Changing minds: The impact of introducing evidence-based practices around the use of episiotomy in a South Indian Tertiary Centre.

BACKGROUND: Episiotomies are still a routine procedure during childbirth in India, reflecting the misconceptions and lack of knowledge in the traditional training programs. There is a marked variation in the use of episiotomy between doctors and midwives. This study was conducted to ascertain and gain insight into this inequality in practice. METHODS: Retrospective data of spontaneous vaginal births across all units of a tertiary care center in South India from 2014 to 2021 was retrieved from medical records. First the total number of episiotomies, who performed them and indications were analysed. In the second part of the study, a questionnaire was distributed among doctors and midwives to delve into their knowledge and attitudes towards using episiotomy. FINDINGS: Of the 35253 spontaneous vaginal births over seven years, 28 % had an episiotomy. Midwives performed 22 % of them and obstetricians did the remaining. The most common indication was presumed fetal compromise. There was a reduction in episiotomy rates from 21 % to 5 % in midwifery practice and 45 % to 35 % for doctors over the study period. The second part of the study revealed a significant difference in the attitudes of doctors and midwives. Doctors leaned in favor of episiotomies despite the contrary evidence. CONCLUSION: Successful institution of any change in behavior needs an understanding of the perception and attitude towards the change. A focus on respectful maternity care, hospital policies based on scientific evidence and an enabling environment for training and education can avoid unnecessary birth practices not recommended for healthy pregnant women.

Exploring the Validity of Available Markers and Indices in the Diagnosis of Nonalcoholic Fatty Liver Disease (NAFLD) in People with Type 2 Diabetes in Saudi Arabia.

Nonalcoholic fatty liver disease (NAFLD) is common among Saudi patients with type 2 diabetes (T2DM). However, recommended clinical procedures to detect it are unavailable in many locations. Therefore, better and more available diagnostic biomarkers for NAFLD are needed. Various serum parameters were suggested, and algorithms that employ routine measurements in clinical practice have been developed for the prediction of fat stores in the liver in different populations. However, no such studies have been conducted on Saudis. We aimed to compare selected biochemical markers and calculated indices in T2DM patients diagnosed with NAFLD and patients without NAFLD to find the best markers associated with NAFLD. A cross-sectional study was employed to recruit 67 people with T2DM from endocrine outpatient clinics at King Abdul-Aziz University Hospital. NAFLD was detected by ultrasonography in 28 patients. Demographic information, anthropometric, and blood pressure (BP) measurements were taken. Fasting blood samples were obtained to measure glucose, glycated haemoglobin, lipid profile, liver function tests, and highly sensitive C-reactive protein. Fatty liver index, hepatic steatosis index, NAFLD-liver fat score, and triglyceride and glucose index were calculated. Following stepwise forward likelihood ratio regression with independent variables included in one model using binary logistic regression with age and waist circumference (WC) entered as covariates, elevated diastolic BP and low high-density lipoprotein- cholesterol remained significantly associated with NAFLD (p = 0.002 and 0.03, respectively). However, none of the investigated indices could be used to diagnose the disease adequately due to low specificity, even after calculating new cut-off values. Investigating novel markers and adjusting existing equations used to calculate indices to improve sensitivity and specificity in our population is needed.

Varicella Zoster in pregnancy.

Chickenpox during pregnancy can cause serious complications for both mother and fetus. This includes varicella pneumonia in the mother, fetal varicella syndrome and varicella of newborn. Primary prevention includes vaccination against varicella infection and is part of standard childhood immunisation programme in many countries. Timely post-exposure prophylaxis of susceptible pregnant women with varicella zoster immunoglobulin is key to preventing chickenpox during pregnancy and its adverse fetomaternal sequelae. Antiviral therapy and appropriate supportive treatment improve maternal and neonatal outcomes.

Toxoplasmosis in pregnancy.

Toxoplasmosis is one of the common chronic infections caused by the parasite Toxoplasma gondii. Even though its infection in healthy non-pregnant women is self-limited and largely asymptomatic, the main concern is the risk to the fetus by vertical transmission in pregnancy. Congenital toxoplasmosis can result in permanent neurological damage and even serious morbidity such as blindness. Screening programs are implemented in various countries depending on the prevalence and virulence of the parasite in the respective regions. Upon diagnosis of infection, appropriate antibiotic therapy should be initiated as it has been proven to reduce the risk of fetal transmission. Primary prevention remains the key intervention to avoid the infection and hence patient education is an important aspect of the management.

Return to the Operation Theatre: An Analysis of Repeat Surgeries in Operative Obstetrics.

