Impact of sodium-glucose cotransporter-2 inhibitors on kidney outcomes in type 2 diabetes: A tertiary center experience.

BACKGROUND: Diabetic nephropathy (DN) is a complication of chronic hyperglycemia associated with diabetes mellitus (DM). Several studies have demonstrated the positive impact of sodium-glucose cotransporter-2 (SGLT2) inhibitors on kidney outcomes. The objective of the study was to evaluate the effects of dapagliflozin, an SGLT2 inhibitor, on kidney outcomes in Saudi patients with type 2 DM. MATERIALS AND METHODS: Study included all Saudi patients with type 2 DM who visited our center from August 1, 2021, to July 31, 2022, and had been on dapagliflozin for at least 3 months. Data was abstracted through chart review for all patients included in the study. Paired t-test or Wilcoxon signed-rank test were used to compare the results before and after treatment for continuous variables and the McNemar test was used to compare the results for categorical data. RESULTS: Study included 184 Saudi patients with type 2 diabetes with a mean age of 61.32 years (SD=9.37). Dapagliflozin 10 mg/day significantly reduced hemoglobin A1C (HbA1C) from a mean (SD) of 9.00 to 8.40 (P < 0.001). Among a subgroup of patients with significant proteinuria (n = 83), dapagliflozin significantly reduced ACR from a median of 93.1 to 64.9 mg/g (P = 0.001). Following treatment, the estimated glomerular filtration rate improved from a mean of 69.83 to 71.68 mL/min and the mean arterial pressure (MAP) fell from 90.03 to 89.06 mmHg, both were not statistically significant. Despite a statistically insignificant increase in the episodes of urinary tract infections (UTIs), the hospitalization rate declined. No episodes of amputations or ketoacidosis occurred during the study period. CONCLUSION: SGLT2 inhibitors had beneficial effects among Saudi patients with type 2 diabetes by improving diabetic control and lowering proteinuria. Dapagliflozin did not result in significant harm, including UTIs, amputations, and ketoacidosis.

The Impact of Female Genital Mutilation on Sexual Function: A Study Conducted in Rural Sudan.

BACKROUND:  There are few studies comparing sexual function in women with female genital mutilation (FGM) in the literature, and most of these were evaluated with the Female Sexual Function Index (FSFI) questionnaire. Only one used the Female Genital Self-Image Scale (FGSIS) questionnaire. AIM: This study aims to evaluate the effects of FGM on sexual function in Sudanese women who did or did not undergo FGM, using the FSFI and FGSIS questionnaires. METHODS:  This descriptive study was conducted on Sudanese women from July 2020 to March 2021. Patients who attended to our hospital's gynecology outpatient clinic for health screening were included in this study. A total of 211 patients 113 with FGM and 98 without FGM were included in the study. The group with FGM was categorized according to the classification of the World Health Organization. The validated Arabic FSFI and FGSIS questionnaires were administered to groups with and without female genital mutilation and cutting (FGM/C). RESULTS: When the FGM types of the cases participating in the study were examined, patients with FGM were classified according to the FGM/C classification defined by the World Health Organization. They were classified as 20.4% (n=23) Type 1, 49.6% (n=56) Type 2, and 30.1% (n=34) Type 3. FSFI and FGSIS scores were significantly lower in the FGM/C group, especially in Type 3 with the highest tissue loss. The survey results statistically support the possibility of sexual dysfunction in FGM group. CLINICAL IMPLICATIONS: Female genital circumcision negatively affects sexual function. Therefore, clinicians should consider and sexual dysfunction in women with FGM attending primary care. Strengths and limitations: The strengths of this study are its originality, as it is the first study in the literature to use validated FGSIS and FSFI questionnaires together to assess sexual function in groups with and without FGM and to evaluate correlation of questionnaire results. We undertook the study it using validated and reliable scales, trained clinical staff, local staff gynecologist, and multivariate analysis. Limitation of the study is the chosen age range. The reason for limiting the age to under 35 is that we wanted to evaluate the more sexually active age group in our study. We cannot comment on the correlation of FSFI and FGSIS in circumcised patients over 35 years of age. CONCLUSION:  Sexual function and sexual self-image of women with FGM/C were found to be significantly lower compared to women without FGM when compared with the validated FSFI and FGSIS questionnaires.

