Inappropriate laboratory test utilization in outpatient tertiary care: Implications for value-based healthcare.

OBJECTIVES: To assess the rate of inappropriate repetition of laboratory testing and estimate the cost of such testing for thyroid stimulating hormone (TSH), total cholesterol, vitamin D, and vitamin B12 tests. METHODS: A retrospective cohort study was carried out in the Family Medicine and Polyclinic Department at King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia. Clinical and laboratory data were collected between 2018-2021 for the 4 laboratory tests. The inappropriate repetition of tests was defined according to international guidelines and the costs were calculated using the hospital prices. RESULTS: A total of 109,929 laboratory tests carried out on 23,280 patients were included in this study. The percentage of inappropriate tests, as per the study criteria, was estimated to be 6.1% of all repeated tests. Additionally, the estimated total cost wasted amounted to 2,364,410 Saudi Riyals. Age exhibited a weak positive correlation with the total number of inappropriate tests (r=0.196, p=0.001). Furthermore, significant differences were observed in the medians of the total number of inappropriate tests among genders and nationalities (p<0.001). CONCLUSION: The study identified significantly high rates of inadequate repetitions of frequently requested laboratory tests. Urgent action is therefore crucial to overcoming such an issue.

Comparing Coronary Artery Calcium Scoring With Cardiac Risk Scores for Predicting Cardiovascular Events in Primary Care Patients in Saudi Arabia.

Background Cardiovascular diseases are the leading cause of death in Saudi Arabia, and cardiac risk-stratification scoring methods are critical in the primary healthcare setting to predict and potentially prevent the fatal outcomes of CVD. Therefore, this study aimed to examine the prognostic value of coronary artery calcium scoring (CACS) and other cardiac risk-stratification scores: arteriosclerotic cardiovascular disease (ASCVD) risk estimator, cardiovascular risk score (QRISK2), and triglyceride glucose index (TyG) in primary healthcare facilities in Riyadh, Saudi Arabia. Methods A retrospective cohort study was conducted at Family Medicine Clinics, and data on patient's demographics, medical records, and chronic illnesses obtained from the Integrated Clinical Information System (ICIS) database that were recorded between 2010 and 2019 were analyzed. We performed descriptive statistics, student's t-test, analysis of variance (ANOVA), Pearson correlation, Cohen's Kappa, and regression analyses. Results QRISK (p<0.001) and ASCVD (p<0.05) risk estimators positively correlated with the CACS score in predicting fatal and non-fatal cardiac outcomes while the TyG score had the lowest prediction ability among all the other risk estimators. CACS (OR = 1.003; 95% CI: 1.005 -1.002) (p<0.001), ASCVD (OR = 18.177; 95%CI: 214.578 - 1.540) (p=0.021), and QRISK2 (OR=154.796; 95%CI: 4137.356 - 5.792) (p=0.003) significantly predict stenosis unlike the TyG score's statistically insignificant prediction (p>0.05). Conclusion These findings show that ASCVD and QRISK2 are consistent with CACS and are effective risk indicators that could be used to predict cardiac-associated fatal and non-fatal cardiac events among primary care patients. This indicates that the integration of multiple risk scores, as necessary, can all contribute to more effective risk assessment and prevention of coronary artery diseases and related cardiovascular events.

The correlation between vitamin B12 and folate levels and bone mineral density among the Saudi population in a primary care setting.

Purpose: Bone health and osteoporosis are significant health problems in Saudi Arabia. Approximately 40%-50% of women and 25%-33% of men sustain osteoporotic fractures in their lifetimes. Hence, identifying the risk factors for osteoporosis is crucial in reducing the incidence of fractures. Materials and Methods: We retrospectively reviewed the electronic medical records of 557 patients (female 60%, male 40%) aged ≥18 years (mean age, 66.53 years [standard deviation ± 14.169]) who underwent bone mineral density (BMD) scans at the Department of Family Medicine & Polyclinics, King Faisal Specialist Hospital and Research Centre (KFSH&RC) between January 2004 and June 2019. Data collected included demographics, BMD values, vitamin B12 levels, and folate levels. Results: This study indicated that the prevalence rates of vitamin B12 and folate deficiencies among the study population were 8.4% and 1.3%, respectively. There was a statistically significant association between vitamin B12 levels and fracture risk (P =0.044). However, no statistically significant correlation was observed between BMD at either site (lumbar spine or femoral neck) and vitamin B12 (P =0.926.,070) and folate levels (P =.683.,79). BMD showed a significant positive correlation with body mass index at the lumbar spine and femoral neck (P = 0.000). There was no statistically significant association between vitamin B12 levels and the use of metformin (P =.26). Conclusion: Vitamin B12 is associated with fracture risk; however, vitamin B12 and folate levels are not correlated to BMD (femoral neck and lumbar spine).