PURPOSE: To determine the risk factors and associated comorbidities with a relaparotomy after primary surgery in pregnant mothers and to identify preventable causes. METHODS: A retrospective observational study was done at a tertiary care centre from January 2009 till August 2014. All records of exploratory laparotomy following primary surgery in the obstetric population during this period were retrieved from the hospital database and analysed. RESULTS: The incidence of relaparotomy was 0.22 %. In 94 % cases, the primary surgery was caesarean section. The commonest indication for relaparotomy was due to haemorrhagic complications like bleeding and haematoma (66.8 %). Sepsis was seen in 36.1 % cases with the predominant organism isolated being E coli (54 %). Most common comorbidity was hypertensive disorders (58 %) followed by liver disorders (19 %). 33.3 % needed ventilatory support, 30.5 % needed massive blood transfusion, 16.6 % were on total parenteral nutrition and 2.7 % needed renal replacement therapy. Maternal mortality was 2.8 %. CONCLUSION: Relaparotomy following caesarean section is considered a near-miss mortality. Care must be taken in primary surgery with meticulous attention to haemostasis. Strict postoperative vigilance must be adhered to for timely detection of complications and appropriate intervention.

The relationship of management modality in Saudi patients with type 2 diabetes to components of metabolic syndrome, γ glutamyl transferase and highly sensitive C-reactive protein.

BACKGROUND: The aim of this study was to investigate the relationship among management modality, glycemic control, components of metabolic syndrome (MS) and serum levels of γ glutamyl transferase (GGT) and C-reactive protein (CRP) in patients with type 2 diabetes (T2DM). METHODS: Patients with T2DM, not suffering from diabetes complications, were recruited from outpatients clinics at two hospitals in Jeddah. Anthropometric measurements and blood pressure (BP) were taken. A treatment plan was recorded. Fasting blood samples were obtained to measure glucose, glycated hemoglobin (HbA1c), lipids profile, highly sensitive (hs)-CRP and GGT. RESULTS: A total of 71 men and 82 women were recruited. Lower mean HbA1c was found in people receiving oral glucose-lowering drugs compared with those on insulin therapy (p < 0.001). Management modality had no effect on mean GGT or hs-CRP. Higher mean GGT was associated with poor glycemic control, dyslipidemia, hypertension, and abdominal obesity. GGT correlated significantly (p < 0.05) and directly with triglycerides in men (r = 0.401) and diastolic BP (r = 0.279 for men, r = 0.194, for women), but inversely with high-density lipoprotein cholesterol (HDL-C) (r = -0.298 for men, r = -0.171 for women). hs-CRP correlated with waist circumference (p < 0.05, r = 0.312, for men, r = 0.305, for women), with a higher mean being found in men with poor glycemic control (p = 0.015), in hypertensive women (p = 0.030), and in patients who were abdominally obese (p < 0.05). CONCLUSIONS: High levels of GGT and hs-CRP are associated with components of MS and poor glycemic control, hence increased cardiovascular risk. Due to their value as independent risk predictors of vascular injury, these measures should be included in routine monitoring of patients with T2DM.

Reported Benefits of Insulin Therapy for Better Glycemic Control in Type 2 Diabetic Patients-Is This Applicable in Saudi Patients?

AIM: To compare the effect of different treatment regimens (oral hypoglycemic agents [OHGs], insulin therapy, and combination of both) on glycemic control and other cardiometabolic risk factors in type 2 diabetes mellitus (T2DM) patients in Saudi. SUBJECTS AND METHODS: Patients with T2DM, but no serious diabetic complications, were randomly recruited from the diabetes clinics at two large hospitals in Jeddah, Saudi Arabia, during June 2013 to July 2014. Only those without change in treatment modality for the last 18 months were included. Blood pressure and anthropometric measurements were measured. Treatment plan was recorded from the patients' files. Fasting blood sample was obtained to measure glucose, HbA1c, and lipid profile. RESULTS: A total of 197 patients were recruited; 41.1% were men and 58.9% were women. The mean (±SD) age was 58.5 ± 10.5 years. Most patients (60.7%) were on OHGs, 11.5% on insulin therapy, and 27.7% were using a combination of insulin and OHGs. The mean HbA1c was lower in patients using OHGs only, compared with means in those using insulin, or combined therapy in patients with disease duration of ≤10 years (P = 0.001) and also in those with a longer duration of the disease (P < 0.001). A lower mean diastolic and systolic blood pressure was found among patients on insulin alone (P < 0.01). No significant differences were found in lipid profiles among the groups. CONCLUSION: Insulin therapy, without adequate diabetes education, fails to control hyperglycemia adequately in Saudi T2DM patients. There is a challenge to find out reasons for poor control and the ways as to how to improve glycemic control in T2DM.

Association of renal failure with thyroid dysfunction: a retrospective cohort study.

