The risk of tuberculosis infection in Saudi patients receiving adalimumab, etanercept, and tocilizumab therapy.

BACKGROUND: The risk of infection including tuberculosis (TB) infection or reactivation during biological therapy with the current various clinical application is a major concern. This risk may be higher in countries endemic to TB. Our aim of this study is to determine the risk of TB infection in patients receiving 3 biological treatments, Adalimumab, Etanercept and Tocilizumab. METHODS: A retrospective cohort study extending over 2 years follow-up for all patients receiving Adalimumab, Etanercept and Tocilizumab for various clinical indications in a tertiary care center in Saudi Arabia. RESULT: Over the period of 2015-2019, A total of 410 patients received Adalimumab, 271 received Etanercept and 58 patients received Tocilizumab. Rheumatoid arthritis was the most common indication for therapy in all groups and for Adalimumab the most common indication was inflammatory bowel disease, for Etanercept was psoriatic arthritis and for Tocilizumab was juvenile idiopathic arthritis. After a mean follow up period of 36 ± 8.9 months for patients receiving Adalimumab, 21.5 ± 8.4 months for patients receiving Etanercept and 21 ± 2.5 months for patients receiving Tocilizumab there were no reported cases of TB infection in all groups. Only one patient was diagnosed with latent TB 7 months later after starting Adalimumab and tow patients after starting Etanercept. The overall Interferon Gamma Release Assays (IGRA) positivity rate was 9.7%. There was significant association between IGRA positivity rate and patient age. The cutoff age in which IGRA positivity has significantly increased was 53.20 years. CONCLUSION: In our study, patients receiving Etanercept, Adalimumab and Tocilizumab had no increased risk of TB infection. Only 0.3% of patients treated with Adalimumab and 0.9% of patients treated with Etanercept converted to a positive IGRA during therapy.

Disseminated tuberculosis: Clinical presentation, diagnosis, and outcomes in a tertiary-care hospital in Saudi Arabia.

Background: Tuberculosis (TB) is the primary infectious cause of mortality worldwide. Although TB incidence and prevalence are declining, the use of immunosuppressive drugs and the growing prevalence of immunocompromising conditions such as comorbidities, malignancies, and the use of immunosuppressive agents are risk factors for disseminated TB (DTB). This study aims to identify the relevant clinical, laboratory, radiological, and histopathological features of DTB, as well as to assess the typical anatomical distributions and treatment outcomes of patients diagnosed with the disease at King Abdulaziz Medical City (KAMC). Methods: A retrospective chart review was conducted, including all patients diagnosed with miliary or DTB at KAMC with retrievable medical files. Results: The study included 55 patients, of whom 35 (63.6%) were male and the median age was 64 years old. 35 (63.6%) of the infected patients were timely diagnosed and eventually cured from the illness. The most common comorbid conditions were diabetes, chronic kidney disease, and immunocompromising conditions, which were present in 37 (67.2%), 12 (21.8%), and 11 (20%) of the patients, respectively. The most common presenting symptoms were fever and cough, present in 31 (56.3%) and 26 (47.2%) of the patients, respectively, followed by weight loss in 25 (45.4%), night sweats in 15 (27.2%), and shortness of breath in 14 (25.4%). Approximately two-thirds of the patients had pulmonary miliary TB (MTB) (38; 69.1%), followed by TB lymphadenitis (21; 38.2%), central nervous system involvement (13; 23.6%), skeletal involvement (11; 20%), gastrointestinal involvement (5; 9.1%), pleural involvement (3; 5.5%), and urogenital TB (2; 3.6%). The mortality rate was 14 (25.5%) patients. Conclusion: MTB is challenging to diagnose due to nonspecific clinical, laboratory, and imaging findings. Clinicians dealing with patients who are at risk of developing DTB should be aware of the typical presentations and abnormal clinical findings. They should also have a low threshold to initiate specific investigations for the disease, as early diagnosis and effective treatment is critical in reducing morbidity and mortality rates.

Physician Attitude toward Their Attires and Laundering Habit Changes during the COVID-19: A Cross-Sectional Survey in a Tertiary Care Center.