COVID-19 pandemic impact on primary immunization uptake.

Purpose/Background: Pediatricians across the world are seeing a steep drop in the number of children coming in for appointments due to COVID-19 pandemic. To prevent outbreaks of serious diseases that pose an even greater threat to children than COVID-19, it is important that children not skip their routine vaccines. The aim of this study was to determine the impact of COVID-19 pandemic on primary immunization activities in Saudi Arabia. Settings and Design: Cross-sectional design. Methods and Material: The study was conducted at a community pediatric clinic. All parents of preschool-age children who visited the community pediatric clinics were asked to complete a self-administrated questionnaire on primary immunization uptake during the pandemic. Statistical Analysis Used: The Chi-square and Fisher's exact test were performed to examine the demographic differences between participants who missed vaccination during the pandemic and reasons for missing the vaccination. Results: Three hundred study participants completed our questionnaire. In total, 90.6% of respondents were up to date with their vaccinations prior to the pandemic, and most respondents believed that children should be immunized at an appropriate age, it is essential for children to be fully immunized, vaccination is effective in preventing serious disease, and childhood immunization is essential during the pandemic (98.3%, 98.7%, 97.3%, and 93.7%, respectively). In total, 72.4% of respondents did not miss their vaccinations during the pandemic, while 26.6% missed vaccinations. The most common reason for missing vaccinations during the pandemic was transportation difficulty and curfew, followed by fear of contracting COVID-19 infection (40.9% and 35.5%, respectively). Those who did not believe that childhood immunization was necessary during the pandemic were more likely to miss vaccinations during the pandemic (P < 0.001). In addition, those who did not have a family member with COVID-19 infection were more likely not to miss the vaccine (P < 0.001). Moreover, those who thought taking vaccinations in a primary care setting or hospital is safe were more likely not to miss the vaccination during the pandemic (P < 0.027) and (P < 0.001). Conclusions: Significant portion of the population was affected and missed immunizations during the pandemic. The perceptions on the importance of immunization and having a family member affected with COVID-19 during the pandemic were important factors in missing immunizations. Moreover, transportation and fear of contracting COVID-19 during the curfew were also common reasons for missing immunizations during the pandemic.

Development of a Cardiovascular Disease Risk Prediction Model: A Preliminary Retrospective Cohort Study of a Patient Sample in Saudi Arabia.

Saudi Arabia has an alarmingly high incidence of cardiovascular disease (CVD) and its associated risk factors. To effectively assess CVD risk, it is essential to develop tailored models for diverse regions and ethnicities using local population variables. No CVD risk prediction model has been locally developed. This study aims to develop the first 10-year CVD risk prediction model for Saudi adults aged 18 to 75 years. The electronic health records of Saudi male and female patients aged 18 to 75 years, who were seen in primary care settings between 2002 and 2019, were reviewed retrospectively via the Integrated Clinical Information System (ICIS) database (from January 2002 to February 2019). The Cox regression model was used to identify the risk factors and develop the CVD risk prediction model. Overall, 451 patients were included in this study, with a mean follow-up of 12.05 years. Thirty-five (7.7%) patients developed a CVD event. The following risk factors were included: fasting blood sugar (FBS) and high-density lipoprotein cholesterol (HDL-c), heart failure, antihyperlipidemic therapy, antithrombotic therapy, and antihypertension therapy. The Bayesian information criterion (BIC) score was 314.4. This is the first prediction model developed in Saudi Arabia and the second in any Arab country after the Omani study. We assume that our CVD predication model will have the potential to be used widely after the validation study.

A Comparison of the Checklist Scoring Systems, Global Rating Systems, and Borderline Regression Method for an Objective Structured Clinical Examination for a Small Cohort in a Saudi Medical School.

