Outcomes associated with cesarean section versus vaginal breech delivery at a university hospital.

OBJECTIVE: To determine whether vaginal breech delivery is associated with increased morbidity in term breech singletons using strict selection criteria. This study encompasses our previous studies (in 1987 and 1995) and extends our experience to 21 years. STUDY DESIGN: Retrospective cohort study from 1980 to 2001 including term, non-anomalous singleton breech deliveries selected by strict criteria. Univariable and multivariable analyses were performed for neonatal and maternal outcomes. RESULTS: Five hundred and eleven women underwent cesarean section and 214 a trial of labor. We found greater overall maternal morbidity in the cesarean section group (odds ratio (OR) 1.89, 95% confidence interval (CI)=1.34-2.65). In the vaginal delivery group, neonates were more likely to have had >1 day of mechanical ventilation (OR 10.0, 95% CI=1.56-63.9). No maternal deaths occurred and no neonatal deaths or seizures occurred. CONCLUSION: Given our findings, offering a trial of vaginal breech delivery to well-counseled strictly selected patients remains an appropriate option.

Evaluation of a pneumonia practice guideline in an interventional trial.

There are few available data to define the medically necessary duration of stay for patients hospitalized with pneumonia. Therefore, we investigated the safety and effectiveness of a practice guideline that provided information about switching patients from parenteral to oral antimicrobials and early hospital discharge. The study was a prospective controlled study with an alternate month design. The practice guideline was studied in 146 "low-risk" pneumonia patients hospitalized during a 22-month period. Medical care consistent with the practice guideline occurred in 64% and 76% of patients during control and intervention periods, respectively (p=0.15). There were no differences in patient outcomes in the control and intervention groups when measured 1 mo after hospital discharge, including hospital readmission rates, health-related quality of life, and patient satisfaction. Explicit and implicit review revealed that 98.6% (95% confidence interval [CI]: 95.1%, 99.8%) of low-risk patients would not have benefited from continued hospitalization after the fourth hospital day. The 30-d survival rate of the low-risk pneumonia patients was 99.3% (95% CI: 96.2%, 100%) and patient outcomes appeared to be favorable compared with previously published values. We conclude that duration of hospital stay was frequently consistent with the practice guideline in both study groups, and patient outcomes remained unchanged. The guideline will require additional testing before it can be recommended for use.

Identification of low-risk hospitalized patients with pneumonia. Implications for early conversion to oral antimicrobial therapy.

PURPOSE: Few available data exist to define either the medically necessary duration of parenteral antimicrobial therapy or length of stay for hospitalized patients with pneumonia. Therefore, we investigated the potential safety and effectiveness of a practice guideline recommending early conversion of low-risk patients with pneumonia from parenteral to oral antimicrobial therapy and early hospital discharge. PATIENTS AND METHODS: The practice guideline was studied retrospectively in 503 hospitalized patients with pneumonia at a teaching community hospital. RESULTS: Thirty-three percent of patients with pneumonia were classified as at low risk for complications and potentially suitable for early conversion to oral antimicrobial therapy according to the guideline. Were the guideline to have been used to guide patient discharge decisions, 619 additional bed-days would have been made available to accommodate incoming patients. A consensus among physician reviewers led to the judgment that quality of care would not have worsened for 98.2 percent of low-risk patients had they been switched to oral antimicrobial therapy on the third hospital day, nor would quality of care have been worsened for 93.4 percent of low-risk patients had they been discharged on the fourth hospital day. CONCLUSION: The practice guideline that we studied has the potential to safely reduce the duration of parenteral antimicrobial therapy and length of hospital stay for selected low-risk patients with pneumonia. The guideline should be studied in a prospective clinical trial.

Haemostatic variables in patients with unstable angina.

