Clinical significance of elevated D-dimer in emergency department patients: a retrospective single-center analysis.

INTRODUCTION: D-dimer is a marker of coagulation and fibrinolysis widely used in clinical practice for assessing thrombotic activity. While it is commonly ordered in the Emergency Department (ED) for suspected venous thromboembolism (VTE), elevated D-dimer levels can occur due to various other disorders. The aim of this study was to find out the causes of elevated D-dimer in patients presenting to a large ED in Saudi Arabia and evaluate the accuracy of D-dimer in diagnosing these conditions. METHODS: Data was collected from an electronic hospital information system of patients who visited the ED from January 2016 to December 2022. Demographic information, comorbidities, D-dimer levels, and diagnoses were analyzed. Statistical analysis was performed using the SPSS software. The different diagnoses associated with D-dimer levels were analyzed by plotting the median D-dimer levels for each diagnosis category and their interquartile ranges (IQR). The receiver operating characteristic (ROC) curves were calculated and their area under the curve (AUC) values were demonstrated. The optimal cut-off points for specific diseases were determined based on the ROC analysis, along with their corresponding sensitivities and specificities. RESULTS: A total of 19,258 patients with D-dimer results were included in the study. The mean age of the participants was 50 years with a standard deviation of ± 18. Of the patients, 66% were female and 21.2% were aged 65 or above. Additionally, 21% had diabetes mellitus, 20.4% were hypertensive, and 15.1% had been diagnosed with dyslipidemia. The median D-dimer levels varied across different diagnoses, with the highest level observed in aortic aneurysm 5.46 g/L. Pulmonary embolism (PE) and deep vein thrombosis (DVT) were found in 729 patients (3.8%) of our study population and their median D-dimer levels 3.07 g/L (IQR: 1.35-7.05 g/L) and 3.36 g/L (IQR: 1.06-8.38 g/L) respectively. On the other hand, 1767 patients (9.2%) were diagnosed with respiratory infections and 936 patients (4.9%) were diagnosed with shortness of breath (not specified) with median D-dimer levels of 0.76 g/L (IQR: 0.40-1.47 g/L) and 0.51 g/L (IQR: 0.29-1.06 g/L), respectively. D-dimer levels showed superior or excellent discrimination for PE (AUC = 0.844), leukemia (AUC = 0.848), and aortic aneurysm (AUC = 0.963). DVT and aortic dissection demonstrated acceptable discrimination, with AUC values of 0.795 and 0.737, respectively. D-dimer levels in respiratory infections and shortness of breath (not specified) exhibited poor to discriminatory performance. CONCLUSION: This is the first paper to identify multiple causes of elevated D-dimer levels in Saudi Arabia population within the ED and it clearly highlights their accurate and diagnostic values. These findings draw attention to the importance of considering the specific clinical context and utilizing additional diagnostic tools when evaluating patients with elevated D-dimer levels.

A Three-Year Retrospective Study Assessing the Quality of the Course of Management of Infective Endocarditis in a Tertiary Hospital in Riyadh, Saudi Arabia.

BACKGROUND: Infective endocarditis (IE) is one of the most misdiagnosed diseases in Saudi Arabia because of the variable treatment regimen. This study aims to assess the quality of the management of infective endocarditis in a tertiary care teaching hospital. METHODS: A single-center retrospective cohort study was conducted, based on electronic medical records extracted from the BestCare electronic medical record system, of all patients who presented with infective endocarditis as a final diagnosis from 2016 to 2019. RESULTS: Out of a total of 99 patients diagnosed with infective endocarditis, 75% of our patients had blood cultures ordered before initiating empirical antibiotic therapy. Positive blood cultures were reported in 60% of patients. Staphylococcus aureus was the most common organism, identified in 18% of our patients, followed by Streptococcus viridans at 5%. Empirical antibiotics were initiated in 81% of patients. Proper antibiotic coverage was initiated within a week for 53% of the patients, and 14% had proper antibiotic coverage within two weeks. On echocardiography, 62% of the patients had vegetation that was present in a single valve. The mitral valve had the highest incidence of vegetation (24%), followed by the aortic valve (21%). Follow-up echocardiography was done in 52% of patients. It showed regressed vegetation in 43% of patients, while only 9% of patients had no vegetation regression. Valve repair was done in 25% of patients. Out of 99 patients, 47 required ICU admission. The mortality rate was 18%. CONCLUSION: Overall management of infective endocarditis in the study hospital was appropriate and highly compliant with guidelines, with a few areas that could be improved further.