BACKGROUND: This study aims to compare the effectiveness of using the checklist and global rating scores to evaluate the clinical competency of medical students in Objective Structured Clinical Examinations (OSCEs). Additionally, the study assesses the appropriateness of using the borderline regression method to set standards for small-scale OSCE exams and determines if the estimated passing marks differ significantly from the university's prefixed passing score of 70%. The study also examines whether the university should utilize the borderline regression method to determine passing scores for each OSCE exam instead of a set passing score. METHODS: The study analyzed medical students' grades in 11 OSCE exams in the 2022-2023 academic year at Alfaisal University, Riyadh, Saudi Arabia. Students received family medicine clerkship rotations, and after each rotation, they took an OSCE exam consisting of three stations that family medicine consultants graded. The exam included a checklist of 30 tasks and a five-level global rank scale. The study collected all the checklist marks and global rank grades and analyzed them using IBM® Statistical Package for Social Sciences (SPSS® Statistics) software. The statistical tests used were descriptive statistics, the T-test, chi-square tests, Fisher's exact test, and Pearson correlation. RESULTS: The study showed that students were more likely to pass when using the global rating system than the checklist scoring system. Additionally, students had a significantly lower passing rate when using the higher cut-off passing score estimated using the borderline regression method compared to the pre-set passing score of 70% established by the university (with a p-value of 0.00). CONCLUSION: Each scoring system has advantages and disadvantages, but they complement each other. Combining scoring systems can produce a more comprehensive and precise evaluation of a candidate's performance. The study also emphasizes the importance of carefully selecting and validating cut-off points in OSCE exams to ensure fairness and consistency in assessment.

Identification and Characterization of Preventable Adverse Drug Events in Family Medicine Clinics from Central Saudi Arabia.

Background: Medication errors can result in adverse drug events (ADEs) and cause considerable patient harm. Limited data are available from Saudi Arabia and the Middle East regarding the prevalence of preventable adverse drug events (pADEs) in primary care settings. Objectives: To estimate the period prevalence of pADEs and assess the medication error severity in primary care setting in Saudi Arabia. Methods: This retrospective study is a continuation of a previous study where 117 of 2000 adult patients managed at the Family Medicine clinics of King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia, were identified to have had least one medication error in the past 15 months. The electronic health records of these 117 patients were analyzed for a 3-month post-medication error period to explore the presence of pADE. Medication errors were categorized according to the National Coordinating Council for Medication Error Reporting and Prevention index (NCC MERP) and the occurrence of pADE was assessed using the NCC MERP scheme. Results: Of the included 117 patients, 9 (7.7% [95% confidence interval (CI): 2.79-12.59]) experienced pADE (Category E), while 108 (92.3% [95% CI: 87.97-98.35]) did not (Category C). All patients who experienced pADE were using over-the-counter medications and were on polypharmacy. Outcomes 2a and 2b (asthma and ß-blocker) accounted for two and four cases, respectively, while Outcomes 6 (warfarin and international normalized ratio), 7 (lithium and lithium level), 16 (new oral anti-coagulant or warfarin and antiplatelet), and 17 (acetylsalicylic acid [aspirin] and antiplatelet) each accounted for one case. Conclusions: This study provides the period prevalence of patients with pADEs from Family Medicine clinics at a major tertiary hospital of Saudi Arabia, and highlights the need for a multicenter study of clinically important medication errors at the prescribing and monitoring stages for the development of quality improvement programs.

Association Between Lipid Profile Measurements and Mortality Outcomes Among Older Adults in a Primary Care Setting: A Retrospective Cohort Study.