Feasibility and acceptability of a mobile model of environmental enrichment for patients with mixed medical conditions receiving inpatient rehabilitation: a mixed methods study.

OBJECTIVES: To investigate the feasibility and acceptability of a mobile model of environmental enrichment (EE), a paradigm that promotes activity engagement after stroke, in patients with mixed medical conditions receiving inpatient rehabilitation. DESIGN: A mixed methods study design was used. An online qualitative survey assessed staff perspectives of acceptability of the mobile EE model including perceived barriers and enablers pre-implementation and post implementation. An A-B quasi-experimental case study of patient activity levels over a 2-week observational period provided feasibility data. This included recruitment and retention rates, completion of scheduled patient activity observations and validated baseline questionnaires, and number of adverse events. SETTING: A 30-bed mixed medical ward in a public hospital that services Brisbane's southern bayside suburbs. The rehabilitation programme operates with patients co-located throughout the medical/surgical wards. PARTICIPANTS: Nursing and allied health professionals working across the rehabilitation programme completed pre-implementation (n=19) and post implementation (n=16) qualitative questions. Patients admitted to the ward and who received the inpatient rehabilitation programme from June to November 2016 were also recruited. INTERVENTIONS: The mobile EE intervention included activities to primarily promote social and cognitive stimulation (eg, puzzles, board games) delivered by hospital volunteers and was designed to be moved throughout the wards. RESULTS: Four themes emerged from staff reports, suggesting that the role of patient, staff and intervention characteristics, and the ward environment were important barriers and enablers to implementation. Of the 12 eligible patients, six consented to the study, and five completed the intervention. All patients completed the baseline measures. No adverse events were reported. CONCLUSIONS: As interest grows in human EE models, it will be important to tailor EE interventions to the unique demands of hospital rehabilitation services. A mobile EE model delivered in a small, mixed rehabilitation ward appears feasible and acceptable to study in a larger controlled feasibility trial.

Effect of Topical Application and/or Systemic Use of Red Ginseng Extract on Wound Healing in Rats With Experimentally Induced Diabetes.

BACKGROUND: Red ginseng (Rg) is an herbal product that has been used in traditional medicine in Asian and European countries for many years. PURPOSE: To study the effects of Rg extract on wound healing when used systemically, locally, or in combination in rats with experimentally induced diabetes. METHODS: A total of 60 rats were randomly divided into 4 groups: saline (control), local Rg (LRg), systemic Rg (SRg), and local + systemic = combined Rg (CRg). A full-thickness wound (2 cm × 1 cm) was created on the back of the rats, and treatment protocols were carried out for 14 days. Wound areas of all rats were measured on days 0 and 14. Tissue samples were taken from the wound areas for histopathologic evaluation of inflammation, epithelialization, and fibrosis. Vascular endothelial growth factor (VEGF), CD4+, and CD8+ expressions were examined by immunohistochemistry. RESULTS: Wound contraction measurements were 63.8%, 80.5%, 88.5%, and 86.6% in the control, LRg, SRg and CRg groups, respectively. Although significant differences were observed for all treated groups (LRg, SRg, and CRg) compared with the control group in terms of wound contraction, there was no difference among the treatment groups. VEGF-positive vessel/mm2 was observed 4.00 ± 0.75, 5.93 ± 0.70, 5.93 ± 1.93, and 7.93 ± 0.70 in the control, LRg, SRg and CRg groups, respectively. There was no difference between LRg and SRg in terms of VEGF expression, but there was significant difference for all other groups compared with each other. CONCLUSION: All usage methods of Rg extract increased wound contraction, and differences were observed compared with the control group. However, the authors believe that the combined usage was more effective due to higher VEGF expression levels and lower CD4+:CD8+ ratio.

Primary hyperparathyroidism in Saudi Arabia revisited: a multi-centre observational study.