Background Patient safety is of utmost importance and every effort is to be made to reduce the risk of hospital-acquired infection. Contaminated attire is proposed as a mode of hospital infections spread. This study aims to assess the laundering habits, the perception of healthcare workers toward the contamination of their attire, and the effect of coronavirus disease 2019 (COVID-19) pandemic on their cleaning practices in non-operative settings. Methods This is a cross-sectional study conducted using a self-administered questionnaire which was distributed among physicians at King Abdul-Aziz Medical city, Riyadh. The questionnaire queried the physicians about their laundering habits, knowledge toward their attire, and the difference in cleaning practices after the emergence of COVID-19. Results Out of 220 questionnaires distributed, 192 physicians responded. Majority of physicians were male (54%) and were in the 20 to 30 age group. Female gender was significantly associated with the frequency of uniform washing ( p- value < 0.0001) and place of cleaning (home vs. outside home) ( p- value <0.0001). Physicians in intensive care were more likely to take off their uniforms daily before leaving the hospital compared to others ( p- value of 0.018). Most physicians did not prefer to use the hospital laundry system for cleaning their uniforms but consultants were the most to use it. COVID-19 pandemic led to changes in washing habits in 108 physicians (60%). Conclusion Majority of physicians accepted washing their uniforms multiple times per week and their washing habits increased during the COVID-19 pandemic. Female gender and younger physician both were associated with increasing washing habits.

A Clot in Transit: A Cause of Death or a Bystander?

Introduction: The clot in transit is a rare manifestation of thromboembolic disease occurring usually in the setting of PE and frequently associated with poor outcomes. The best therapeutic option is not well established. We describe a series of 35 patients diagnosed with clots in transit including their therapeutic interventions and outcome between the period January 2016 to December 2020. Methods: a retrospective chart review of all patients with an Echocardiogram showing thrombi in the right heart chambers including patients with thrombus in the presence of central lines or other devices. We exclude patients where masses were described as tumors or vegetation and masses in the presence of bacteremia. Results: There were 35 patients with echocardiographic evidence of a thrombus in the right heart chambers. In 12 of those patients, the thrombus was related to an intracardiac catheter. 37.1% of CT chest was done along with Echocardiogram and showed a concomitant PE in 77%. On echocardiogram, 66% of the thrombi were mobile. RV strain was present in 17% while abnormal RVSP (>30 mmHg) was present in 74%. Respiratory support was required in 37.1% and only 17% required inotropic support. There was a total or partial resolution in 80% those who had repeated echocardiogram after four weeks of therapy. Heparin was started in the majority of patients (74%). Warfarin was the most frequently used follow-up anti-coagulant in 51.4%. The mortality rate was significantly higher in those patients with RVSP >50, UFH group, O2 or inotropic support. 26% of patients died within the first 28 days after the diagnosis, while first 7 days mortality was 6% only. Conclusion: a clot in transit in our study was not directly associated with poor outcomes in the first week of therapy, UFH is still the most frequently used initial method to treat clots in transit. However, only 26% had a total resolution of clot within 4 weeks of treatment.

Recurrent Urinary Tract Infection in Adult Patients, Risk Factors, and Efficacy of Low Dose Prophylactic Antibiotics Therapy.

BACKGROUND: Recurrent urinary tract infection (UTI) occurs in sizable percentages of patients after a single episode and is a frequent cause of primary healthcare visits and hospital admissions, accounting for up to one quarter of emergency department visits. We aim to describe the pattern of continuous antibiotic prophylaxis prescription for recurrent urinary tract infections, in what group of adult patients they are prescribed and their efficacy. METHODS: A retrospective chart review of all adult patients diagnosed with single and recurrent symptomatic urinary tract infection in the period of January 2016 to December 2018. RESULTS: A total of 250 patients with a single UTI episode and 227 patients with recurrent UTI episodes were included. Risk factors for recurrent UTI included diabetes mellitus, chronic renal disease, and use of immunosuppressive drugs, renal transplant, any form of urinary tract catheterization, immobilization and neurogenic bladder. E. coli infections were the most prevalent organism in patients with UTI episodes. Prophylactic antibiotics were given to 55% of patients with UTIs, Nitrofurantoin, Bactrim or amoxicillin clavulanic acid. Post renal transplant is the most frequent reason to prophylaxis antibiotics (44%). Bactrim was more prescribed in younger patients (P < 0.001), in post-renal transplantation (P < 0.001) and after urological procedures (P < 0.001), while Nitrofurantoin was more prescribed in immobilized patients (P = 0.002) and in patients with neurogenic bladder (P < 0.001). Patients who received continuous prophylactic antibiotics experienced significantly less episodes of urinary tract infections (P < 0.001), emergency room visits and hospital admissions due to urinary tract infections (P < 0.001). CONCLUSION: Despite being effective in reducing recurrent urinary tract infection rate, emergency room visits and hospital admissions due to UTI, continuous antibiotic prophylaxis was only used in 55% of patients with recurrent infections. Trimethoprim/sulfamethoxazole was the most frequently used prophylactic antibiotic. Urology and gynecological referral were infrequently requested as part of the evaluation process for patients with recurrent UTI. There was a lack of use of other interventions such as topical estrogen in postmenopausal women and documentation of education on non-pharmacological methods to decrease urinary tract infections.