To Admit or Not to Admit to the Emergency Department: The Disposition Question at a Tertiary Teaching and Referral Hospital.

BACKGROUND: Disposition decision-making in the emergency department (ED) is crucial to patient safety and quality of care. It can inform better care, lower chance of infections, appropriate follow-up care, and reduced healthcare costs. The aim of this study was to examine correlates of ED disposition among adult patients at a teaching and referral hospital based on patients' demographic, socioeconomic, and clinical characteristics. METHOD: A cross-sectional study conducted at the ED of the King Abdulaziz Medical City hospital in Riyadh. A two-level validated questionnaire was used-a patient questionnaire and healthcare staff/facility survey. The survey employed a systematic random sampling technique to recruit subjects at a pre-specified interval as patients arrived at the registration desk. We analyzed 303 adult patients visiting the ED, who were triaged, consented to participate in the study, completed the survey, and admitted to a hospital bed or discharged home. We used descriptive and inferential statistics to summarize and determine the interdependence and relationships of variables. We used logistic multivariate regression analysis to establish relationships and the odds of admission to a hospital bed. RESULTS: The mean age of the patients was 50.9 (SD = 21.4, Range 18 to 101). A total of 201 (66%) were discharged home while the rest were admitted to a hospital bed. Results of the unadjusted analysis suggest that older patients, males, patients with low level of education, and those with comorbidities and middle-income were more likely to be admitted to the hospital. The results of the multivariate analysis suggest that patients with comorbidities, urgent conditions, prior history of hospitalization, and higher triage levels were more likely to be admitted to a hospital bed. CONCLUSIONS: Having proper triage and timely stopgap review measures in the admission process can help new patients to locations that best support their needs and improve the quality and efficiency of the facility. The findings may be a sentinel indicator that informs overuse or inappropriate use of EDs for non-emergency care, which is a concern in the Saudi Arabian publicly funded health system.

Mitigation strategies for heat-related illness during mass gatherings: Hajj experience.

Introduction: To mitigate morbidity, mortality, and impacts of heat-related illnesses (HRIs) on health, it was vital to implement a comprehensive framework for HRI prevention and control. A recognized tool from the field of trauma prevention known as the Haddon matrix was applied. The matrix states that any event is affected by three factors: host, agent, and environment. In addition, another recognized tool known as the combined model was used in this study. The combined model is a three-dimensional model that includes the idea for the three axes of Haddon's matrix with the methodology of the community risk reduction (CRR) model. Aim of the study: To identify the environmental and individual risk factors of HRIs based on the Haddon matrix and the recommended prevention strategies by the CRR tool by using the combined model. Methodology: An extensive literature review was conducted to assess all the risk factors associated with HRI, as well as preventive measures. Then the Haddon matrix was used to structure, separating human factors from technical and environmental details and timing. After that, the combined model was used to set all responses and mitigation measures for each element obtained from the Haddon matrix tool. Conclusion: Projected increases in heat stress over the globe require the formulation and implementation of evidence-based HRI mitigation and preventive measures. In this study, we implemented the combined model that was utilized as a systematic strategy for the more theoretical framework of Haddon's matrix. Using the Haddon matrix to determine the HRI risk factors and the combined model to mitigate its impact was practical and helpful in planning, preparedness, and mitigating the HRIs during Hajj, provided a broad approach equivalent to the Swiss cheese model, and would facilitate an informed decision.

The optimal oral body temperature cutoff and other factors predictive of sepsis diagnosis in elderly patients.