To assess the contribution of thrombus formation in the pathogenesis of unstable angina, we employed the recently developed assays of small fragments which reflect the degree of activation of various components of the haemostatic system. Such haemostatic measurements were undertaken in patients with unstable angina (n = 47) from the time of their admission to the coronary care unit (CCU) at 8-h intervals in the first 24 h and then daily for a total of 5 days. The results obtained were compared with healthy control values. Patients exhibited lower ATIII, prolongation of the APTT and TT, but not PT or the reptilase time, which is a consequence of heparinization. There was significant elevation of fibrinogen, factor VIII:C, von Willebrand factor:antigen and von Willebrand factor:ristocetin cofactor throughout the study period. There was also evidence of thrombin generation as indicated by the elevated levels of fibrinopeptide A (FPA) and thrombin-antithrombin complexes. The platelet release proteins, beta-thromboglobulin (BTG) and platelet factor 4 (PF4), were markedly elevated in the first 2 days and dropped gradually thereafter. The fibrinolytic inhibitor, plasminogen activator inhibitor (PAI), levels were elevated throughout. Proteins C and S, plasminogen and alpha 2-antiplasmin remained unchanged. It was concluded that in patients with unstable angina, there is significant activation of the clotting system and inhibition of fibrinolysis which confirms the existence of a tendency towards thrombus formation in patients with unstable angina.

Smoking habits of King Saud University students in Riyadh.

The smoking habits of 2264 students at King Saud University were investigated. Thirty-seven percent of the students smoked, and over a half smoked more than 15 cigarettes per day. Cigarettes were the main form of smoking. Most of the smokers knew about the hazards of smoking through the media and wished to stop smoking. Nonsmokers cited religious consideration and nonsmoking parents as the most important reasons for not smoking. A public health campaign is strongly recommended to reduce the prevalence of smoking.

Non-invasive evaluation of the myopathy of coronary artery disease.

The application of cross-sectional echocardiography to the evaluation of patients with ischaemic heart diseases has been limited to certain specific situations, such as recognition of generalised ventricular dysfunction and regional wall motion abnormalities. Myocardial perfusion scintigraphy using thallium-201 has been used at rest and after exercise to display perfusion defects. Clinical, echocardiographic data and thallium-201 studies of 36 patients with chronic congestive heart failure and coronary artery disease were analysed to confirm the differential diagnosis of the myopathy of coronary artery disease. Thirty patients (85 per cent) had a history of one or more myocardial infarctions, 22 per cent cardiomegaly, 16 per cent mitral insufficiency and 30 per cent anginal pain. Echocardiographic studies showed global hypokinesia in 40 per cent of patients, aneurysmal dilatation of the left ventricle in 11 per cent, markedly reduced shortening fraction in 40 per cent and increased left ventricular systolic and diastolic dimensions in all the tested cases (100 per cent). All patients displayed perfusion defects, with reverse redistribution defects in 10 cases only (30 per cent) and extensive fixed defects in 26 cases (70 per cent). This study indicates that ischaemic cardiomyopathy is a distinct entity, since it results from multiple infarcts producing multifocal ventricular wall motion abnormalities with reduced left ventricular function.

Prolapse of the mitral valve in hyperthyroid patients in Saudi Arabia.

Eighty-two patients (60 females and 22 males) who were under treatment for hyperthyroidism at the King Saud University affiliated hospitals in Riyadh, Saudi Arabia, were evaluated by M-mode and cross-sectional echocardiography for the presence of mitral valve prolapse. Sixty-seven patients (51 females and 16 males) had diffuse toxic goitre while 15 of them (9 females and 6 males) had nodular toxic goitre. The overall frequency of prolapse was 37.8% (31 of 82) and the frequency was similar for both sexes, being 38.3% in females and 36.3% in males. Prolapse was associated with both diffuse toxic goitre (overall frequency 35.8%) and nodular toxic goitre (overall frequency 46.6%); and the highest frequency was in females with nodular toxic goitre (55.5%). Out of the total of 31 patients with prolapse, early systolic and holosystolic prolapse were each present in 12 patients, while mid-to-late systolic prolapse was found in 7 patients. Cross-sectional echocardiography demonstrated prolapse in 16 cases, the M-mode was positive in 5 cases while the two methods confirmed it in 10 patients. The prevalence of prolapse of the mitral valve in otherwise healthy Saudi subjects has previously been found to be 12-15%. This study has confirmed a high frequency of prolapse in hyperthyroid patients and has demonstrated that sex, ethnic or racial origin and type of hyperthyroidism are not determinants of this association.

Primary cardiac echinococcosis: report of two cases with review of the literature.