Adequacy of physician clinical rounds and nursing care elements for non-COVID-19 infected patients admitted during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic created many challenges for healthcare systems. Frontline workers and especially healthcare professionals were the most severely affected through increased working hours, burnout and major psychological distress. OBJECTIVES: To evaluate the changes in standard care elements which occurred during the COVID-19 pandemic, specifically the physician clinical rounds and nursing care provided to non-COVID-19 infected patients. DESIGN: Observational retrospective study. SETTINGS: The study was conducted at King Abdulaziz Medical City, Riyadh Saudi Arabia. KAMC is a 1200 bed tertiary care referral academic medical center. PATIENTS (MATERIALS) AND METHODS: We compared the physician clinical rounds and nursing care elements in all admissions due to non-COVID-19 pneumonia and ST elevation myocardial infarction during the lockdown period with similar admissions in a baseline period in the same weeks in the previous pre-lockdown. MAIN OUTCOME MEASURES: To evaluates the changes occurring during the COVID-19 pandemic in terms of the standard care elements, such as the physician rounds and nursing care. SAMPLE SIZE: Total of 113 patients records were analyzed. RESULTS: During the lock down period, a total of 113 patients were admitted to the medical and cardiology wards, (95 patients with pneumonia and 18 patients with ST segment elevation myocardial infarction (STEMI)) compared to 89 patients in the pre lockdown period (74 patients with pneumonia and 15 patients with STEMI). Both groups were similar in age, gender, disposition, length of stay, goal of care planning and outcome. Chronic respiratory disease and Diabetes were more present in patients admitted on the pre lockdown time. Azithromycin was more frequently used as part of the initial antibiotic regimen for pneumonia during the pre-lockdown while doxycycline was significantly more during the lockdown. For the 95 patients admitted in the medical wards during the lockdown, there were a total of 820 physicians' clinical rounds opportunities for senior and junior physicians each. The residents missed 133 (16.2%) and consultant missed 252 (30.7%) of those clinical rounds opportunities. Missed clinical rounds opportunities during the pre-lock down period was higher for residents and consultants at 19.3% (P = 0.429 ) and 36.3% respectively (P = 0.027 ). Similarly, missed clinical rounds opportunities was less during the lockdown period from 35.2% to 25% (p 0.022) and from 38.8% to 30.6% (p = 1 ) for junior staff and consultant cardiology respectively compared to pre lockdown period. For nursing care elements, there was a decrease in missed opportunities in vital signs measurement (p 0.47 and p 0.226), pain assessment (p 0.088 and p 0,366) and skin care (p 0.249 and p 0.576) for patients admitted during the lockdown period in medical and cardiology wards. CONCLUSIONS: Caring for patients admitted for non COVID 19 infection reasons, physicians' clinical rounds did marginally increase compared to pre lockdown period while nurses monitoring for those patients was significantly higher. No difference in mortality was observed for patients admitted pre and during lockdown. The number of missed opportunities to do clinical rounds by physicians remains high during both periods and measures to improve adherence of physicians to performed clinical rounds are needed.

Longevity of Middle East Respiratory Syndrome Coronavirus Antibody Responses in Humans, Saudi Arabia.