INTRODUCTION: The aim of this study was to identify the optimal oral temperature cut-off value and other factors predictive of sepsis in elderly patients presenting to emergency department. METHODS: A hospital-based retrospective study was performed on all elderly patients who presented to the Adult Emergency Department at King Abdulaziz Medical City in Riyadh (January to December 31, 2018). RESULTS: Of total of 13,856 patients, 2170 (15.7%) were diagnosed with sepsis. The associated area under the curve estimate was 0.73, 95% confidence interval (CI) 0.72-0.74. Body temperature ≥37.3 was found as optimal cut-point with sensitivity = 50.97% and specificity = 87.22% and 82.39% of patients with sepsis will be correctly classified using this cut-off. An increase of 1° in body temperature was associated with an odds ratio of 9.95 (95% CI 8.95-11.06, P < 0.0001). Those aged ≥100 years having 11.12 (95% CI 2.29-20.88, P < 0.0001) times the likelihood for sepsis diagnosis compared with those aged 60-69 years. People admitted in weather such as winter, spring, or autumn were more likely to develop sepsis than people admitted in summer. CONCLUSION: The risk factors of sepsis such as age, temperature, and seasonal variation inform important evidence-based decisions. The hospitals dealing with sepsis patients should assess older patients for other severe illnesses or co-morbid that might lead to sepsis if left untreated. Therefore, older patients need to be prioritized over younger patients. The body temperature of patients admitted to hospitals needs to be monitored critically and it is important to consider seasonal fluctuations while managing cases of sepsis and allocating resources. Our findings suggest that clinicians should explore the possibility of sepsis in elderly patients admitted to emergency units with oral temperature ≥37.3°C. Risk factors for sepsis reported in this study could inform evidence-based decisions.

The effect of COVID-19 on the characteristics of adult emergency department visits: A retrospective cohort tertiary hospital experience in Riyadh.

BACKGROUND: On March 2, 2020, Saudi Arabia identified the first positive COVID-19 case. Since then, several aspects of the COVID-19 impact on Emergency Departments (EDs) use have been reported. The objective of this study is to describe the pattern and characteristics of Emergency Department visits during the COVID-19 pandemic period, compared with the same period in the previous year, including the patients' demographic information, acuity level, length of stay, and admission rate. METHODS: Data were collected from King Abdulaziz Medical City in Riyadh, Saudi Arabia. The health records of all the patients who presented at the Emergency Department from January 2019 to September 2020 were retrospectively reviewed. The variations in the patient and the visit characteristics were described for the periods before and during COVID-19. RESULTS: The records of 209,954 patients who presented at the Emergency Department were retrieved. In contrast to 2019, the number of visits during the pandemic period reduced by 23%. A dramatic decrease was observed after the announcement of the first COVID-19 diagnosed case in Saudi Arabia, and subsequently the numbers gradually increased. The patients who presented at the Emergency Department during the pandemic period were slightly older (mean age, 43.1 versus 44.0 years), more likely to be older, more urgent and had a higher admission rate compared to the pre-pandemic period. There was a slight increase in visits during the daytime curfew hours and a decrease during the nighttime. CONCLUSION: We report a considerable decrease in the number of Emergency Department visits. The reduction was higher in non-urgent and less urgent cases. Patients presenting at the Emergency Department during the curfew times were more likely to stay longer in the Emergency Department and more likely to be admitted, compared with the pre-pandemic period.

Prevalence of discharge against medical advice and its associated demographic predictors among pediatric patients: A cross-sectional study of Saudi Arabia.

BACKGROUND: Discharge against medical advice (DAMA) occurs when the patient or their caretaker leaves the hospital against the recommendation of their treating physician. DAMA may expose the children to a high risk of inadequate treatment, which may result in readmission, prolonged morbidity, and mortality. The study aimed to identify the predictors of DAMA in the emergency department (ED) within the pediatric age group. METHODS: This was a cross-sectional study. The study used the medical records of pediatric patients (n = 5609) that were admitted to the ED of King Abdullah Bin Abdulaziz University Hospital (KAAUH) in Riyadh, Saudi Arabia, during 2017 and 2018. Descriptive statistics, Chi-square, or Fisher's exact test were used. Unadjusted and adjusted odds ratios with their 95% CI were reported by performing logistic regression modeling. RESULTS: A significant interaction between age and gender was observed in the multivariate analysis after adjusting for the other covariates. The odds of DAMA for a 5-year-old female child were 4.43 times higher than those of a 5-year-old male child (P < 0.1). CONCLUSIONS: The public should be educated about the consequences of DAMA. Continued health education and the promotion of child survival strategies at the community level, combined with an improvement in the socioeconomic conditions of the population, may further reduce DAMA and improve the chances of survival for children. Future studies should assess the socioeconomic status of the patients and estimate the cost that is incurred by the patients.