Background Lipid profile components play a role in predicting the development of cardiovascular disease and hence mortality, but recent studies have shown mixed results in the older population. The aim of our study was to investigate the association between levels of lipid profile components with all-cause mortality and cardiovascular outcomes among older adults in a primary care setting in Riyadh, Saudi Arabia. Methods A retrospective cohort study was performed among 485 individuals aged 60 years and older who visited the family medicine clinics linked to a tertiary care hospital during the first six months of 2010. The electronic charts of the participants were reviewed up to April 2022 to gather relevant data. Each lipid profile component, including total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TGs), was categorized into four quartiles. LDL was calculated using the Friedewald formula. Cardiovascular outcomes included ischemic heart disease (IHD), heart failure (HF), and stroke. Results The mean follow-up period was 12 years. The elderly participants with the lowest HDL-C quartile (<1.1 mmol/L) were at higher risk of all-cause mortality (adjusted hazard ratio of 2.023 (95% CI 1.21-3.38)) and IHD (adjusted hazard ratio 3.2 (95% CI 1.6-6.2)). High TC (≥5.7 mmol/L) was associated with an increased risk of HF (adjusted hazard ratio 2.1 (95% CI 1.1-4.0)). Conclusion In patients aged 60 years and older, low HDL-C (<1.1 mmol/L) was associated with a higher risk for all-cause mortality and IHD, and high TC was associated with an increased risk of having HF. No significant association was found for LDL-C, TC, and TGs with all-cause mortality.

Breast Cancer Diagnosis and Survival among Patients Diagnosed by a Structured Community Based Screening Program Compared to Opportunistic Diagnosis: A Case Control Study.

INTRODUCTION: Breast cancer is ranked as the most common type of cancer effecting women worldwide. Early detection is associated with improved morbidity and mortality, along with decreased recurrence rates, due to regular breast cancer screening recommendations advised for women over the age of 40. Women in the Kingdom of Saudi Arabia (KSA) typically present with advanced symptoms at later stages due to lower-than-average rates of breast cancer awareness and screening. METHODS: A case-control study was conducted utilizing data collected over 20 years in the primary care clinics linked to at a tertiary hospital to demonstrate the role of structured breast cancer screening programs within well-established primary care setting. Results were compared with outcomes of cancer cases diagnosed in the community through opportunistic diagnosis. RESULTS: A total 292 patients included in the study had an overall mean survival time of 160 months, with a statistically significant higher survival time noted amongst the primary care group of 49 patients (p<0.01) by approximately 85 months. Clinical stages and clinical response rates between the two patient groups were found to be statistically significant (p<0.01), where 35 (73.3%) primary care patients were stage IIA and below, compared to 41 (30%) oncology patients. Patients who were diagnosed with breast cancer in the primary care group with well-established breast cancer screening programs were noted to present with breast cancer at earlier stages, have better prognosis and lower mortality as opposed to the oncology patient group. CONCLUSION: Our study highlights the need of structured breast cancer screening programs within well supported primary health services in Saudi Arabia and the region. Such programs were associated with improved survival outcomes and more favorable clinical responses. There is an urgent need to enable primary care services with the appropriate resources to significantly impact patient morbidity and mortality.

Assessing the Validity of Health Messages Used by the Saudi Public in WhatsApp.

Objective: WhatsApp is the most frequently used social media platform in Saudi Arabia. Inaccurate information could negatively impact public health. The number of studies worldwide investigating health-related misinformation in social media increased steadily, with limited data from Arabic-speaking communities. This study aimed to estimate the validity and safety of Arabic-language health information messages circulated on WhatsApp and identify the different categories of these messages based on their credibility. Participants and Methods: A descriptive, analytical cross-sectional study was conducted from February to April 2021. A total of 374 students were randomly selected from the common first preparatory year college at King Saud University in Riyadh, Saudi Arabia, and participated by sharing up to three health-related WhatsApp messages per student that they or their relatives had recently read. Four board-certified physicians reviewed and classified the messages based on their credibility and sources. Results: 282 students provided 326 messages (1.2 messages per student). Most messages (86%) had either invalid or inaccurate content, and 83.7% came from unknown sources. Only 26 messages (8%) of the total were written by trusted scientific sources. Most of the messages from unknown sources or unqualified persons were either invalid or invalid, with potential health risks for the public, and the difference from trusted sources was statistically significant. Conclusion: This study showed a high percentage of inaccurate and invalid health-related messages on WhatsApp. Invalid messages with potential health risks were authored mostly by unknown sources or unqualified persons. Most health messages written by trusted authorities and qualified persons were valid. Trusted scientific authorities should thus be more active in public education on social media platforms. They should advise their communities on how to discern the validity of such messages. More efforts are needed to guide patients from where to obtain accurate and valid health information.

An Evaluation of Mentorship for Hospital Residents in Saudi Arabia: A Qualitative study using Semi-structured Interviews.