Two case reports of Saudi patients with primary cardiac hydatid cysts are presented. In the first case, a multilocular cyst was located in the wall of the left ventricle, whereas in the second case a cyst was located in the pericardial sac and another cyst in the left ventricular wall. The diagnosis was based on a history of animal contact, full clinical examination, serological tests and the use of plain radiography, including conventional tomogram, two-dimensional echocardiography, computed tomography and thallium perfusion isotope scan. This study has indicated that non-invasive radiological methods are sufficient to diagnose cardiac echinococcosis and could provide the same information as, or even more than if invasive techniques were used. Further screening of the two patients showed no involvement of other organs by hydatid cysts.

Prevalence of mitral valve prolapse in healthy Saudi women.

Two-hundred-and-thirty-two Saudi young women were prospectively clinically examined for the presence of mitral valve prolapse. Phonocardiograms recorded in all subjects at rest in supine position revealed 10.7% incidence of systolic clicks and/or mid to late systolic murmurs. Echocardiographic studies were performed in supine, left lateral as well as sitting up positions. Twenty-eight subjects were found to have mitral valve prolapse. Of these, 21 subjects had mid to late systolic prolapse when the other seven subjects were found to have pansystolic prolapse (holosystolic). Eight of the 28 positive subjects had auscultatory evidence of mitral valve prolapse. It seems that mitral valve prolapse is more common than expected in healthy Saudi women population.

Lymphadenitis in Sowda.

Sowda is a form of onchocerciasis in Yemen characterized by unilateral dermatitis of one limb, with enlargement of the regional lymph nodes. Previous pathologic studies of lymph nodes from cases of Sowda describe only follicular hyperplasia without microfilariae in the lymph nodes. This contrasts with African onchocerciasis, where the lymph nodes tend to be atrophic and microfilariae are usually present. In the present report, a case of Sowda with microfilariae in the lymph nodes is described and the implications of this finding are discussed.

Hydatid liver disease, is it a diagnostic problem? Analysis of 42 consecutive cases in Saudi patients.

Analysis of 42 patients clinically suspected of having hydatid liver disease is presented. Diagnosis was made using clinical criteria, serology, skin tests and non-invasive imaging techniques. The distribution of the cysts according to age, sex, location and number is discussed. It is suggested that histopathological study is no longer essential to confirm the diagnosis of hydatid disease of the liver.

Dilated cardiomyopathy in Saudi Arabia: a review of 55 cases.

A review of 55 cases with dilated cardiomyopathy seen at King Abdul Aziz University Hospital, Riyadh, Saudi Arabia between 1404-1405 (1984-1985) was carried out. These 55 cases were analyzed and compared with cases of clinically identifiable ischaemic heart disease. The diagnosis was established on clinical grounds as well as electrocardiographic and echocardiographic studies. The findings suggest that dilated cardiomyopathy is a frequent cause of heart disease in this area.

Autoimmune thrombocytopenic purpura in the course of Kaposi's sarcoma--report of a case.

Autoimmune thrombocytopenic purpura associated with Kaposi's sarcoma in a 42-year-old male from the south of Saudi Arabia is reported. This association has not previously been reported in the medical literature. The occurrence of Kaposi's sarcoma in renal transplant recipients and in those suffering from acquired immune deficiency syndrome has been well documented. Kaposi's sarcoma has been infrequently reported in association with autoimmune disorders. The diagnosis of autoimmune thrombocytopenic purpura was made after all secondary causes of thrombocytopenic purpura has been excluded. The diagnosis of Kaposi's sarcoma was confirmed by the histopathological examination of a skin biopsy. To the best of our knowledge, this is the first report of such an association.

Measurement of reversibility of airways obstruction: which parameters to use?

Maximum expiratory flow-volume (MEFV) curves recorded before and after salbutamol inhalation on 100 patients with various lung diseases were studied. Improvement was found to occur more frequently in MEF50, FEF25-75, FVC and MEF25, than in FEV1, FEV1/FVC%, or MTT. If improvement in only one of the first four parameters was taken as a measure of reversibility of airways obstruction, many cases showing improvement in the others were missed. Improvement in any of the last three parameters was rarely missed if improvement in any of the first four was present. It was concluded that there is no single best measurement for assessment of bronchodilator response. FVC, FEF25-75, MEF50 and MEF25 should all be measured. A flow-volume record of forced expiration from which all these measurements can be derived would therefore be preferable for this purpose to the time-volume spirometer record from which only FVC and FEF25-75 can be determined.