Saudi Health System and Health Security Structure: A Scope Review Study Addressing the National Need for Governing the Health Security.

Health security has gained significant attention at the national and global levels, "security" is not a simple term; instead, it is "essentially contested" - that is, it induces debates about what it means and how to use it. This study aimed to define three terms frequently used in health security discussions. These terms are national health security, Global Health Security, and public health. The research method was a scoping review performed in three stages. The first stage was electronic searching based on selection criteria among multiple sources at various time points during the year 2023. These sources included online literature searches, websites of non-governmental organizations (NGOs), and other governmental health agencies. The second stage involved determining the relevance of the selected papers to the study's objectives; the selected papers had moderate to high relevance to the study's objectives. The third stage was to evaluate the methodological quality of a study; we selected peer-reviewed published papers and websites recognized as trustworthy sources of information. The search yielded 143 articles; five met the inclusion criteria and were subjected to the definition of health security. Despite proposed definitions, agreement has yet to be reached on the content and scope of health security. Another main finding is that health security requires more state and international collaboration efforts to reach Global Health Security. To the best of our knowledge, no known government body or organization is responsible for governing health security in Saudi Arabia. However, the current study presents a definition of health security and differentiates it from the public health approach, in addition to emphasizing the importance of governing the related health sectors within each country in order to improve health security and have a positive impact on overall Global Health Security.

Vancomycin-Induced Fever and Neutropenia in an Immunocompetent Patient With Complicated Community-Acquired Pneumonia.

Drug-induced fever can be caused by many medications through several mechanisms. One of the most common mechanisms is an immunologic reaction mediated by drug-induced antibodies. Herein, we report the case of a rare adverse reaction with vancomycin. A six-year-old girl being treated for necrotizing pneumonia with vancomycin developed mild neutropenia, skin rash, and fever two weeks into her therapy. These resolved after stopping vancomycin, with noted reversal of neutropenia and leukopenia. Upon rechallenging the patient with vancomycin, she developed a fever in less than 24 h from the administration. Vancomycin-induced fever was made as a diagnosis of exclusion after all other possible causes were ruled out.

Defining consensus opinion to develop randomised controlled trials in rare diseases using Bayesian design: An example of a proposed trial of adalimumab versus pamidronate for children with CNO/CRMO.

INTRODUCTION: Chronic nonbacterial osteomyelitis (CNO) is a rare autoinflammatory bone disorder primarily affecting children and adolescents. It can lead to chronic pain, bony deformities and fractures. The pathophysiology of CNO is incompletely understood. Scientific evidence suggests dysregulated expression of pro- and anti-inflammatory cytokines to be centrally involved. Currently, treatment is largely based on retrospective observational studies and expert opinion. Treatment usually includes nonsteroidal anti-inflammatory drugs and/or glucocorticoids, followed by a range of drugs in unresponsive cases. While randomised clinical trials are lacking, retrospective and prospective non-controlled studies suggest effectiveness of TNF inhibitors and bisphosphonates. The objective of the Bayesian consensus meeting was to quantify prior expert opinion. METHODS: Twelve international CNO experts were randomly chosen to be invited to a Bayesian prior elicitation meeting. RESULTS: Results showed that a typical new patient treated with pamidronate would have an 84% chance of improvement in their pain score relative to baseline at 26 weeks and an 83% chance on adalimumab. Experts thought there was a 50% chance that a new typical patient would record a pain score of 28mm (pamidronate) to 30mm (adalimumab) or better at 26 weeks. There was a modest trend in prior opinion to indicate an advantage of pamidronate vs adalimumab, with a 68% prior chance that pamidronate is superior to adalimumab by some margin. However, it is clear that there is considerable uncertainty about the precise relative merits of the two treatments. CONCLUSIONS: The rarity of CNO leads to challenges in conducting randomised controlled trials with sufficient power to provide a definitive outcome. We address this using a Bayesian design, and here describe the process and outcome of the elicitation exercise to establish expert prior opinion. This opinion will be tested in the planned prospective CNO study. The process for establishing expert consensus opinion in CNO will be helpful for developing studies in other rare paediatric diseases.