Background: In this study, we explore how doctors in training perceive mentorship and leadership and whether they believed that mentoring influences the development of leadership skills. The study also addressed whether certain leadership styles lend themselves better to mentoring. Methods: A qualitative research method was employed in this study and ethical approval was granted by the Research Ethics Committee (REC) at King Faisal Specialist Hospital and Research Centre (KFSH&RC), after which twelve hospital residents were recruited using purposive sampling. Semi-structured interviews were conducted by the authors and thematic data analysis was performed. Results: Three themes emerged and were later refined, using Braun and Clarke's 2006 thematic analysis method:1. Purpose of mentorship, with sub themes: a. Expectations, b. Perception of mentorship as supervision, and c. The role of mentorship, including informal mentoring in leadership development2. Role of mentorship in leadership development.3. Perceptions of a leader, with sub-themes: a. The leader as a manager, b. The leader as a role model, and c. The merits of different leadership styles. Discussion: Most of the residents (doctors in training) viewed mentorship in a positive way. However, when the mentor was perceived more as a supervisor, the usefulness of mentoring was less clear. However, they found that informal mentoring would contribute to leadership skills and would inspire them to become leaders themselves. They were likely to be influenced positively when they saw the leader as a role model, rather than a manager.

The yield of fecal occult blood testing as a screening tool for colon cancer in a primary care setting.

Background/Aims: The most common cancer among men and the third most common among women in Saudi Arabia is colon cancer. This study aimed to evaluate the yield of the fecal occult blood test (FOBT) used as a screening tool for colon cancer. Settings and Design: Medical records of all patients above the age of 50 years who had visited the Family Medicine clinic at King Faisal Specialist Hospital and Research Centre in Riyadh, Saudi Arabia and who had undergone the FOBT screening between January 2002 and March 2017 were retrospectively reviewed. Materials and Methods: We collected patients' demographic data, FOBT results, and colonoscopy pathology reports results. Statistical Analysis: Data were analyzed using the Statistical Package for Social Science Version 25 (IBM Corp., Armonk, NY, USA). Results: We included 2179 patients in this study. The mean age was 59.8 ± 8 years. As a result of the FOBT screening, 19.7% of the patients had a positive FOBT. Colon cancer accounted for 3.5% of all abnormal colonoscopy pathology reports. The Saudi age-standardized incidence rate (ASIR) in our study was 26.56 per 100,000 persons. Conclusion: FOBT is a feasible tool that can be used for colon cancer screening in primary care settings. The Saudi ASIR in our study was higher than the Saudi Cancer Registry, but it was still lower in comparison to other countries. We recommend the establishment of a national community-based colon cancer screening program.

Attitude and hesitancy of human papillomavirus vaccine among Saudi parents.

Background: Human papillomavirus (HPV) is closely associated with cervical cancer. The HPV vaccine is expected to protect against two-thirds of cervical cancer cases in Saudi Arabia. Objectives: To determine the awareness and attitude regarding the HPV vaccine among Saudi parents attending family medicine clinics in Riyadh. Materials and Methods: All Saudi parents of patients of Family Medicine Pediatric Clinics, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, were invited to participate in this study between November 2019 and May 2020. A culturally sensitive and specially designed questionnaire was administered using an interview-based model. The data collected included sociodemographic information, knowledge of HPV and its vaccine, and attitudes regarding HPV acceptance. Results: A total of 296 study participants completed our questionnaire on the HPV vaccine. About 70.6% of the participants were not aware of the HPV vaccine and the majority of them either did not know or did not associate HPV as an etiology for cervical cancer (38.8 and 37.8%, respectively). Only 28.6% of the participants were aware that cervical cancer can be prevented by a vaccine and 89.5% of the study participants did not receive the HPV vaccine for themselves or their children. The employee status was significantly associated with a history of receiving the HPV vaccine (χ2 (2) = 10.607, P =0.005), while age and the level of education had a statistically significant relationship with planning on having the HPV vaccine ((χ2 (9) = 51.841, P <.001) and (χ2 (12) = 23.977, P =0.02), respectively). The level of awareness of the HPV vaccine was significantly associated with a history of having the HPV vaccine; (χ2 (1) = 38.486, P <.001) as well as with planning on having the HPV vaccine (χ2 (1) = 38.486, P <.001). Moreover, the reasons for hesitancy were a statistically significant factor for unvaccinated respondents who were not planning to have the HPV vaccine (χ2 (21) = 97.689, P <.001) while it was not significantly associated with the unvaccinated respondents who were planning to have the HPV vaccine (χ2 (9) = 6.989, P =.63). Conclusion: Our study clearly demonstrated a poor level of awareness and attitude toward the HPV vaccine among Saudi parents. A higher level of awareness of the HPV vaccine was significantly associated with planning on having the vaccine. There is a need for effective awareness programs for better HPV-related education in order to increase the acceptance of the HPV vaccine among Saudi parents.