Understanding the immune response to Middle East respiratory syndrome coronavirus (MERS-CoV) is crucial for disease prevention and vaccine development. We studied the antibody responses in 48 human MERS-CoV infection survivors who had variable disease severity in Saudi Arabia. MERS-CoV-specific neutralizing antibodies were detected for 6 years postinfection.

A Case of Seronegative Pediatric Neurobrucellosis Presenting With Ataxia.

Neurobrucellosis is an uncommon and dangerous complication of brucellosis. Meningitis is the most common presentation of neurobrucellosis, but it may present in a wide range of clinical manifestations such as myelitis, brain abscess, radiculopathy, and cranial nerve involvement. It tends to present insidiously with symptoms appearing gradually. Acute presentation of neurobrucellosis is very uncommon. Here, we report a case of a female child who presented with an acute onset of ataxia and slurred speech with positive cerebrospinal fluid (CSF) and neuroimaging findings for neurobrucellosis. In endemic countries such as Saudi Arabia, neurobrucellosis should be considered as a differential diagnosis for patients presenting with unexplained neurological symptoms.

Outcome of COVID19 in Patients With Osteogenesis Imperfecta: A Retrospective Multicenter Study in Saudi Arabia.

Background: Although genetic diseases are rare, children with such conditions who get infected with COVID-19 tend to have a severe illness requiring hospitalization. Osteogenesis imperfecta (OI) is a rare genetic disorder of collagen resulting in fractures and skeletal deformities. Kyphoscoliosis, restrictive lung disease, and pneumonia worsen the prognosis of patients with OI. The use of bisphosphonate improves bone mineral density (BMD) and reduces fractures in OI. There is no literature describing the impact of COVID-19 in patients with OI. Methodology: A retrospective multi-center study was performed in three hospitals in Jeddah and Riyadh, Saudi Arabia, from March 1st, 2020, until August 31st, 2021, aiming to evaluate the outcome of COVID-19 in patients with OI. Demographics, vaccination status, underlying kyphoscoliosis, functional status, use of bisphosphonate, BMD, and COVID-19 severity, and course were recorded for all patients. Results: Twelve cases of confirmed COVID-19 were identified among 146 patients with OI. 9 (75%) of patients were less than 18 years, 6 (50%) were male, 5 (41%) had kyphoscoliosis, and 5 (41%) were wheelchair-bound. 6 (50%) received bisphosphonate, and 7(58%) had normal BMD. All patients had mild disease and did not require hospitalization. None of OI the patients with COVID-19 were fully vaccinated before the infection, and some were ineligible for vaccination. Conclusion: Patients with OI and COVID-19 in our study recovered without complications, unlike patients with other genetic diseases. Young age and mild illness contributed to the favorable outcome. Half of the patients received bisphosphonate and had normal BMD.

Knowledge and Confidence of Final-Year Medical Students Regarding Critical Care Core-Concepts, a Comparison between Problem-Based Learning and a Traditional Curriculum.

BACKGROUND: Medical undergraduates should be prepared to recognize life threating critical conditions. Undergraduate medical curriculum development to incorporate more critical care education is an essential requirement. Problem Based Learning curriculum has a potential advantage in providing more focused critical care education to medical undergraduate. OBJECTIVES: We aimed to evaluate the final year medical students' knowledge and confidence in key critical care concepts in Problem Based Learning (PBL) curriculum compared to those in Traditional (Lecture) Based Learning curriculum. We also aimed to evaluate undergraduate's level of satisfaction with the exposure to critical care education during medical education and training. MATERIALS AND METHODS: This is a cross-sectional anonymous self-administered survey questionnaire completed by two groups of final-year medical students (PBL and TBL) from three Saudi medical schools to assess the degree of undergraduate exposure to critical care and their knowledge of key critical care assessment parameters. RESULTS: The responses of 279 final year medical students was analyzed (70% response rate). The majority (53%) was male and the mean age 23.9 ± 1.4 years. Only 13% of students felt confident to manage hypovolemic shock and 15% could recognize the signs of a threatened airway. One third of the students (29%) correctly identified the critical level of lactic acid in shock and less than 2% of the sample responded correctly to all the questions related to the formal assessment of critically ill patients. Lectures were the main source of information in acute care. More than two-thirds (46%) of the sample indicated that they received tuition in critical care, however the total duration spent in a critical care rotation or teaching was 1 day or less. The medical students, who completed their training with a Problem-Based Learning curriculum, had a higher knowledge base and were more confident in many critical care concepts. Only 6.5% choose critical care as their likely future career. CONCLUSION: Medical undergraduates in PBL have an overall better knowledge on key concepts and assessment tools applicable to evaluating and managing critically ill patients compared to students in TBL. However the gap in knowledge and confidence in assessing ill patients in both groups is evident. Critical care was not chosen as a preferred future career in all surveyed students. There is a need for institutional support and endorsement of undergraduate critical care exposure and education in Saudi Universities both to better prepare medical students for their imminent post-graduates exposure to ill patients and to help in closing the gap in critical care physicians through promoting the specialty.