Association Between Low-Molecular-Weight Heparin and Risk of Bleeding Among Hemodialysis Patients: A Retrospective Cohort Study.

BACKGROUND: Low-molecular-weight heparins (LMWH) replaced unfractionated heparin (UFH) in multiple indications. Although LMWH efficacy in hemodialysis was demonstrated through multiple studies, their safety remains controversial. The potential bioaccumulation in patients undergoing chronic hemodialysis raised the question of bleeding risk among this population. OBJECTIVE: The aim of this study was to evaluate bleeding risk among patients with chronic hemodialysis receiving LMWH or UFH for the extracorporeal circuit anticoagulation. DESIGN: We conducted a retrospective cohort study on data extracted from the Régie de l'assurance maladie du Québec (RAMQ) and Med-Echo databases from January 2007 to March 2013. SETTING: Twenty-one hemodialysis centers in the province of Québec, Canada. PATIENTS: Chronic hemodialysis patients. MEASUREMENTS: Bleeding risk evaluated by proportional Cox model for time-dependent exposure using demographics, comorbidities, and drug use as covariates. METHODS: Minor, major, and total bleeding events identified using International Classification of Diseases, Ninth Revision (ICD-9)/International Classification of Diseases, Tenth Revision (ICD-10) codes in the RAMQ and Med-Echo databases. Exposure status to LMWH or UFH was collected through surveys at the facility level. RESULTS: We identified 5322 prevalent and incident patients with chronic hemodialysis. The incidence rate for minor, major, and total bleeding was 9.45 events/1000 patient-year (95% confidence interval [CI]: 7.61-11.03), 24.18 events/1000 patient-year (95% CI: 21.52-27.08), and 32.88 events/1000 patient-year (95% CI: 29.75-36.26), respectively. We found similar risks of minor adjusted hazard ratio (HR: 1.04; 95% CI: 0.68-1.61), major (HR: 0.83; 95% CI: 0.63-1.10), and total bleeding (HR: 0.90; 95% CI: 0.72-1.14) when comparing LMWH with UFH. LIMITATIONS: Potential misclassification of patients' exposure status and possible underestimation of minor bleeding risk. CONCLUSION: LMWH was not associated with a higher minor, major, or total bleeding risk. LMWH did not increase the risk of bleeding compared with UFH for the extracorporeal circuit anticoagulation in hemodialysis. The convenience of use and predictable effect made LMWH a suitable alternative to UFH in hemodialysis.