Chronic renal failure is often associated with multiple organ co-morbidities, including thyroid dysfunction. This has been associated with poorer prognosis, particularly in patients with end-stage renal disease. This study aimed to examine the relationship between renal failure and thyroid dysfunction in an outpatient setting at the King Abdulaziz University Hospital, Saudi Arabia, from January 2011 to June 2012. Demographic and biochemical data were extracted from medical records. Differences in the levels of thyroid hormones and lipids between the four renal function groups were analyzed using the chi-square test for categorical variables and Kruskal- Wallis test for binomial variables. A total of 486 patients were included in the study population, of whom approximately half were female, and the median (range) age was 61 (17-90) years. According to creatinine measurements, renal function was normal in 48 participants, 290 had mild renal failure, 122 had moderate renal failure and 26 had severe renal failure. No significant relationships were observed between renal failure and cardiac or pulmonary dysfunction. Free triiodothyronine (FT3) levels were significantly reduced (P = 0.005) and both free thyroxin (FT4; P = 0.034) and parathyroid hormone (PTH; P = 0.028) significantly increased with increasing severity of renal failure. Patients with moderate to severe renal failure displayed reduced hemoglobin levels and were significantly more likely to be anemic (P <0.001). Highly significant increases in alkaline phosphatase (P <0.001), uric acid (P <0.001) and low-density lipoprotein-cholesterol (P = 0.014) levels were also observed with increasing renal dysfunction. To conclude, it was observed that renal dysfunction is associated with notable changes to other organ systems, including the thyroid. Further studies may investigate the association of multiple organ co-morbidities with prognosis in patients with chronic renal failure.

Increased serum sclerostin and decreased serum IGF-1 are associated with vertebral fractures among postmenopausal women with type-2 diabetes.

Insulin-like growth factor 1 (IGF-1) is a determinant of bone mass and is inversely associated with vertebral fractures (VFs). Sclerostin regulates bone formation by inhibiting Wnt/ß-catenin signaling. Currently, there is little information on circulating sclerostin levels among postmenopausal women with type-2 diabetes mellitus (T2DM) with VFs in relation to serum IGF-1 (s-IGF-1). We investigated the relationships between serum sclerostin, s-IGF-1, and VFs in postmenopausal women with T2DM. We assessed cross-sectionally 482 postmenopausal women with T2DM and 482 age-matched postmenopausal women without T2DM who were recruited at diabetic clinics and primary health care centers for inclusion in a bone health survey. The main outcome measures were serum sclerostin, s-IGF-1, bone mineral density (BMD), and bone turnover markers. Lateral X-rays of the thoracic and lumbar spine were taken to diagnose VFs. Serum sclerostin levels were increased, whereas s-IGF-1 levels were decreased when T2DM women were stratified by the number of VFs (P<0.0001). Multiple logistic regression analysis showed that serum sclerostin levels were positively associated with 1 VF (odds ratio [OR]=1.27, (95% CI:1.01-2.03), P=0.016), 2 VFs (OR=1.41, (95% CI:1.03-2.36), P=0.006), and ≥3 VFs (OR=1.54, (95% CI:1.12-2.44) P=0.005). s-IGF-1 levels were inversely associated with 1 VF (OR=0.58, (95% CI:0.39-0.88), P=0.041), 2 VFs (OR=0.42, (95% CI:0.21-0.90), P=0.012), and ≥3 VFs (OR=0.19, (95% CI: 0.14-0.27), P<0.001). Increased serum sclerostin and decreased s-IGF-1 were associated with VFs among postmenopausal women with T2DM, suggesting that sclerostin and/or IGF-1 may be involved in increased bone fragility in T2DM and could be potential markers of VF severity.

Clinical profile of dengue fever infection in King Abdul Aziz University Hospital Saudi Arabia.

BACKGROUND: The study aimed to compare the clinical profile of all patients diagnosed with dengue viral infection at King Abdul Aziz University Hospital (KAAUH), during 2005-2008. METHODOLOGY: This retrospective study included 147 patients infected with dengue virus, age < or =16 years. Laboratory and haematological data were included. RESULTS: Two peaks of infection occurred during 2006 and another two in 2008. Common clinical symptoms were fever, vomiting, and abdominal pain. Common haematological abnormalities were thrombocytopenia and leucopoenia. Differences existed between the years in the percentage of patients with fever, elevated alanine aminotransferase (ALT), direct bilirubin, lactate dehydrogenase (LDH), fibrin degradation products (FDPs), and haemoglobin (Hb) levels. Differences were found in nationalities between the years, but patient nationality had no effect on disease incidence. Differences were noted in the percentages of patients' immunoglobulin M (IgM) and polymerase chain reaction (PCR) positive. There was a slight inverse correlation of IgM positive with patient age. PCR, fever, ALT, direct bilirubin, LDH, FDPs, Hb, blood transfusion, and platelet transfusion showed no correlation with age or nationality. In 2005, all the patients survived, but there were 4.55%, 25%, and 2.7% deaths during 2006-2008. CONCLUSIONS: Significant differences in the clinical presentation of dengue virus (DENV) infection, indicative of a variation in disease severity from dengue fever (DF) to dengue hemhorrhagic fever (DHF)/dengue shock syndrome (DSS), were noted over the years. Possible reasons are infection with different serotypes, concurrent/sequential infection of more than one serotype, and differences in host immune responses associated with host genetic variations.