Predictors and clinical outcomes of silent hypoxia in COVID-19 patients, a single-center retrospective cohort study.

BACKGROUND: Patients with COVID-19 usually present with fever and respiratory symptoms such as cough, sputum production, and dyspnea. However, they may suffer from severe hypoxemia without a clinical correlation with the respiratory symptoms, also known as silent or apathetic hypoxia. The aim of the study was to assess the predictors and clinical outcomes of COVID-19 patients without dyspnea. METHODS: A single-center retrospective cohort study, based on data extracted from the electronic hospital information system, with COVID-19 patients over a 10-month period in Riyadh, Saudi Arabia. RESULTS: Of the COVID-19 patients presenting at the Emergency Department with a SpO2 < 90%, 13% had silent hypoxia. The majority of the patients required BiPAP, 34% were intubated and 60% were admitted to an intensive care unit. There was no association between dyspnea and gender, age group, body mass index, or comorbidity. Cough, fever, and chronic cardiac diseases were predictive for dyspnea in a regression analysis. There was no difference in the clinical outcome between patients with silent dyspnea or dyspnea. Age and obesity were significantly associated with a decrease in survival, and an increase in the initial SpO2 increased survival. CONCLUSION: Patients with cardiac disease are more likely to present with silent hypoxia. The SpO2 saturation in COVID-19 may be an independent predictor of survival. Silent hypoxia in COVID-19 patients does not appear to have an association with increase in mortality.

The association between overweight/obesity and psychological distress: A population based cross-sectional study in Saudi Arabia.

OBJECTIVES: The objective of this study was to compare the association between mental well-being between obese (classes 1 and 2), over-weight and non-obese population-based individuals. METHODS: A population-based cross-sectional study was conducted in Al-Kharj, Saudi Arabia. A total of 1019 Saudi nationals aged ≥ 18 years participated in the survey. BMI scores were used to categorize participants into three groups: Obese, overweighted and non-obese/non-overweight. Mental well-being was evaluated by using the validated Arabic version of the General Health Questionnaire version 12 (GHQ-12). RESULTS: We used total GHQ score (Mean=12; SD=5.23) to compare mental well-being between the four BMI class categories. The overall one-way ANOVA model was statistically significant (F = 7.018, d = 6, P < 0.001). In multivariate analysis, after adjusting for sociodemographic variables, diabetes and smoking statuses we found that higher psychological distress (as evident by a higher total GHQ score) was associated with higher BMI. The unstandardized Beta regression coefficient = 2.627; P = 0.034). Females were more likely to have higher psychological distress than males (unstandardized Beta = 1.466, P = 0.003). Job status whether being unemployed or 'civilian' (civil worker) was significantly associated with higher psychological distress (unstandardized Beta = 1.405, P = 0.041). Being diabetic has a 1.6 times higher risk of psychological distress (unstandardized Beta = 1.604, P = 0.027). CONCLUSION: The study highlights the public health implications of psychological distress amongst individuals with overweight and obesity in Saudi Arabia. Future longitudinal studies should explore the temporality of this relationship.

The Prevalence of Headache and Associated Factors in Al-Kharj, Saudi Arabia: A Cross-Sectional Study.

Background: Only few studies have investigated the prevalence and risk factors of headaches among the Saudi population. The study aimed to estimate the prevalence of headache and to explore its associated risk factors Al-Kharj, Saudi Arabia. Methods: The multistage sampling technique was used to enroll 1200 population-based participants who were asked to complete a self-administered questionnaire about headaches, demographics, and several other parameters such as smoking status and different chronic and psychological illnesses. The chi-square test and multivariate logistic regression analysis were used to test the association. Results: The overall prevalence of headaches in this study was 3%. The multiple logistic regression analysis showed that females were more likely to have headaches than males (odds ratio (OR) 0.735, 95% confidence interval (CI) = 0.612-1.341; P=0.024). Being a current smoker was also significantly associated with higher "odds" of having headache (OR = 1.319, 95% CI = 0.932-2.462; P=0.037). Participants who were overweight had a significantly higher risk of headache (OR = 1.631, 95% CI = 1.48-1.854; P=0.037). Nonmarried people were significantly more likely to have headache pain, compared to married individuals (OR = 0.875, 95% CI = 0.646-2.317; P=0.047). Conclusion: The prevalence of headaches was 3%, and four significant associated factors were identified: females, nonmarried, smoking, and overweight. The temporality of the relationship between these factors and headache cannot be confirmed in this cross-sectional study; so future longitudinal studies are needed to confirm these potential causal relationships.