PURPOSE: Primary hyperparathyroidism (PHPT) is a common cause of hypercalcemia and remains understudied within the Arabian population. The present study, the largest of its kind within the Gulf Cooperation Council (GCC) countries, aims to determine the demographics and clinical presentation of PHPT in Saudi Arabia. METHODS: In this multi-center retrospective study involving three tertiary hospitals in different geographic locations of Saudi Arabia namely, Riyadh, Al Ahsa and Jeddah, a total of 205 out of 243 confirmed PHPT cases aged 16 to 93 years old were included (N = 96 from Riyadh; N = 59 from Al Ahsa and N = 50 from Jeddah). Demographics, clinical manifestations and surgical outcomes were recorded as well as laboratory and radiologic investigations including serum parathyroid hormone (PTH), 25(OH)D, adjusted calcium, estimated glomerular filtration rate (eGFR) and nuclear scan outcome. RESULTS: PHPT cases appeared to increase over time when compared to other local studies published so far, with 12.8 cases per 100,000 hospital population. Females outnumber males (3:1) with 86% seen as out-patients. The average age was 59.8 ± 15.5 years. Abnormal PTH scan was seen in 171 patients (83.4%). Kidney stones was the most common renal manifestation (32 cases, 15.6%) and osteoporosis was the most common skeletal manifestation (67 cases, 32.7%). Al Ahsa had the highest prevalence of multiple comorbidities at 54% and the highest prevalence of obesity as a single comorbidity (17%) compared to other regions (p < 0.05). Jeddah recorded the highest prevalence of osteoporosis with bone and joint pains (30%) (p < 0.05). CONCLUSION: Comparison of present data with previous local studies suggest an increasing trend in PHPT cases in Saudi Arabia. Regional variations in the clinical presentation of PHPT were observed and warrant further investigation.

Spatial distribution and mapping of COVID-19 pandemic in Afghanistan using GIS technique.

Geographic information science (GIS) has emerged as a unique tool that is extremely valuable in various research which involves spatial-temporal aspects. The geographical distribution of the epidemic is considered a significant characteristic that can be analyzed using GIS and spatial statistics. Proper knowledge can assist in controlling, mitigating, and mapping factors for detecting the transmission as well as the disease dynamics, and it provides geographical information of the outbreak and it can also give a glimpse of the disease trend and hotspots as well as provide ways to further evaluate the associated risk. This study analyzed the countries' total confirmed cases, total death cases, and the total recovered cases using an (IDW) geospatial technique which is an inherent tool used in ArcMap for spatial analysis. In order to identify the hotspots for COVID-19 cases, the Getis-Ord Gi* statistic method was applied with a confidence level of 95% in Herat and 90% for Kabul, Kapisa, and Logar provinces. The data considered in this research ranged from the period of 23rd July 2020 to 24th February 2021. All the COVID-19 confirmed, recovered, and death cases were correlated with provincial population density using the Pearson Correlation coefficient. Among the total cases 54,487, 32% cases were reported in the capital of the country (Kabul), and the mortality rate was 31% followed by Herat (18% deaths), Balkh (7% deaths), and Nangarhar (6% deaths). Most of the recoveries were observed in Kabul with (30%) followed by Herat (16%), Bamyan (10%), Balkh (5%), and Kandahar (5%). The results for Global Moran's I showed that the incidence rate of the total COVID-19 cases was in the random pattern, with the Moran Index of - 0.14. Given the z-score of - 1.62, the pattern does not appear to be significantly different than random. There was a strong correlation between the COVID-19 variables and population density [with r(33) = 0.827], [r(33) = 0.819] and [r(33) = 0.817] for the total cases, death cases, and recovered cases, respectively. Even though GIS has limited applicability in detecting the type and its spatial pattern of the epidemic, there is a high potential to use these tools in managing and controlling the pandemic. Moreover, GIS helps us better in comprehending the epidemic and assists us in addressing those fractions of the population and communities which are underserved during the disease outbreak.

Troponin Levels and the Severity of COVID-19 Pneumonia.