Awareness of medical law among health care practitioners in Saudi Arabia.

OBJECTIVES: To determine the level of awareness of medical law among healthcare practitioners and to identify factors that influence that level of awareness in Saudi Arabia. METHODS: This cross-sectional study was carried out in Riyadh, Saudi Arabia in 2020-2021 via a survey including 750 healthcare practitioners, from different specialties including all regions in Saudi Arabia. Participants included consultants, senior registrars, interns, and residents. RESULTS: Majority of enrolled healthcare practitioners had poor awareness of medical law (approximately 97%). Only 1.5% had adequate awareness of medical law, and only 1.5% had moderate awareness. Factors associated with increased medical law awareness were the age group between 25 and 34, being from the central region, and having a clinical practice for less than 10 years p-value of <0.05. CONCLUSION: Awareness of medical law among healthcare practitioners is limited in Saudi Arabia. Professional medico-legal education should be part of required competencies for undergraduate and postgraduate levels of medical education. Health care practitioners must be educated with laws and regulations of practicing health professions in the country.

The Prognostic Value of Coronary Arteries Calcium Scoring in a Primary Health Care Setting in Riyadh, Saudi Arabia: A Retrospective Cohort Study.

BACKGROUND/PURPOSE: Coronary Artery Calcium Scoring (CACS) by CT, the American Atherosclerotic Cardiovascular Disease (ASCVD) Score, and the British Cardiovascular Risk (QRISK2) score are the most frequently used cardiovascular risk stratification scores to predict cardiac outcomes and aid in the decision of implementing preventative and/or interventional measures. The aim of this study is to assess CACS, ASCVD score, QRISK2 score, and their capacity to predict cardiovascular events among family medicine patients in King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia. METHODOLOGY: All medical records of patients (18 years and above) who had a CACS done in Family Medicine Clinics at KFSH&RC from January 2010 to March 2018 were reviewed, retrospectively. The study variables included demographics, comorbidities, CACS, ASCVD Score, QRISK2 score, and cardiovascular events. RESULTS: We included 218 patients. Our study population included: 77% men, a mean age of 51 years (SD±8), and a mean BMI of 29 kg/m2 (SD±5). CACS was significantly associated with coronary events (p-value < .05). There was significant association between high CACS (>400) and family history of cardiac disease (p-value = .006), prior cardiovascular events (p-value = .01) and advancing age (p-value < .001). High concordance was found between QRISK2 score and CACS (90.6%), and moderate concordance between ASCVD score and CACS (69.4%). Moderate concordance was found between ASCVD score and QRISK2 score (74.3%). The majority of the subjects (88%) fell into the low-risk group (CACS <100) with (63%) having a CACS of zero. CONCLUSION: QRISK2 cardiac assessment tool provides better risk assessment and higher concordance with CACS. To improve cost-effectiveness and minimize unnecessary radiation exposure, QRISK2 scoring should be implemented for initial cardiovascular risk stratification prior to ordering the CACS imaging modality.

Association Between Vitamin D Levels and Glycemic Control Among Adult Diabetic Patients in Riyadh, Saudi Arabia.