T-cell responses to MERS coronavirus infection in people with occupational exposure to dromedary camels in Nigeria: an observational cohort study.

BACKGROUND: Middle East respiratory syndrome (MERS) remains of global public health concern. Dromedary camels are the source of zoonotic infection. Over 70% of MERS coronavirus (MERS-CoV)-infected dromedaries are found in Africa but no zoonotic disease has been reported in Africa. We aimed to understand whether individuals with exposure to dromedaries in Africa had been infected by MERS-CoV. METHODS: Workers slaughtering dromedaries in an abattoir in Kano, Nigeria, were compared with abattoir workers without direct dromedary contact, non-abattoir workers from Kano, and controls from Guangzhou, China. Exposure to dromedaries was ascertained using a questionnaire. Serum and peripheral blood mononuclear cells (PBMCs) were tested for MERS-CoV specific neutralising antibody and T-cell responses. FINDINGS: None of the participants from Nigeria or Guangdong were MERS-CoV seropositive. 18 (30%) of 61 abattoir workers with exposure to dromedaries, but none of 20 abattoir workers without exposure (p=0·0042), ten non-abattoir workers or 24 controls from Guangzhou (p=0·0002) had evidence of MERS-CoV-specific CD4+ or CD8+ T cells in PBMC. T-cell responses to other endemic human coronaviruses (229E, OC43, HKU-1, and NL-63) were observed in all groups with no association with dromedary exposure. Drinking both unpasteurised camel milk and camel urine was significantly and negatively associated with T-cell positivity (odds ratio 0·07, 95% CI 0·01-0·54). INTERPRETATION: Zoonotic infection of dromedary-exposed individuals is taking place in Nigeria and suggests that the extent of MERS-CoV infections in Africa is underestimated. MERS-CoV could therefore adapt to human transmission in Africa rather than the Arabian Peninsula, where attention is currently focused. FUNDING: The National Science and Technology Major Project, National Institutes of Health.

Brucellosis in Saudi Children: Presentation, Complications, and Treatment Outcome.

Background Brucellosis, an endemic disease in Saudi Arabia, has an infection rate of 70 per 100,000 people, with a varying morbidity rate in different parts of the country. The aim of this study was to assess the epidemiological and clinical features, laboratory findings, treatment modalities, complications, and outcomes in children with brucellosis. Materials and methods The medical records of 153 patients attending King Abdullah Specialist Children's Hospital in Riyadh, Saudi Arabia, from January 2015 to January 2019 were reviewed retrospectively. Demographic data, laboratory test results, serum agglutination test titer, and the results of the blood cultures were obtained. The diagnosis of brucellosis was based on compatible signs and symptoms with a positive serology titer of ≥1:160 or a blood culture positive for Brucella species. Results The majority of the sample (69.6%, n=107) were males, with a mean age of 7.75 ± 3.28 years. Ingestion of unpasteurized camel dairy products was the most frequent transmission risk factor. The most prevalent presenting symptoms were constitutional and musculoskeletal symptoms. Six patients (3.9%) had complicated brucellosis, with neurobrucellosis diagnosed in three cases. Hospitalization for brucellosis was required in 15% of the patients. The majority (99.35%, n=152) of the patients had a serum agglutination test (SAT) titer of ≥1:160. A blood culture was positive in 52 (34%) of the 111 patients tested. The most frequently prescribed regimen was rifampicin + co-trimoxazole in 81 (52.9%) patients. Relapse occurred in a small proportion (4.6%, n=7), and the majority (95.4%, n=146) had a complete remission. Conclusions The main route of transmission was the ingestion of unpasteurized dairy products. Brucellosis had a wide range of clinical presentation, involving multiple organ systems. Neurobrucellosis was the most frequent complication. The SAT was the most useful and reliable test for the diagnosis of brucellosis. Most patients were successfully treated with rifampicin and co-trimoxazole for six weeks.