CONTEXTE: Les héparines de faible poids moléculaire (HFPM) ont remplacé les héparines non fractionnées (HNF) dans de multiples indications. Quoique l'efficacité des HFPM en hémodialyse ait été démontrée par un grand nombre d'études, leur innocuité demeure controversée; la possible bioaccumulation des HFPM chez les patients en hémodialyse chronique soulève le risque d'hémorragie au sein de cette population. OBJECTIF DE L'ÉTUDE: Cette étude visait à évaluer le risque d'hémorragie dans une cohorte de patients en hémodialyse chronique et traités par HFPM ou HNF comme anticoagulant pour le circuit extracorporel. TYPE D'ÉTUDE: Nous avons mené une étude de cohorte rétrospective sur les données de janvier 2007 à mars 2013, extraites des bases de données de la RAMQ et de Med-Echo. CADRE: Les données proviennent de 21 centres d'hémodialyse de la province de Québec (Canada). SUJETS: Patients en hémodialyse chronique. MESURES: Le risque d'hémorragie a été évalué par un modèle proportionnel de Cox pour l'exposition en fonction du temps et avec les covariables suivantes : données démographiques, comorbidités existantes et usage de médicaments. MÉTHODOLOGIE: Les épisodes d'hémorragie mineure, majeure et totale ont été colligés à l'aide des codes de la CIM-9 et de la CIM-10 dans les bases de données de la RAMQ et de Med-Echo. Des sondages menés dans les établissements ont permis de déterminer l'exposition aux HFPM ou aux HNF. RÉSULTATS: Nous avons retenu un total de 5 322 cas incidents et prévalents de patients en hémodialyse chronique pour l'étude. Les taux d'incidence pour les hémorragies mineures, majeures et totales étaient de 9,45 événements par 1 000 années-patients (IC 95 % : 7,61-11,03), de 24,18 événements par 1 000 années-patients (IC 95 % : 21,52-27,08) et de 32,88 événements par 1 000 années-patients (IC 95 % : 29,75-36,26) respectivement. Nous avons observé un risque comparable d'hémorragie mineure (rapport de risque corrigé : 1,04; IC 95 % : 0,68-1,61), majeure (rapport de risque corrigé : 0,83; IC 95 % : 0,63-1,10) et totale (rapport de risque corrigé : 0,90; IC 95 % : 0,72-1,14) lorsque nous avons comparé les HFPM aux HNF. LIMITES: Nos résultats sont limités par les probables erreurs dans le classement de l'exposition des patients aux héparines, de même que par une possible sous-évaluation des risques d'hémorragies mineures. CONCLUSION: Les HFPM n'ont pas été associées à un risque accru d'hémorragies mineures, majeures ou totales. De plus, lorsqu'elles ont été utilisées comme anticoagulant du circuit extracorporel en hémodialyse, les HFPM n'ont pas augmenté le risque d'hémorragie par rapport aux HNF. Ainsi, la commodité d'utilisation et l'effet prévisible des HFPM en font une solution de remplacement adéquate aux HNF en hémodialyse.

Intimate Partner Violence, Depression, and Child Growth and Development.

BACKGROUND: Evidence on the relationship between maternal depression and exposure to intimate partner violence (IPV) with child physical growth and development is equivocal. Our aim in the current study is to examine these relationships among women and their children in Tanzania. METHODS: The Bayley Scales of Infant Development and anthropometric measures were used to assess children 18 to 36 months of age (n = 1031). Maternal exposure to IPV and depression were assessed using the Tanzania Demographic and Health Survey questionnaire and the Patient Health Questionnaire-9, respectively. We used linear regression models to calculate standardized mean differences (SMDs) for developmental outcomes and generalized linear models to estimate the associations with nutritional status. RESULTS: Mild depressive symptoms in mothers (Patient Health Questionnaire-9 ≥5) and exposure to physical and sexual IPV were associated with lower SMDs for motor skills (-0.14 [P = .023] and -0.23 [P < .01], respectively), expressive communication (-0.13 [P = .187] and -0.23 [P < .01], respectively), receptive communication (-0.19 [P < .009] and -0.16 [P = .03], respectively), and cognitive development (-0.08 [P = .245] and -0.12 [P = .07], respectively). Exposure to physical and sexual IPV was associated with higher risk for stunting (relative risk = 1.6; P < .001). CONCLUSIONS: This study reveals that maternal depressive symptoms and IPV are associated with adverse child nutritional and developmental outcomes. Further research is needed to develop programs to address IPV and depression among women and enhance the growth and development of their children.

Sun-protective behaviors in patients with cutaneous hyperpigmentation: A cross-sectional study.