Psychological predictors of chronic pain in Al Kharj region, Saudi Arabia.

BACKGROUND: Psychological distress is one of the major determinants for the experience progression, and recovery of chronic pain. However, it is unclear whether physical pain in specific body sites could be predictive of psychological illness. In this study, we aim to investigate the link between chronic pain in specific anatomical sites and psychological distress represented in the General Health Questionnaire-12 (GHQ-12 items). METHODS: A population-based cross-sectional study was conducted in Al Kharj region of Saudi Arabia. We included 1003 participants. Data were collected using the GHQ-12, and a subjective report on eight anatomical pain sites. Data analysis used statistical software SPSS version 26.0 for Windows statistical package. RESULTS: Chronic musculoskeletal pain in the neck and head regions was significantly associated with higher psychological distress. Other sites (back, lower limb, chest, abdominal and upper limb pain) were not associated with psychological distress. In multiple regression analysis, chronic 'general' pain was significantly associated with higher psychological distress (unstandardized Beta regression coefficient = 2.568; P < 0.0001). The patients with younger age were more likely to develop negative psychological disorders (unstandardized Beta = - 3.137; P = 0.038). Females were more likely to have higher psychological distress than males (unstandardized Beta = 2.464, P = 0.003). Single (not-married) people have a higher risk of psychological distress than married people (unstandardized Beta = 2.518, P = 0.025). Also, job type/status whether being unemployed (not working) or 'civilian' (civil servant/worker) was positively and significantly associated with an increased probability of psychological distress (unstandardized Beta = 1.436, P = 0.019). CONCLUSION: Chronic 'general' pain was significantly associated with negative psychological disorders. The government of Saudi Arabia needs to focus on patients with chronic 'general' pain, females, young and unmarried individuals as potentially 'high-risk' population subgroups for adverse psychological disorders, and subsequent long-term complications.

Epidemiology of Frequent Visits to the Emergency Department at a Tertiary Care Hospital in Saudi Arabia: Rate, Visitors' Characteristics, and Associated Factors.

BACKGROUND: Emergency department overcrowding is becoming a challenge for the healthcare management system globally and locally. This study aimed to estimate the frequency of ED visits, describe the patients' profile along with visit-related characteristics, and associated factors in a tertiary care hospital. METHODS: A retrospective cohort study was conducted at a tertiary care hospital. The study included patients age 14 years and above visiting the main emergency department in year 2013. Data were extracted from electronic medical records by a qualified data extraction team. Statistical analyses were performed, including the odds ratio and 95% confidence interval for the factors associated with highly frequent (≥14 visits) ED visits using logistic regression models. RESULTS: There were 150,727 visits to the emergency department within a year. The number of frequent visitors was 7696 (9.38%), with 42,226 visits (28.01% of total ED visits). Highly frequent visitors totaled 249 (0.30%), with 5173 visits (3.43% of total ED visits). The frequent visitors' average age was 42.55 (SD 20.14), and 48.99 (SD 21.33) for the highly frequent visitors' group. More than half of the emergency visitors were females. The most common complaints among the highly frequent visitors were Gastrointestinal (21.34%), followed by Respiratory (13.47%), Orthopedic (12.57%), and Cardiovascular (12.43%). Multivariate analysis indicated that age, history of diabetes, history of cardiac diseases, insurance status, and nationality were significant predicators of highly frequent visits to the hospital emergency. CONCLUSION: Frequent and highly frequent visitors to emergency departments represent a significant proportion of adult patients presenting to ED. Their visits constitute almost one-third of total ED visits. Several factors associated with highly frequent ED visits have been identified. This study provides local empirical evidence to develop improvement policy and actions related to chronic issue of frequent and highly frequent visitation to hospital ED.

