The risk of tuberculosis infection in 410 Saudipatients receiving adalimumab therapy.

BACKGROUND: Adalimumab is a fully humanized monoclonal antibody inhibitor of tumor necrosis factor-a used to treat various autoimmune disorders. Adalimumab poses a risk for tuberculosis (TB) infection, especially in countries where TB is endemic. OBJECTIVE: Determine the rate of TB infection after adalimumab therapy in Saudi Arabia. DESIGN: Medical record review. SETTINGS: Tertiary care center in Riyadh. PATIENTS AND METHODS: Demographic and clinical data were retrieved from the electronic healthcare records of all patients who received adalimumab treatment from 2015 to 2019. MAIN OUTCOME MEASURES: Occurrence of TB after adalimumab therapy. SAMPLE SIZE: 410 patients (median ([QR] age, 37 [28], range 4-81 years), 40% males RESULTS: Rheumatoid arthritis was the most frequent indication (n=153, 37%). The patients were followed for a mean of 36 (8.9) months. No case of TB infection or reactivation was observed. An inter-feron-gamma release assay (IGRA) was requested in 353/391 (90.3%) patients, prior to initiating therapy. The IGRA was positive in 26 cases (6.6%). The IGRA-positive patients received isoniazid prophylactically. Bacterial infectious complications of adalimumab therapy occurred in 12 (2.9%) patients. Urinary tract infection was the most frequent complication (culture requested in 48 patients, positive in 8). CONCLUSION: Adalimumab treatment was not associated with a risk of TB disease or TB reactivation in our cohort over the follow-up observation period. No TB reactivation occurred with adalimumab therapy when TB prophylaxis was used. The positive IGRA rate in patients on adalimumab treatment was low (7%). LIMITATIONS: Single center and one geographical area in Saudi Arabia. CONFLICT OF INTEREST: None.

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.

Family Satisfaction in Critical Care Units: Does an Open Visiting Hours Policy Have an Impact?

For critically ill patients, the interaction between health care providers and family members is essential in daily decision making. Improving this relationship has a positive impact on satisfaction with the overall care provided to patients and reduces family member symptoms of depression, anxiety, and posttraumatic stress disorder. In this study, we analyzed the impact of visitation policy (open versus restricted) on family satisfaction using the previously well-validated Critical Care Family Satisfaction Survey (CCFSS) questionnaire. METHODS: This is a cross-sectional prospective observational study conducted between November 1, 2009, and January 31, 2010, in 2 critical care units with 2 different visiting policy systems, unit A (open visiting hours) and B (restricted visiting hours), comparing family satisfaction in both units using the CCFSS questionnaire. Responses were grouped in 5 satisfaction constructs, namely, the support construct, which assesses the degree of satisfaction with the support of the intensive care staff as perceived by relatives; the assurance construct, which assesses the degree of satisfaction regarding honest answers being given and the responder's confidence that the patient is receiving the best care possible; the proximity construct, which assesses the degree of satisfaction with the physical and emotional access to the patient; the information construct, which assesses the degree of satisfaction with the adequacy of information given to relatives; and the comfort construct, which assesses satisfaction with physical comfort and amenities. RESULTS: During the study period, 115 questionnaires were distributed in each of the 2 sites. The response rates in units A and B were 92% (106) and 100% (115), respectively. The mean stay time in the intensive care unit was 3.7 days. There were more trauma cases in unit A and more cardiac patients in unit B. There was no significant difference between the 2 units in any of the 5 satisfaction constructs, the support, assurance, proximity, information, and comfort constructs, although there was a nonsignificant trend favoring the unit with the more liberal visit policy regarding amenities (unit A). CONCLUSIONS: We concluded that family satisfaction to care provided in intensive care as measured by the CCFSS questionnaire was not influenced by frequency of visitation among Saudi families. Factors other than open visiting hours may be important to evaluate.

Acute respiratory distress syndrome complicating community-acquired pneumonia secondary to mycobacterium tuberculosis in a tertiary care center in Saudi Arabia.

OBJECTIVES: To discuss our center's experience with acute respiratory distress syndrome (ARDS) secondary to pulmonary tuberculosis (TB) in a major tertiary referral hospital in the Kingdom of Saudi Arabia. METHODS: A retrospective review of medical records of all patients with community-acquired pneumonia secondary to mycobacterium TB infection who were admitted for critical care in a single center of King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia from 2004 to 2013. RESULTS: In our review of 350 patients with community-acquired pneumonia admitted to Intensive Care Unit, 11 cases of TB complicated with ARDS were identified. The mean age of patients was 51.9 years. The median time from hospital admission to pulmonary TB diagnosis and start of therapy was 5 days, while the median time from onset of symptoms to initiation of treatment was 18 days. The mortality rate was 64%, and the median length of hospital stay before death was 21.4 days. Delayed treatment, as well as high acute physiology and chronic health evaluation II and CURB-65 scores at presentation, were independent risk factors for death.  CONCLUSION: Patients with pulmonary TB infrequently present to intensive care with acute symptoms that meet all criteria for ARDS. Such a presentation of TB carries a high mortality risk.