Patient reluctance to accept Do Not Resuscitate order: impact on clinical care.

BACKGROUND: A Do Not Resuscitate (DNR) order should only impede the performance of cardiopulmonary resuscitation in case of cardiac or respiratory arrest; it should not interfere with any other treatment decisions. AIMS: To study the impact of DNR order placement on daily clinical care of patients. METHODS: This was a retrospective cohort study of 72 patients in a tertiary care centre in Saudi Arabia. Daily clinical care measures were collected for 2 weeks prior and 2 weeks after DNR order placement and included vital signs, nursing care, comfort measures, documentation, visits by senior and junior physicians, and tests completed. RESULTS: Malignancy was the most common diagnostic category (43.1%). There was a significant reduction in vital signs documentation, tests completed, documentation, and visits by physicians after DNR orders, with no change in nursing care and comfort measures. No differences were seen for place of DNR order (intensive care unit vs medical ward), category of disease, or sex, but there were differences for documentation (more in females) and vital signs (more in males). More vital signs were documented and more tests were done in patients who survived compared to those who died. Regression analysis showed that the frequency of post-DNR order vital signs measurements and investigations done was not related to sex, age, diagnosis, time from admission to DNR order, or location of patients. Time to death was only related to sex and post-DNR order summary documentation. CONCLUSIONS: Placement of DNR orders significantly reduced vital signs measurements, investigations done, documentation and visits by physicians but not nursing care and comfort measures.

Occurrence of vancomycin MIC creep in methicillin resistant isolates in Saudi Arabia.

BACKGROUND: "MIC creep" is a phenomenon that describes an increase of an organism MICs over time and have been reported from different parts of the world. High MIC in MRSA has been theoretically liked to treatment failure and may be a precursor to hVISA and VISA. This study was conducted to assess presence of vancomycin minimum inhibitory concentration (MIC) creeps among clinical isolates of methicillin-resistant Staphylococcus aureus (MRSA) in Saudi Arabia. METHODS: Minimum inhibitory concentration (MIC) of vancomycin by E test of all MRSA isolates of from 2013 to 2018 were reviewed. RESULTS: Of the 736 isolates evaluated, no isolates with MIC above 2 were found. Majority of MRSA isolates were susceptible to vancomycin with MIC less than 1. There was a significant increase in both Arithmetic and geometric mean MIC for vancomycin during the first three years which progressively declined in the next three years. CONCLUSIONS: Although most of MRSA isolated remained very susceptible to vancomycin there was evidence of dynamic vancomycin MIC creep over time.

Top Ethical Issues Concerning Healthcare Providers Working in Saudi Arabia.

BACKGROUND: Healthcare providers working in Saudi Arabia come from various nationalities, cultures, and training backgrounds. This study aimed to assess the perceptions of healthcare providers working in Riyadh hospitals about ethical dilemmas and solutions. METHODS: This is a cross-sectional study among physicians working in Riyadh's private and governmental hospitals between June and December 2017. The study collected information on demographics, knowledge about medical ethics, the sources of such knowledge, and common ethical issues in general and the top ethical issues and dilemmas encountered in their daily practice. RESULTS: A total of 455 physicians from government and private hospitals were enrolled in the study. The mean age of the participants was 34.29 ± 10.5 years, females were 29.7% and mean years of practice was 13.0 ± 11.5. The top ethical issues identified by the participants were "disagreement with the patients' relatives about treatment" (91%), patient disagreement with decisions made by professionals (84%), treating the incompetent patient (79%), conflict with administration policy and procedures (77%), scarcity of resources (72%), and making decision about do-not-resuscitate or life-sustaining treatment (68%). There were significant differences in dealing with ethical issues in relation to gender, confidence about ethical knowledge, nationality, seniority, training site, and private or government hospitals academic and nonacademic. CONCLUSION: Healthcare providers in Riyadh hospitals face multiple ethical challenges. In addition to improvement in ethics knowledge through educational program among healthcare professional, there is a valid need for healthcare professionals and other sectors within society to engage in serious and continuous dialogue to address these issues and propose recommendations.