The prevalence of hypercholesterolemia and associated risk factors in Al-Kharj population, Saudi Arabia: a cross-sectional survey.

BACKGROUND: Hypercholesterolemia (HC) is an important precursor to many cardiovascular, cerebrovascular, and peripheral vascular diseases. A report conducted by the American Heart Association showed the prevalence of HC to be 11.9%, with around 28.5 million adults age ≥ 20 years having high cholesterol levels. This study aimed to evaluate the prevalence of HC and its associated risk factors among the general population of Al-Kharj, Saudi Arabia. METHOD: A cross-sectional study was conducted on the general population of Al-Kharj, Saudi Arabia in 2016. The representative sample consisted of 1019 individuals, who all participated on a voluntary basis. The statistical analysis was performed using SPSS version 25. RESULTS: The results of this study showed the prevalence of HC in the sample to be 12.5%. There was a significant moderate positive association between increasing age and the prevalence of HC (r = 0.240, P < 0.0001). Males had a significantly higher prevalence of HC (56.7%) compared to their female counterparts (43.3%) (X2 = 23.093, P ≤ 0.0001). BMI was positively and significantly associated with high cholesterol status. Participants in the overweight category had a significantly higher risk of HC (OR = 1.727; 95% CI = 1.58-1.914; P = 0.046). The non-obese (< 25 kg/m2) participants had an inverse significant association with the risk of hypercholesterolemia. (OR = 0.411; 95% CI = 0.216-0.783; P = 0.007). CONCLUSION: In this population-based study, the predominant risk factors of HC in Al-Kharj region were being of a Saudi nationality, male, having obesity, being unemployed, and being a civilian worker. There is a clear need for future screening studies of HC, as most previous studies have reported contradictory prevalence data (because they were conducted in different regions of KSA). Furthermore, well-designed prospective cohort studies are needed in the future to assess how the association between lifestyle behavioural factors such as dietary intake patterns and levels of physical activity may affect the relative risk of HC status.

The relationship between chronic pain, prehypertension, and hypertension. A population-based cross-sectional survey in Al-Kharj, Saudi Arabia.

Background: Chronic pain and hypertension are highly prevalent in both developing and developed countries. Although they may appear to be two separate phenomena, several studies in developed countries have found them associated at the population level. Studies in developing countries are scarce and association between pain with prehypertension are rarely explored. The objective of this study was to explore the potential association between prehypertension, hypertension, and chronic pain in a Saudi population.Methods: A cross-sectional general population-based study was conducted on a random sample of employees and university students over a period of 6 months from January 2016 to June 2016 in Al Kharj, Saudi Arabia. A total of 1200 general population adults (aged 18 years and above) were invited to participate in the study.Results: With a response rate of 85.9%, 1031 individuals were included in the final analysis. Among the general population of Al-Kharj, statistically significant association was found between age and chronic pain [Odds ratio (OR) = 1.764 [95% C.I. = 1.391-1.927], P < 0.0001] and between hypertension and chronic pain [(OR) = 1.039 [95% C.I. = 1.018-1.060], P < 0.0001], respectively. The association between prehypertension and chronic pain was not statistically significant [(OR) = 1.211 [95% C.I. = 0.879-1.668, P = 0.243].Conclusion: Results of this survey suggests a statistically significant relationship between hypertension (but not prehypertension) and chronic pain. The temporality of the relationship between hypertension and chronic needs to be explored in future longitudinal studies.

Risperidone-Induced Acute Laryngeal Dystonia: A Case Report.