Introduction In late 2019, a novel coronavirus was identified as the pathogen responsible for a cluster of pneumonia cases in Wuhan, a city in the Hubei Province of China. Elevated cardiac troponin is a marker of myocardial injury, which is commonly seen in hospitalized patients with COVID-19 due to unclear reasons. The frequency of elevated troponin levels in patients with COVID-19 is variable and is reported in up to 7-36% of patients. The troponin level may be associated with the severity of COVID-19, and mild cases of COVID-19 tend to have a normal troponin level. This study aims to determine the frequency of patients with COVID-19 who had elevated troponin levels on presentation to the ED and determine the factors associated with elevated troponin levels. Additionally, the study aims to identify the association of elevated troponin and the outcome of COVID-19. Methodology A retrospective study wherein the factors associated with elevated troponin levels in COVID-19 pneumonia were evaluated. The study was conducted in King Fahd Hospital of the Imam Abdulrahman Bin Faisal University. The Hospital Information System was used to identify all visits to the ED from March 2020 to November 2020 for patients who tested positive for SARS-CoV-2. In addition, a structured data collection form was used to collect data from the electronic health records. The data collection was conducted by emergency medicine physicians who were given a detailed explanation of the purpose of the study and had training and supervision by the principal investigator. Results The study involved 214 patients who presented to the ED and had positive results on the SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) test and had troponin-I levels measured. Patients with elevated troponin levels were more likely to require supplementary oxygen compared with those with normal troponin levels (88.0 vs. 58.5%; P < 0.01). In total, 36 (76.6%) patients with elevated troponin levels required admission to the ICU compared with 58 (45.0%) patients with normal troponin levels (P < 0.01). Multivariable binary logistic regression analysis was used to identify the predictors of elevated troponin levels on presentation. The model revealed that being admitted in the ICU was the single independent predictor (P = 0.02). Conclusion The study demonstrated that the troponin level on presentation to the ED was a viable independent prognostic factor in COVID-19 pneumonia. However, further studies are needed to investigate targeted therapeutic interventions among patients with elevated troponin levels, such as cardioprotective therapies like corticosteroids, immunosuppressants, antivirals, or immunoglobulins.

Electronic early notification of sepsis in hospitalized ward patients: a study protocol for a stepped-wedge cluster randomized controlled trial.

BACKGROUND: To evaluate the effect of screening for sepsis using an electronic sepsis alert vs. no alert in hospitalized ward patients on 90-day in-hospital mortality. METHODS: The SCREEN trial is designed as a stepped-wedge cluster randomized controlled trial. Hospital wards (total of 45 wards, constituting clusters in this design) are randomized to have active alert vs. masked alert, 5 wards at a time, with each 5 wards constituting a sequence. The study consists of ten 2-month periods with a phased introduction of the intervention. In the first period, all wards have a masked alert for 2 months. Afterwards the intervention (alert system) is implemented in a new sequence every 2-month period until the intervention is implemented in all sequences. The intervention includes the implementation of an electronic alert system developed in the hospital electronic medical records based on the quick sequential organ failure assessment (qSOFA). The alert system sends notifications of "possible sepsis alert" to the bedside nurse, charge nurse, and primary medical team and requires an acknowledgment in the health information system from the bedside nurse and physician. The calculated sample size is 65,250. The primary endpoint is in-hospital mortality by 90 days. DISCUSSION: The trial started on October 1, 2019, and is expected to complete patient follow-up by the end of October 2021. TRIAL REGISTRATION: ClinicalTrials.gov NCT04078594 . Registered on September 6, 2019.

Managing critical care during COVID-19 pandemic: The experience of an ICU of a tertiary care hospital.

BACKGROUND: The COVID-19 pandemic has strained ICUs worldwide. To learn from our experience, we described the critical care response to the outbreak. METHODS: This is a case study of the response of the Intensive Care Department (75-bed capacity) at a tertiary-care hospital to COVID-19 pandemic, which resulted in a high number of critically ill patients. RESULTS: Between March 1 and July 31, 2020, 822 patients were admitted to the adult non-cardiac ICUs with suspected (72%)/confirmed (38%) COVID-19. At the peak of the surge, 125 critically ill patients with COVID-19 were managed on single day. To accommodate these numbers, the bed capacity of 4 ICUs was increased internally from 58 to 71 beds (+40%) by cohorting 2 patients/room in selected rooms; forty additional ICUs beds were created in 2 general wards; one cardiac ICU was converted to managed non-COVID-19 general ICU patients and one ward was used as a stepdown for COVID-19 patients. To manage respiratory failure, 53 new ICU ventilators, 90 helmets for non-invasive ventilation and 47 high-flow nasal cannula machines were added to the existing capacity. Dedicated medical teams cared for the COVID-19 patients to prevent cross-contamination. The nurse-to-patient and RT-to-patient ratio remained mostly 1:1 and 1:6, respectively. One-hundred-ten ward nurses were up-skilled to care for COVID-19 and other ICU patients using tiered staffing model. Daily executive rounds were conducted to identify patients for transfer and at least 10 beds were made available for new COVID-19 admissions/day. The consumption of PPE increased multiple fold compared with the period preceding the pandemic. Regular family visits were not allowed and families were updated daily by videoconferencing and phone calls. CONCLUSIONS: Our ICU response to the COVID-19 pandemic required almost doubling ICU bed capacity and changing multiple aspects of ICU workflow to be able to care for high numbers of affected patients.