Background: Diabetes is one of the most common diseases worldwide. It can cause serious complications, such as cardiovascular events, end-stage renal disease, and blindness if not controlled. Vitamin D is believed to play an essential role in glucose metabolism and insulin resistance. However, few studies have been conducted in Saudi Arabia to confirm or reject this hypothesis. Thus, this study explored the relationship between vitamin D levels and glycemic control in a Saudi diabetic population. MATERIALS AND METHODS: This is a retrospective cohort study including all adults 18 years of age or older diagnosed with diabetes who underwent at least five years of regular follow-up at the family medicine clinic at the King Faisal Specialist Hospital (KFSH) from January 2015 to January 2021. Data were obtained from the patients' medical records and included detailed histories, physical examination records, and laboratory findings. Participants were divided into vitamin D deficiency and vitamin D sufficiency groups based on vitamin D levels. RESULTS: A total of 370 patients with type 2 diabetes mellitus were enrolled in the study. The majority of the patients (60%) were over 65 years of age. The mean serum 25(OH) vitamin D level of the participants was 62.75 ± 22.79 nmol/L. There was a significant association between glycemic control and vitamin D levels (p < 0.001). The mean level of vitamin D was higher in the good glycemic control group (70.96 ±22.66) than in the poor glycemic control group (54.81 ±19.98). A total of 13.74% (25) of the good glycemic control group had vitamin D levels < 50 nmol/L, while 52.13% (98) of the poor glycemic control had vitamin D levels < 50 nmol/L. Patients with poor glycemic control were 2.4 times more likely to have low vitamin D levels than patients in the well-controlled glycemic group. CONCLUSION: Based on the study results, serum vitamin D has a significant inverse relationship with HbA1c levels among diabetics. This finding highlights the need for routine screening of vitamin D status in all patients with diabetes and early treatment for those found to be deficient.

Clinical and epidemiological aspects of herpes zoster disease in a primary care setting in Riyadh, Saudi Arabia: A retrospective cohort study.

Context: Herpes zoster (HZ), or shingles, is one of the most common infectious diseases. HZ can be associated with other diseases, such as cancer and immunocompromised conditions. Thus, early recognition of the disease characteristics and clinical manifestations is critical to decrease the disease burden and to avoid further complications. Aim: To assess the epidemiology of HZ disease, its clinical manifestations, coexisting and post-existing conditions, complications, and management among patients in a primary care setting. Subjects and Methods: This was a retrospective, single-armed, cohort study. Data of all patients diagnosed with HZ, aged 18 years and older, who visited the Family Medicine Department at King Faisal Specialist Hospital and Research Center from January 2014 to August 2021 were reviewed from their medical records. All data analyses were performed using IBM Statistical Package for the Social Sciences (SPSS) statistical software, version 20.0. Results: A total of 330 cases were included over the study period. The male-to-female ratio was 1:2, with a higher occurrence of HZ (44.5%) in those aged ≥ 50 years. Only 4.5% of the patients were recipients of zoster vaccines. Thoracic dermatome was the most affected dermatome (38%). The most common coexisting disease was diabetes (21.5%). The most common post-existing disease was cardiovascular disease (3%), and the most common complication was postherpetic neuralgia (15.2%). Suboptimal dosage of acyclovir was the most commonly used treatment for HZ infections (69.7%). Conclusions: Zoster vaccination uptake was low. A national program for adult vaccination, including zoster vaccination, should be developed, and a guideline to direct primary health-care professionals in the management of HZ infections should be implemented.

Attitude of parents towards seasonal influenza vaccination for children in Saudi Arabia.

INTRODUCTION: The aim of this study is to assess attitudes, beliefs, and behavior towards seasonal influenza vaccination for children among parents in Saudi Arabia and to correlate parental demographic characteristics with hesitancy. METHODOLOGY: This is a cross-sectional study conducted in the Family Medicine clinics linked to a tertiary referral hospital in Riyadh. Inclusion criteria were: being a parent, having a child aged six months to 14 years whom is following at that hospital, and living in Saudi Arabia. The Parent Attitudes about Childhood Vaccines (PACV) survey was used for data collection. Demographic questions were added. RESULTS: The number of participants was 388. Out of these, 298 (76.8%) parents were not hesitant for their child to get vaccinated. Whereas 90 (23.2%) parents were hesitant. Parental gender and age were the only demographic factors found to have a statistically significant impact on their hesitant behavior. For the influenza season of 2018-2019, 148 (38.14%) children received the influenza vaccine. The most common reason for not receiving it was the belief that the vaccine is not necessary. While 25 (27.78%) of the 90 parents who were hesitant allowed their child to get vaccinated, 123 (41.28%) of the 298 parents who were not hesitant allowed their child to get vaccinated, creating a statistically significant difference (p = 0.0255). CONCLUSION: Despite the overall positive attitude and low hesitancy, the vaccine uptake was low. Improving access, education about the importance of the vaccine, advocacy from doctors, and correction of misconceptions about it will facilitate an increase in the uptake.