BACKGROUND Antipsychotic medications are associated with multiple adverse effects, including metabolic syndrome, prolonged QT interval, and extrapyramidal symptoms. Acute laryngeal dystonia (ALD) is a rare and lethal form of extrapyramidal reaction. CASE REPORT A 27-year-old woman with schizophrenia on risperidone presented to our Emergency Department with a sensation of choking and respiratory distress, mimicking a panic attack. She developed a generalized dystonic reaction in the hospital, leading to diagnosis risperidone-associated ALD as a cause of her initial problems. She was discharged with an emphasis on being compliant with anticholinergic medication. However, her persistent respiratory symptoms prompted us to revisit the management plan. Her risperidone dose was tapered down to discontinue and an alternate drug was chosen. CONCLUSIONS ALD must be considered as a differential diagnosis when patients on antipsychotic medications present with respiratory distress. Our case highlights the association of ALD with an atypical antipsychotic agent, risperidone. Prompt recognition of this entity is necessary to prevent complications and guide definitive management.

Emergency medicine in Saudi Arabia: a century of progress and a bright vision for the future.

Although emergency medical services (EMS) and pre-hospital care have existed in the Kingdom of Saudi Arabia (KSA) since 1934, emergency medicine (EM) is a relatively new medical field in the country that was not formally recognized as a medical specialty until 2001. In 2005, the Saudi Board of Emergency Medicine formed to develop, implement, and evaluate a standardized curriculum for EM residents. Since then, EM and the pre-hospital system in the KSA has evolved and grown. This article provides an overview of emergency medicine in Saudi Arabia and the progress it has made in the pre-hospital system, healthcare delivery system, and emergency medicine training. Finally, we will discuss the challenges and opportunities faced as this specialty continues to develop.

Seventy-two-hour emergency department revisits among adults with chronic diseases: a Saudi Arabian study.

BACKGROUND: Despite the increase in adult emergency department (ED) utilization in Saudi Arabia, no studies have evaluated the 72-hour revisits. This study estimates the rate of 72-hour ED revisits and identifies its reasons and predictive factors among adults with chronic diseases. PATIENTS AND METHODS: A hospital-based retrospective study that included 24,206 ED discharges for adults with chronic diseases at the adult ED of King Abdulaziz Medical City, Riyadh between September 13, 2015 and July 29, 2017 was performed. We extracted data on demographic information, reasons for ED visits/revisits, health insurance coverage, weekend ED arrival, and mortality. RESULTS: A sample of 24,206 ED discharges for 19,697 adults with at least one chronic disease was included in the analysis. The rate of 72-hour revisits in this study population was high: 3,144/24,206 (13%) had the first revisit and 319/3,144 (10.1%) had the second ED revisit within 72 hours. Diseases of the circulatory (19%) and genitourinary (15.8%) systems were the major reasons for the first ED revisit. The adjusted relative rate (aRR) of 72-hour ED revisits was higher in adults with chronic diseases and aged ≥60 years (aRR=1.360, 95% CI: 1.41-1.83; P=0.001), patients of female gender (aRR=1.24, 95% CI: 1.09-1.41; P=0.001), patients with health insurance coverage (aRR=4.23, 95% CI: 2.60-6.90; P=0.001), patients arriving to ED on a weekend (aRR=2.13, 95% CI: 1.03-4.41; P=0.041), and new patients (aRR=1.47, 95% CI: 1.25-1.73; P=0.001). CONCLUSION: The rate of 72-hour revisits is high among adults with chronic diseases. Advancing age, female gender, health insurance coverage, weekend ED arrival, and new patients are the important predictive factors of the high rate of 72-hour revisits. Continuous quality assessment and monitoring of factors related to patients are needed to reduce the frequency of early ED revisits after discharge.

Emergency department 72-hour revisits among children with chronic diseases: a Saudi Arabian study.

BACKGROUND: Emergency Department (ED) revisits have often been used as an indicator of medical care quality. This study aimed to quantify the frequency of ED revisits within 72 h of discharge and identify its factors among children with chronic diseases. METHODS: We designed a retrospective cohort study of children with at least one chronic disease who were also under 18 years of age and had attended and were discharged from the ED at King Abdullah Specialist Children's Hospital (KASCH-RD), Riyadh, Saudi Arabia between April 19, 2015 and July 29, 2017. The outcome measure was the frequency of ED revisits during a period of 72 h after discharge. RESULTS: The study included 11,057 ED discharges of children with at least one chronic disease. Their revisit rate was 1211 (11%), with 83 (6.9%) having had a second ED revisit within 72 h of ED discharge. According to ICD-10 codes, the most common causes of ED revisits were respiratory, digestive, genitourinary, symptoms, and external causes. Factors of frequent ED revisits within 72 h were young age, institutional health insurance coverage, year of new health information system (2015), external causes, and genitourinary. CONCLUSION: The rate of 72-h ED revisits after discharge of children with chronic diseases treated at KASCH-RD was relatively high, and was associated with young age, institutional health insurance coverage, year of a new health information system implementation, and external causes of ED visit. These study findings amplify the need for intervention to reduce the rate of early ED revisits among children with chronic diseases.