Community- versus nosocomial-acquired severe sepsis and septic shock in patients admitted to a tertiary intensive care in Saudi Arabia, etiology and outcome.

BACKGROUND: Sepsis syndrome is a major worldwide cause of morbidity and mortality. While community-acquired severe sepsis and septic shock constitutes a major cause of admission to the intensive care unit, hospital-acquired severe sepsis and septic shock remain major preventable causes of ICU admission. This study evaluates the rate, etiology, complication and outcome of community- and hospital-acquired sepsis in a tertiary care hospital in Saudi Arabia. METHOD: This is a retrospective evaluation of all admissions with severe sepsis and septic shock to a general intensive care unit over a period of six months. RESULTS: A total number of 96 patients were included, which represented 15% of the total number of admissions during the study period. The mean age was 57.4 (SD 21). Sixty percent of cases were due to hospital-acquired infections, and 40% were community-acquired. The majority of the infections acquired in the hospital occurred in medical wards and intensive care units (27% and 21%, respectively). At least one co-morbid condition was present in 94% of the sample patients, with cardiovascular disease and diabetes being the most frequently encountered disorders (58%). Both community and hospital-acquired severe sepsis and septic shock carry very high mortality (58%). The ICU length of stay was significantly longer for hospital and ICU acquired infections. CONCLUSION: Both community and hospital-acquired infections carry high mortality. Hospital-acquired severe sepsis is frequent in medical wards and ICUs, and measures to further evaluate risk factors are prudent.

Ultrasound-guided core biopsy in the diagnostic work-up of tuberculous lymphadenitis in Saudi Arabia, refining the diagnostic approach. Case series and review of literature.

OBJECTIVE: Tuberculous cervical lymphadenitis is the most common presentation of extrapulmonary tuberculosis (TB) in Saudi Arabia and worldwide. Obtaining a tissue biopsy for culture and histopathology is frequently needed to establish the diagnosis. The available diagnostic tools include excisional surgical biopsy, fine needle aspiration (FNA) and ultrasound-guided core lymph node biopsy. We present a single center experience of the use of ultrasound-guided core lymph node biopsy as a diagnostic tool for tuberculous lymphadenitis. METHODS: A retrospective review of the interventional radiology database for all of the patients with cervical lymphadenopathy undergoing ultrasound-guided core biopsy at King Abdulaziz Medical City-Riyadh, Saudi Arabia from January 1 2008 to December 30 2011. The data were the patient demographics, clinical characteristics, biopsy method and pathological and clinical diagnoses. RESULTS: Five cases underwent ultrasound-guided cervical lymph node biopsy during the study period. A total of 55 cases underwent excisional cervical lymph node biopsy in the same period. The age of the patients who underwent the core biopsy ranged from 18 to 76 years old. All of the biopsies were performed as one-day surgery, and all of the patients were discharged on the same day with no complications. The final diagnosis was confirmed in all of the cases (100%); with tuberculosis being the diagnosis in four of the five cases (80%), and one case being diagnosed as lymphoma. CONCLUSION: Ultrasound-guided core biopsy is an underutilized procedure in our hospital and could be a very valuable asset in the diagnostic algorithm of tuberculous lymphadenitis in Saudi Arabia. The widespread use of the procedure would positively affect patient care, providing earlier diagnosis and treatment.

Physicians' attitudes toward reporting medical errors-an observational study at a general hospital in Saudi Arabia.

OBJECTIVE: : Accurate medical error reporting is crucial for reducing the occurrence of such errors and their adverse consequences. This study aims to investigate the views of physicians about medical error reporting in a tertiary care hospital in Saudi Arabia. METHODS: : This is a cross-sectional self-administrated survey study. All physicians in the hospital were invited to complete an anonymous survey questionnaire addressing demographic details, as well as attitudes, practice, and views on medical error reporting. RESULTS: : One hundred seven physicians completed the questionnaires (66.5% response rate). Mean (SD) age was 39.8 (9.0) years. One-fifth of the respondents worked in the emergency department, and half had a workload of 40 to 59 h/wk. The reason given by 41.1% for not reporting a medical error by a colleague was that "it is not their responsibility." However, the gravity of the outcome of a medical error by a colleague to the patient was thought to be an important incentive for reporting. Of the physicians, 43% agreed that they would conceal the occurrence of a medical error they incurred to "avoid punishment." Nevertheless, most of the respondents held the view that there exists an ethical underpinning for reporting medical errors and that reporting of medical errors serve a valuable purpose. CONCLUSIONS: : The physicians in our study are likely to disclose errors made by a colleague only if the error resulted in a severe damage to the patient, and as such, medical errors go underreported for a variety of reasons. It was felt that assurance of confidentiality and protection from backlash would promote medical error disclosure.