Incidence of Cardiovascular Complications and Nephropathy in Patients with Type 2 Diabetes in a Primary Care Setting in Riyadh, Saudi Arabia.

BACKGROUND: Diabetes mellitus is prevalent in Saudi Arabia. Our study aims to estimate the rate and time of developing macrovascular and microvascular complications in diabetic patients in a primary care setting. METHODOLOGY: This is a retrospective cohort study. All collected data were retrieved using medical files and the electronic patient records of all diabetics having regular follow-ups in Family Medicine clinics, King Faisal Specialist Hospital & Research Centre in Riyadh, Saudi Arabia, from the beginning of January 2002 to the end of December 2018. The data included the demographics of patients diagnosed with diabetes mellitus, their HbA1c, and the follow-up duration of the development of complications, which included cardiovascular complications and diabetic nephropathy. RESULTS: We included 365 patients, of whom 47.1% males and 52.9% were females. The mean age of diabetes mellitus diagnosis in our population was 50 years (SD±11.3). The mean duration of follow-up was 7.14 years (SD±3.9). The rate of developing cardiovascular complications and diabetic nephropathy was 11.2% and 10.4%, respectively. The mean time to develop cardiovascular complications and diabetic nephropathy was 6 (SD±3.9) and 5.24 (SD±3.2) years, respectively. The mean time to develop the first diabetes complication was 5.5 years (SD±3.6). There was no statistical significance in the mean of HbA1c between patients who developed diabetic complications and those who did not. CONCLUSION: Diabetes complications are common in the Saudi community. The duration of the development of cardiovascular complications and diabetic nephropathy was shorter than that indicated in international and national reports. Robust screening programs to diagnose and improve the control of diabetes mellitus should be established in the Kingdom.

Potential health risks of maternal phthalate exposure during the first trimester - The Saudi Early Autism and Environment Study (SEAES).

Phthalates are the most ubiquitous contaminants that we are exposed to daily due to their wide use as plasticizers in various consumer products. A few studies have suggested that in utero exposure to phthalates can disturb fetal growth and development in humans, because phthalates can interfere with endocrine function. We collected spot urine samples from 291 pregnant women in their first trimester (9.8 ± 2.3 gestational weeks) recruited in an ongoing prospective cohort study in Saudi Arabia. A second urine sample was collected within 1-7 d after enrollment. The aims of this study were to: (1) assess the extent of exposure to phthalates during the first trimester and (2) estimate the risk from single and cumulative exposures to phthalates. Most phthalate metabolites' urinary levels were high, several-fold higher than those reported in relevant studies from other countries. The highest median levels of monoethyl phthalate, mono-n-butyl phthalate (MnBP), mono-iso-butyl phthalate (MiBP), and mono-(2-ethylhexyl) phthalate (MEHP) in µg/l (µg/g creatinine) were 245.62 (197.23), 114.26 (99.45), 39.59 (34.02), and 23.51 (19.92), respectively. The MEHP levels were highest among three di (2-ethylhexyl) phthalate (DEHP) metabolites. %MEHP4, the ratio of MEHP to four di (2-ethylhexyl) phthalate metabolites (∑4DEHP), was 44%, indicating interindividual differences in metabolism and excretion. The hazard quotient (HQ) of individual phthalates estimated based on the reference dose (RfD) of the U.S. Environmental Protection Agency indicated that 58% (volume-based) and 37% (creatinine-based) of the women were at risk of exposure to ∑4DEHP (HQ > 1). Based on the tolerable daily intake (TDI) from the European Food Safety Authority, 35/12% (volume-/creatinine-based data) of the women were at risk of exposure to two dibutyl phthalate (∑DBP) metabolites (MiBP and MnBP). The cumulative risk was assessed using the hazard index (HI), the sum of HQs of all phthalates. The percentages of women (volume-/creatinine-based data) at health risks with an HI > 1 were 64/40% and 42/22% based on RfD and TDI, respectively. In view of these indices for assessing risk, our results for the anti-androgenic effects of exposing pregnant women to ∑4DEHP and ∑DBP early during pregnancy are alarming.