3 (+/- 9.9) years and male to female ratio was 8:1. The mean size of the DU was 1.21 (+/- 0.79) cm. After a 4-week therapy all patients showed significant improvement and repeat endoscopy in 24 out of 27 patients (89%, 95% confidence interval; 78% to 100%) showed healed ulcer. Clinical assessment of pain relief at 4-week showed significant drop in the mean score of baseline daytime (from 1.85 to 0.13) and baseline nocturnal pain (from 1.70 to 0.10) (p less than 0.0001 and less than 0.0001, respectively). Also shown was the significant decrease in the mean gastrointestinal symptoms score from 5.89 at baseline to only 0.89 at 4-week (p less than 0.0001). Despite that all those who failed to show ulcer healing at 4-week were smokers, logistic regression analysis could not identify smoking or any other risk factors as adverse predictors of ulcer healing. None of the patients experienced significant side effects or adverse reactions. We conclude, that a single nocturnal dose of famotidine is a practical, highly effective and safe approach for the management of DU.

Myelofibrosis and pancytopenia in systemic lupus erythematosus.

A 13-year-old Saudi girl presented with severe clinical features of systemic lupus erythematosus of 3 months' duration. In addition to laboratory evidence of the disease, the patient was found to have pancytopenia and myelofibrosis. While pancytopenia was considerably improved by steroids, myelofibrosis was not reversed. The coexistence of myelofibrosis and pancytopenia in patients with systemic lupus erythematosus has been reported, but their possible causal relationship remains unresolved.