Prevalence of sleep duration among Saudi adults.

OBJECTIVES: To examine the associations between sleep duration and a variety of demographic and clinical variables in a sample of Saudi adults.  Methods: A cross-sectional study among 2,095 participants was conducted at King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia, between May and October 2014. A questionnaire was administered to collect data related to clinical health outcomes and demographic characteristics. Participants were asked to report their average sleep duration per night in hours.  Results: One-third (33.8%) reported short sleep duration of less than 7 hours/night. Short sleep duration was more prevalent in females (37.3% versus 31.4%, p=0.004). The most common medical problems reported were obesity with body mass index of greater than 30 Kg/m2 (39.1%), hypertension (33.9%), diabetes mellitus (20.8%), depression (4.3%), asthma (17.3%), COPD (6.6%), and hyperlipidemia (2.7%). Diabetes mellitus was associated with long sleep of more than 9 hours/night (25.4%, p=0.011) and hypertension (54.2%, p=0.001). The linear regression model tend to reduce their sleep duration by roughly 22 minutes in female gender, 66 minutes in participants with hyperlipidemia, and 70 minutes in participants with poor sleep quality.  Conclusions: Short sleep duration per night was prevalent, it affects one in every 3 Saudi adults. Long sleep duration of more than 9 hours was associated with increased comorbid conditions.

Frequency and clinical significance of respiratory isolates of non-tuberculous mycobacteria in Riyadh, Saudi Arabia.

BACKGROUND AND AIMS: The prevalence of pulmonary non-tuberculous mycobacteria (NTM) disease is increasing worldwide. The aim of this study was to assess the frequency and clinical significance of NTM isolated from respiratory specimens at King Abdul-Aziz Medical City-Riyadh, Saudi Arabia. METHODS: The medical records of all patients who had at least one respiratory specimen that was positive for growth of NTM between 2006 and 2012 were retrospectively reviewed. The clinical significance of the isolates was determined using the diagnostic criteria for NTM disease published by the American Thoracic Society (ATS). RESULT: A total of 380 respiratory specimens with positive culture for NTM from 142 patients were identified. Forty patients (28%) had definite pulmonary NTM disease with a mean (± standard deviation) age of 54 ± 16 years, 58% were male and 50% had had underlying chronic lung disease. Mycobacterium avium complex (MAC) (n = 19, 48%) and Mycobacterium abscessus (n = 10, 25%) were the most commonly encountered NTM. The clinical manifestations of NTM lung disease are non-specific, with symptoms indistinguishable from pulmonary tuberculosis (TB). The most common radiological features of NTM lung disease were nodular bronchiectasis (45%) and fibrocavitary lesions (40%). CONCLUSIONS: Twenty-eight percent of the patients with NTM isolates met the ATS diagnostic criteria for NTM lung disease. MAC and M. abscessus were the most encountered NTM isolated species that caused NTM lung disease in our population, which is a rate similar to many previous studies.

Monitoring activity of inpatient lower limb prosthetic users in rehabilitation using accelerometry: Validation study.