BACKGROUND: Disorders of hyperpigmentation are seen commonly in clinical practice. Despite numerous studies investigating sun-protective habits among healthy persons, little is known about these behaviors within patient populations with hyperpigmentation disorders. OBJECTIVE: We sought to examine photo-protective behaviors and their associations in individuals with disorders of hyperpigmentation. METHODS: This cross-sectional study was conducted with 404 adults who complained of cutaneous hyperpigmentation. RESULTS: About 67.5% reported using a product containing sunscreen, and 91% endorsed using one with a sun protection factor of 21 or higher. Among the participants, 48.5% were not sure if their sunscreen provided broad-spectrum protection, and only 7.6% reapplied every 2 hours. The odds of a patient with melasma using sunscreen were 6.7 times the odds of a patient with postinflammatory hyperpigmentation using sunscreen (P < .001). Additional predictors for sunscreen use were female sex (OR = 3.8, P = .0004) and disease duration of ≥1 year (OR = 2.1, P = .003). In a multivariate analysis, the odds ratio of sunscreen use among African Americans compared to whites was 0.31 (P = .008). LIMITATIONS: Limitations included recall bias, question misinterpretation, and reporter bias. CONCLUSION: Patients diagnosed with postinflammatory hyperpigmentation, men, and those with disease duration <1 year reported lower sunscreen usage. These groups might benefit from increased counseling on sun-protective behaviors.

Association of erythropoiesis-stimulating agents and the incidence risk of cancer diagnosis among chronic dialysis patients: a nested case-control study.

BACKGROUND: Erythropoiesis-stimulating agents (ESAs) are the cornerstone of the treatment for anemia in end-stage renal disease (ESRD) patients. Although a correlation has been established between ESAs and increased tumor growth among patients with cancer-related anemia, an association with a higher incidence of cancer among chronic dialysis patients remains relatively unclear. METHODS: We completed a nested case-control study in a cohort of 4574 patients who began chronic dialysis treatment between 1 January 2001 and 31 December 2007 in Quebec, Canada, utilizing dialysis registry and administrative databases exclusively to extract our data. We excluded patients with a prior diagnosis of cancer. Eligible cases were identified by the time of initial cancer diagnosis obtained from either the hospital's discharge or physician billing form. We then randomly selected up to 10 controls for each case. ESA exposure was evaluated between 6 and 9 months prior to the initial cancer diagnosis. The mean weekly exposure was used to categorize ESA usage as either a low dose (<30 µg/week), moderate dose (30-70 µg/week) or high dose (>70 µg/week). We estimated the association between ESAs and the risk of developing cancer using a multivariable conditional logistic regression. RESULTS: We identified 419 cases of cancer and 3895 matched controls during the study period. The use of ESAs was associated with a higher risk of cancer {odds ratio [OR] 1.04 [95% confidence interval (CI) 1.02-1.07]}. Specifically, patients in the high exposure group (>70 µg/week) had an increased risk of developing cancer [OR 1.77 (95% CI 1.18-2.66)] compared with patients in the unexposed group. CONCLUSION: High-dose ESA was associated with an increased incidence risk of new cancer diagnosis among chronic dialysis patients.

Effectiveness of Program Modification Strategies of the Diabetes Prevention Program: A Systematic Review.

PURPOSE: The purpose of this study is to review the effectiveness of commonly used program modifications classified under cultural adaptation and program translational strategies for the Diabetes Prevention Program (DPP) in terms of risk reduction for type 2 diabetes. METHODS: Authors extracted data about weight, body mass index (BMI), and 5 areas of program modification strategies from 28 interventions and analyzed them in SPSS software. Bivariate analyses examined the odds of achieving a significant reduction in outcomes by each modification of the DPP and by presence of a maintenance component, as well as the mean reduction of weight and BMI by more versus fewer modifications and by the presence of a maintenance component. RESULTS: There were no statistically significant differences in achieving a significant reduction in weight or BMI by any type of modification or by the presence of a maintenance component. Programs with fewer modifications reported significantly greater reduction in mean weight at 12 months postintervention and the furthest time point extracted. Programs with a maintenance component achieved significantly greater reduction in mean weight measured at the furthest time point extracted. CONCLUSIONS: The DPP appears to be programmatically robust to a variety of cultural adaptation and translational strategies. Potentially cost-saving modifications do not seem to reduce effectiveness, which should encourage implementation on a broader scale. Program planners should, however, make efforts to include maintenance components because they appear to significantly reduce risk for acquiring type 2 diabetes.