Attitudes and behaviours of physicians towards the relationship with the pharmaceutical industry in Saudi Arabia.

BACKGROUND: The relationship and interactions between physicians and the pharmaceutical industry can affect patient care. A physician's practice can be influenced by this relationship. It is believed that these interactions are common among doctors in Saudi Arabia. AIMS: This study was undertaken to assess the frequency of such relationships and physicians' attitudes and behaviours toward them. METHODS: This was a cross-sectional questionnaire survey completed by practicing physicians at four Saudi government and private tertiary care centres in Riyadh, Saudi Arabia. The questionnaire addressed the frequency of meetings with representatives of pharmaceutical companies (PRs) and of receiving gifts and considered the physicians' attitudes and behaviours towards PRs. RESULTS: A total of 300 completed questionnaires were obtained. Among the physicians surveyed, 223 (74.3%) met PRs one to three times per month. Up to 191 (64%) of physicians admitted receiving gifts. More than two thirds of physicians-192 (63%) have been invited to activities sponsored by pharmaceutical companies. Among the physicians, 239 (80%) agreed that PRs use promotional techniques in their approach and 251 (84%) of them stressed the need for expert physicians to attend presentations by PRs to correct the facts. CONCLUSION: The frequent meetings between physicians and PRs and the use of promotional techniques by PRs are concerning. Future studies should assess the impact of this involvement on medical practice and drugs prescription in Saudi Arabia.

Advance directive preferences of patients with chronic and terminal illness towards end of life decisions: a sample from Saudi Arabia.

BACKGROUND: Advance directives towards end of life decisions are seldom used among Arabs. AIMS: This study aimed at investigating advance care preferences among a sample of Arab patients. METHOD: This cross-sectional study was undertaken over the period March 2012-March 2013 on a sample of 300 patients with chronic illness in King Fahad National Guard Hospital, Riyadh, a major tertiary care hospital in Saudi Arabia. RESULTS: Mean age of patients in the study was 48.7 years (standard deviation 16.4). There were 104 patients on haemodialysis, 73 with advanced malignancy, 81 with chronic liver disease and 35 with chronic respiratory disease. More than 80% of the respondents felt that the physician should make the decision about cardiopulmonary resuscitation. Over 60% wished to remain at home when their condition deteriorated to impending death. There were no significant correlations between the patients' end of life decision preferences and religiosity, quality of life, disease duration, or other demographic characteristics. CONCLUSION: Despite a significant lack of knowledge among our participants regarding resuscitation, a majority of patients with chronic illness were willing to discuss the options and were capable of making advance directive plans regarding their health status.

MERS-CoV as an emerging respiratory illness: A review of prevention methods.

INTRODUCTION: Middle East Respiratory Coronavirus Virus (MERS-CoV) first emerged from Saudi Arabia in 2012 and has since been recognized as a significant human respiratory pathogen on a global level. METHODS: In this narrative review, we focus on the prevention of MERS-CoV. We searched PubMed, Embase, Cochrane, Scopus, and Google Scholar, using the following terms: 'MERS', 'MERS-CoV', 'Middle East respiratory syndrome' in combination with 'prevention' or 'infection control'. We also reviewed the references of each article to further include other studies or reports not identified by the search. RESULTS: As of Nov 2019, a total of 2468 laboratory-confirmed cases of MERS-CoV were diagnosed mostly from Middle Eastern regions with a mortality rate of at least 35%. A major outbreak that occurred outside the Middle East (in South Korea) and infections reported from 27 countries. MERS-CoV has gained recognition as a pathogen of global significance. Prevention of MERS-CoV infection is a global public health priority. Healthcare facility transmission and by extension community transmission, the main amplifier of persistent outbreaks, can be prevented through early identification and isolation of infected humans. While MERS-CoV vaccine studies were initially hindered by multiple challenges, recent vaccine development for MERS-CoV is showing promise. CONCLUSIONS: The main factors leading to sustainability of MERS-CoV infection in high risk courtiers is healthcare facility transmission. MERS-CoV transmission in healthcare facility mainly results from laps in infection control measures and late isolation of suspected cases. Preventive measures for MERS-CoV include disease control in camels, prevention of camel to human transmission.