PURPOSE: Due to limited accuracy of self-reported activities of lower limb prosthetic users, there is increasing interest in providing accurate walking time for those who are mobilising using their prosthesis in the rehabilitation ward. The aim of this study was to test the accuracy of a tri axial accelerometer (ActivPAL) in measuring walking activity of amputee patients while using their prosthetic limb. METHOD: For the study, 21 subjects wore accelerometer devices taped to the thigh on both the amputated and non-amputated side. Each subject was asked to perform a set of activity routines: walking with prosthesis for 5 minutes, self-propelling in a wheel chair for 3 minutes and being pushed in a wheel chair for 3 minutes. Each activity was observed and timed by a physiotherapist and the observed times were compared with the output from accelerometer monitoring. RESULTS: Using the Bland-Altman method, the mean difference between observed and ActivPal monitor for total time spent walking for the non-amputated side was 0.004 seconds (limits of agreement -0.09 to 0.10 seconds) and for amputated side was 0.11 seconds (limits of agreement -0.43 to 0.66 seconds). An analysis between monitored and observed time found the sensitivity for the non-amputated side was 90.5% and 86% for the amputated side. CONCLUSION: The use of ActivPAL accelerometers in measuring walking time for an individual using a prosthesis is within acceptable levels of accuracy for continuous ambulation monitoring. It has potentially important clinical application for prescribing prostheses.

Using the International Classification of Functioning, Disability and Health framework to categorise goals and assess goal attainment for transition care clients.

AIM: To classify goals according to the International Classification of Functioning, Disability and Health (ICF) and to examine factors associated with goal attainment for transition care program (TCP) clients. METHODS: Recorded goals at admission were rated at discharge as achieved, partially achieved or not achieved. Two researchers independently linked each statement to the most closely corresponding ICF categories. RESULTS: Of 268 TCP clients, 215 had 851 goal statements recorded. Of these, 794 (93%) statements were linked to 12 different ICF categories. A total of 515 (61.4%) were attained at discharge, 117 (14%) were partially attained and 207 (24.6%) were not attained. Multivariate analysis identified number of goals, TCP length of stay and high or very high case manager perception of goal attainment to be significant predictors for goal attainment. CONCLUSIONS: The ICF framework can be used to identify and structure clients' goals in transitional care. Goal attainment can be used to determine overall functional improvement.

Medical grand rounds in Riyadh, Saudi Arabia: Current attitudes and barriers.

BACKGROUND: Medical grand rounds (MGRs) are considered key educational tools in most academic medical institutions. In this multi-center cross-sectional survey, we tried to determine the current attitudes of local medical practitioners to MGRs, as well as perceived barriers. METHODOLOGY: A total of 120 physicians from the National Guard Hospital, King Fahad Medical City, King Khalid University Hospital and King Faisal Specialist Hospital participated in the survey. The questionnaire consisted of statements on attitudes and perceived barriers against participating in MGRs, as well as participants' levels of agreement. RESULTS: Most participants attend MGRs regularly (94.2%), claiming that it is mandatory (88%). Participants also agreed that MGRs were important tools for continuing medical education (89.2%) and that they provided an opportunity to both present materials and interact with their colleagues in other divisions (86.7% and 81.6%, respectively). The vast majority of respondents agreed that "topic review/update" and "inviting guest speakers" were the two most preferred suggestions for improving MGRs (94.2% and 92.5%, respectively). Major barriers included constraints of time (43.3%) and topics that were not patient-related (40.8%). CONCLUSION: MGRs in the major Tertiary Hospitals in Riyadh are well attended, and the majority of the local practitioners believe in the positive effect of MGRs in delivering quality and up to date medical knowledge. Time and physician-specific issues were identified as major barriers that needed to be addressed in order to maximize participation of medical staff.

Level of dietary awareness among Saudi dialysis patients and the influence of various factors.

Our objective was to investigate the degree of dietary awareness of Saudi patients on chronic hemodialysis and influencing factors on this awareness. This is an interviewadministered survey-based cross-sectional study carried out on adult dialysis patients at the King Abdulaziz Medical City, Riyadh. The first part of the survey consisted of the collection of demographic data and the second part consisted of questions in the areas of awareness on the dietary influence of sodium, potassium, fluid intake and calcium/phosphorous and lipids. The questions are simply answered as "yes" or "no." The overall awareness score was 79%. The awareness scores were highest in the area of lipids (86.5%) and lowest in the fluid intake area (71.3%). The scores for sodium, phosphorous/calcium and potassium were 80%, 79.6% and 73%, respectively. The degree of awareness was influenced by the number of visits by the dietitian (P = 0.008) and the educational level of the patients (P = 0.02), but not by age, duration on dialysis or gender. In conclusion, our findings suggest that there is a need for better of awareness among our dialysis patients. The highest score for awareness was seen in the cholesterol-related questions and the lowest score was seen in the fluid intake questions area. This is influenced by the number of visits by the dietitian and the educational level of the patients, but not by age, duration on dialysis or gender.