A Grave Outcome of Posterior Reversible Encephalopathy Syndrome in a Patient Receiving Avastin (Bevacizumab) for Metastatic High-Grade Serous Ovarian Cancer.

A 45-year-old female developed neurological symptoms and elevated diastolic blood pressure while on bevacizumab (Avastin) and gemcitabine for recurrent carboplatin-resistant high-grade serous ovarian cancer. A brain MRI diagnosed our patient with posterior reversible encephalopathy syndrome. We are discussing her presenting symptoms in this paper as well as the management and the outcome. We emphasize the importance of keeping this rare but very serious complication in all patients receiving bevacizumab.

Spermatocytic seminoma at the National Institute of Oncology in Morocco.

BACKGROUND: Spermatocytic seminoma (SS) is a distinct testicular germ cell tumor, representing less than 1% of testicular cancers. The clinical features that distinguish ss from classical seminoma are an older age at presentation and a reduced propensity to metastasize. The aim of our work is to underline the epidemiological, clinical, histological, therapeutical and prognostic features of this tumor. FINDINGS: A retrospective analysis of patients referred to the national institute of oncology with seminoma, identified from the institutional tumor registry, between January 1996 and February 2009, was performed. Information reviewed included demographics, clinical, pathological staging, surgical management, adjuvant treatment and last follow-up. We studied four cases of spermatocytic seminoma, which represented 1% of testicular tumor and 6,4% of all seminoma treated at our institution during the study period. Median age at diagnosis was 45 years (range: 42-48). Mean delay before consulting was 9 months and the mean tumor size was 13,75 cm (10-18 cm). No patient had a history of maldescended testis. The main clinical complaint was unilateral testis mass with low progression. Pathology showed that tumors had a polymorphic appearance with small, intermediate and large cells. In all cases, the tumor was limited to the testis. immunohistochemical studies showed that tumors were negative for all the classical antibodies tested (LCA, cytokeratins, PLAP, lymphoid markers, CD117). Thoraco-abdomino-pelvic CT scan and tumor markers (AFP and hCG) were normal. All patients were Stage I. Treatment consisted on an orchidectomy associated with adjuvant radiotherapy in one patient. After a median follow-up of 6 years ranging from 2 to 15 years, we did not note any relapse or metastasis. CONCLUSION: The diagnosis of spermatocytic seminoma must be considered in all patients aged of more than 50 with testicular tumor. With only three cases of metastatic disease confirmed in the literature, this is a subgroup of patients in whom radiotherapy can safely be omitted.

Prosthetic treatment time and satisfaction of edentulous patients treated with conventional or implant-stabilized complete mandibular dentures: a case-control study (part 2).

PURPOSE: The aim of this study was to compare, prospectively, treatment with implant-retained mandibular overdentures versus conventional complete dentures. MATERIALS AND METHODS: Part 2 of this paper reports on the outcome after 7 years of denture use, using additional questionnaires. RESULTS: Patients with implant-stabilized overdentures continued to be more satisfied with their mandibular dentures and their diet than those using conventional complete dentures. About 50% of the implant group who completed the questionnaire had had their dentures remade. The other 50% remained satisfied with their original dentures and were still using them at the 7-year review. The average chairside time spent on them was 467 minutes. CONCLUSIONS: Mandibular overdentures with two endosseous implants permit better function than conventional complete dentures.

Prosthetic treatment time and satisfaction of edentulous patients treated with conventional or implant-supported complete mandibular dentures: a case-control study (part 1).