Development of a risk-prediction model for Middle East respiratory syndrome coronavirus infection in dialysis patients.

Introduction The Middle East respiratory syndrome coronavirus (MERS-CoV) infection can cause transmission clusters and high mortality in hemodialysis facilities. We attempted to develop a risk-prediction model to assess the early risk of MERS-CoV infection in dialysis patients. Methods This two-center retrospective cohort study included 104 dialysis patients who were suspected of MERS-CoV infection and diagnosed with rRT-PCR between September 2012 and June 2016 at King Fahd General Hospital in Jeddah and King Abdulaziz Medical City in Riyadh. We retrieved data on demographic, clinical, and radiological findings, and laboratory indices of each patient. Findings A risk-prediction model to assess early risk for MERS-CoV in dialysis patients has been developed. Independent predictors of MERS-CoV infection were identified, including chest pain (OR = 24.194; P = 0.011), leukopenia (OR = 6.080; P = 0.049), and elevated aspartate aminotransferase (AST) (OR = 11.179; P = 0.013). The adequacy of this prediction model was good (P = 0.728), with a high predictive utility (area under curve [AUC] = 76.99%; 95% CI: 67.05% to 86.38%). The prediction of the model had optimism-corrected bootstrap resampling AUC of 71.79%. The Youden index yielded a value of 0.439 or greater as the best cut-off for high risk of MERS infection. Discussion This risk-prediction model in dialysis patients appears to depend markedly on chest pain, leukopenia, and elevated AST. The model accurately predicts the high risk of MERS-CoV infection in dialysis patients. This could be clinically useful in applying timely intervention and control measures to prevent clusters of infections in dialysis facilities or other health care settings. The predictive utility of the model warrants further validation in external samples and prospective studies.

Early identification of pneumonia patients at increased risk of Middle East respiratory syndrome coronavirus infection in Saudi Arabia.

BACKGROUND: The rapid and accurate identification of individuals who are at high risk of Middle East respiratory syndrome coronavirus (MERS-CoV) infection remains a major challenge for the medical and scientific communities. The aim of this study was to develop and validate a risk prediction model for the screening of suspected cases of MERS-CoV infection in patients who have developed pneumonia. METHODS: A two-center, retrospective case-control study was performed. A total of 360 patients with confirmed pneumonia who were evaluated for MERS-CoV infection by real-time reverse transcription polymerase chain reaction (rRT-PCR) between September 1, 2012 and June 1, 2016 at King Abdulaziz Medical City in Riyadh and King Fahad General Hospital in Jeddah, were included. According to the rRT-PCR results, 135 patients were positive for MERS-CoV and 225 were negative. Demographic characteristics, clinical presentations, and radiological and laboratory findings were collected for each subject. RESULTS: A risk prediction model to identify pneumonia patients at increased risk of MERS-CoV was developed. The model included male sex, contact with a sick patient or camel, diabetes, severe illness, low white blood cell (WBC) count, low alanine aminotransferase (ALT), and high aspartate aminotransferase (AST). The model performed well in predicting MERS-CoV infection (area under the receiver operating characteristics curves (AUC) 0.8162), on internal validation (AUC 0.8037), and on a goodness-of-fit test (p=0.592). The risk prediction model, which produced an optimal probability cut-off of 0.33, had a sensitivity of 0.716 and specificity of 0.783. CONCLUSIONS: This study provides a simple, practical, and valid algorithm to identify pneumonia patients at increased risk of MERS-CoV infection. This risk prediction model could be useful for the early identification of patients at the highest risk of MERS-CoV infection. Further validation of the prediction model on a large prospective cohort of representative patients with pneumonia is necessary.