A case of first degree AV block in carbon monoxide poisoning patient.

Carbon monoxide (CO) intoxication is one of the most common types of poisoning. Cardiac manifestations of CO poisoning are limited to case reports of Electrocardiogram (ECG) changes, myocardial dysfunction and myocardial ischemia. A 22 year old Saudi male was admitted to the emergency department with decreased level of consciousness after being involved in a fire at home. ECG showed first degree AV block. To the best of our knowledge, this case report is the first CO poisoning case in the literature presented with first degree AV block.

Improper inhaler technique is associated with poor asthma control and frequent emergency department visits.

BACKGROUND: Uncontrolled asthma remains a frequent cause of emergency department (ED) visits and hospital admissions. Improper asthma inhaler device use is most likely one of the major causes associated with uncontrolled asthma and frequent ED visits. OBJECTIVES: To evaluate the inhaler technique among asthmatic patients seen in ED, and to investigate the characteristics of these patients and factors associated with improper use of inhaler devices and its relationship with asthma control and ED visits. METHODS: A cross-sectional study of all the patients who visited the ED with bronchial asthma attacks over a 9-month period was undertaken at two major academic hospitals in Saudi Arabia. Information was collected about demographic data and asthma management and we assessed the inhaler techniques for each patient using an inhaler technique checklist. RESULTS: A total of 450 asthma patients were included in the study. Of these, 176(39.1%) were males with a mean age of 42.3 ±16.7 years and the mean duration of asthma was 155.9 ± 127.1 weeks. The improper use of asthma inhaler devices was observed in 203(45%) of the patients and was associated with irregular clinic follow-ups (p = 0.0001), lack of asthma education (p = 0.0009), uncontrolled asthma ACT (score ≤ 15) (p = 0.001), three or more ED visits (p = 0.0497), and duration of asthma of less than 52 weeks (p = 0.005). Multiple logistic regression analysis revealed that a lack of education about asthma disease (OR =1.65; 95% CI: 1.07, 2.54) or a lack of regular follow-up (OR =1.73; 95% CI: 1.08, 2.76) was more likely to lead to the improper use of an asthma inhaler device. CONCLUSION: Improper asthma inhaler device use is associated with poor asthma control and more frequent ED visits. We also identified many avoidable risk factors leading to the improper use of inhaler devices among asthma patients visiting the ED.

Rehabilitation of the older vascular amputee: a review of the literature.

The aim was to review the literature on factors affecting prosthetic rehabilitation of older vascular lower extremity amputees. A search of the literature was carried out using the MEDLINE, EMBASE and CINAHL databases up to September 2010. Only original English language articles were accepted. Relevant studies were reviewed and selected based on prespecified inclusion criteria namely: age more than 65 years; vascular cause for the amputation; amputation level of below knee, through-the-knee or above knee; and discussed factors affecting rehabilitation. Age alone is not an absolute contraindication to prosthetic limb prescription; however, it does influence the potential success of gait retraining. Other factors influencing prosthetic fitting and use include comorbidities, premorbid function, level of amputation, status of the remaining limb and patient motivation. Prosthetic gait retraining is not possible in every older dysvascular amputee; however, almost all amputees will benefit from a rehabilitation program to increase independence in transfers and learn wheelchair skills. The MESH key words were: "aged" "diabetes complications" "peripheral vascular diseases" "amputees" "amputation" "rehabilitation" and "artificial limbs".

Acute brucellosis presenting as gastroenteritis: case report.

Brucellosis is a systemic infection with multiple presentations. In spite of its oral mode of transmission and gastrointestinal pathogenesis, systemic symptoms are usually more prominent than gastrointestinal ones. Acute brucellosis presenting as gastroenteritis is rare in adults and could be the only manifestation of the disease. We report a case of gastroenteritis caused by Brucella species.