PURPOSE: The aim of this study was to compare prospective treatment with implant-retained mandibular overdentures (IROs) versus conventional complete dentures (CDs). This paper reports on the study design and 1-year outcomes. Part 2 in this series will report the 7-year outcomes. MATERIALS AND METHODS: Sixty edentulous patients with severely resorbed mandibles, already using a conventional CD, participated. Thirty patients received an IRO and 30 received a conventional CD. The patients were retrospectively matched for age, gender, and social class. The length of each treatment session was recorded. Both groups provided a subjective assessment of their current dentures, and satisfaction with their new dentures was evaluated using questionnaires focusing on denture-related complaints and a general satisfaction scale. RESULTS: Patients with IROs were more satisfied with the performance of their dentures than those using conventional CDs, especially with regard to subjective fit, looseness, and quality of chewing; however, more clinical treatment was required. The mean time taken by the prosthodontist to construct CDs was 268 minutes, compared to 327 minutes for IROs, to the time of the second review appointment after insertion. CONCLUSIONS: Mandibular IROs provided enhanced performance but required more clinical resources.

Midline mandibular deformation during nonmasticatory functional movements in edentulous subjects with dental implants.

PURPOSE: Mandibular deformation during function in patients with implant-supported prostheses is associated with increased strain at the bone-implant interface when dental implants are connected by a relatively rigid superstructure. Whilst there is a body of evidence concerning deformation as measured between the corpora, there are little data on its effects in the midline. This study measured 3 types of midline mandibular deformation during nonmasticatory functional mandibular movements in edentulous subjects with dental implants. MATERIALS AND METHODS: A range of custom displacement transducers was fabricated for 5 edentulous subjects who had been treated with dental implants in the anterior mandible. These transducers were mounted on contralateral implant abutments adjacent to the midline to measure medial convergence, corporal rotation, and anteroposterior shear. Their output was recorded for offline analysis by a personal computer. RESULTS: The values of medial convergence ranged from 15 to 42 microm during opening, from 10 to 21 microm during lateral excursions, and from 18 to 53 microm during protrusion. Corporal rotation varied from 0.05 to 0.11 degrees during opening, from 0.03 to 0.08 degrees during lateral excursions, and from 0.03 to 0.15 degrees during protrusion. Anteroposterior shear varied from 38 to 93 pm during opening, from 28 to 56 microm during lateral excursions, and from 52 to 103 pm during protrusion. DISCUSSION AND CONCLUSIONS: Nonmasticatory physiological mandibular movements cause the jaw to deform about the midline in at least 3 directions. It is important for the clinician to be aware of the phenomenon of mandibular deformation, which should be taken into consideration in the design and monitoring of mandibular prostheses.

The effect of phosphorylcholine-coated materials on the inflammatory response and fibrous capsule formation: in vitro and in vivo observations.

Several experiments were performed to compare the in vitro adhesion of human macrophage and granulocyte inflammatory cells to polyethylene terephthalate substrate and the same coated with a phosphorylcholine (PC)-based polymer. The inclusion of various types of serum at different stages in the assay indicated that protein adsorption and passivation of the surface may be responsible for reducing the number of inflammatory cells adhering to the uncoated polyethylene terephthalate controls. In all of the assays performed there was a statistically significant reduction (p < 0.05; analysis of variance) of the number of inflammatory cells adhering to the PC-coated samples, linked to the ability of these surfaces to resist protein adhesion. Implantations of PC-coated stainless steel and high-density polyethylene USP control samples were made in a rabbit intramuscular model. Histological examination of the number of inflammatory cells present around the implant sites 4 weeks postimplantation showed there were 40% less cells associated with the PC-coated samples compared with control, but this was not statistically significant. Fibrous capsule thickness, however, whereas marginally less at 4 weeks, had almost completely regressed for the PC-coated sample at 13 weeks postimplantation and was statistically thinner (p < 0.01; Mann-Whitney U test) than the high-density polyethylene USP control. These findings support the view that low biointeractions observed for PC-based technology in vitro can result in reduced inflammation and foreign body reaction in vivo.