Pattern of Dermatological Disease Encountered in a Hematology Ward: A Retrospective Analysis of Dermatology Consultation in a Hematology Ward in a Tertiary Care Center in Saudi Arabia.

Introduction. Skin manifestations are common in hematology ward patients and can result from infection, malignancy, or chemotherapy. The purpose of this study was to identify the most common dermatological problems encountered in the adult hematology ward at King Abdullah Specialist Children Hospital (KASCH). Methods. This was retrospective chart review of 78 dermatology consultations based on electronic health records for all inpatients in hematology wards at KASCH between January 2016 and December 2017. Data were presented as mean ± SD for continuous variables. Results. During the study period, a total of 1391 inpatients were referred to the dermatology department. A total of 403 (29.0%) referrals were from the internal medicine department and 78 (5.6%) were from the hematology department, six of which were rejected by the dermatology department. Almost all requests for referral were managed on the same or the next day with only two requests after 3 days. There were more female (n = 40; 51.3%) than male patients (n = 38; 48.7%) and the average age ± SD was 40.7 ± 19.8 years. Patients were diagnosed with a diverse range of hematological diseases. A total of 27 (35.1%) patients were diagnosed with acute myeloid leukemia. Overall, 98 differential diagnoses were made by dermatologists with only 26 being confirmed by skin biopsy. Eight (30.8%) patients were diagnosed with graft versus host disease confirmed by skin biopsy. The diagnoses were changed in 12 cases after skin biopsy. Several types of dermatitis were diagnosed in hematology ward patients including stasis dermatitis and contact dermatitis. The source of infection was not specified in most cases and the infection was treated empirically. Conclusion. Various dermatological disorders and cutaneous manifestations are observed in hematology inpatients with morbilliform drug eruption and graft versus host disease being the most common.

Candida Bloodstream Infection: Changing Pattern of Occurrence and Antifungal Susceptibility over 10 Years in a Tertiary Care Saudi Hospital.

BACKGROUND: Candida has emerged as one of the most important pathogens that cause bloodstream infection (BSI).Understanding the current Candida BSI trends, the dominant species causing disease and the mortality associated with this infection are crucial to optimize therapeutic and prophylaxis measures. OBJECTIVES: To study the epidemiology and to evaluate the risk factors, prognostic factors, and mortality associated with candidemia and to compare these findings with previously published studies from Saudi Arabia. DESIGN: A retrospective medical record review. SETTING: Tertiary hospital in Riyadh. PATIENTS AND METHODS: The analysis included all cases of Candida blood stream infection who are >18 years old over the period from 2013 to 2018. Continuous variables were compared using the parametric T-test while categorical variables were compared using the Chi-squared test. MAIN OUTCOME MEASURE: Incidence, resistance, and hospital outcomes in Candida blood stream infection. SAMPLE SIZE: 324 patients. RESULTS: Three hundred and twenty-four episodes of Candida blood stream infections were identified. Median age of patients was 49.7 SD ± 28.1 years, and 53% of patients were males. More than half of the patients had an underlying disease involving the abdomen or laparotomy, 78% had an indwelling intravenous catheter, and 62% had suffered a bacterial infection within 2 weeks prior to candidemia. Candida albicans represents 33% of all isolates with decreasing trend overtime. There was an increase in the number of nonalbicans Candida overtime with Candida tropicalis in the lead (20%). Use of broad spectrum antibiotics (82%), prior ICU admission (60%) and use of central venous catheters (58%) were the most prevalent predisposing factors of candidemia. Azole resistance was variable overtime. Resistance to caspofungin remained very low (1.9%). Fourteen days crude mortality was 37% for ICU patients and 26.7% in non-ICU patients, while hospital crude mortality was 64.4% and 46.7%, respectively. CONCLUSION: There is an increasing trend of nonalbicans Candida blood stream infection. Fluconazole resistance remained low to C. albicans. Most isolates remain susceptible to caspofungin, voriconazole, and amphotericin B. Candida bloodstream infection is associated with high 14-day hospital mortality.