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.

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.

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.

Comparison of achievement of NICE targets in type 2 diabetes in Riyadh, Saudi Arabia and Grimsby, United Kingdom: an audit.

OBJECTIVE: To compare the achievement of NICE guidelines for diabetic care at two hospitals in Riyadh, Saudi Arabia and Grimsby, United Kingdom. METHODS: Electronic records of type 2 diabetic patients followed up at internal medicine clinics at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia and Diana Princess of Wales Hospital (DPWH), Grimsby, United Kingdom were studied and compared for meeting the NICE standards of diabetic care regarding HbAlc, lipid profile, hypertension and urine dipstick testing and control. RESULTS: Out of 100 patients studied at each hospital, yearly blood pressure recording, HbA1c, lipid profile and urine dipstick testing were done in 95, 89, 84, 51 and 100, 81, 92, 95 percent at KAMC and DPWH, respectively. Patients achieving the NICE targets for overall, systolic, diastolic blood pressure and HbA1c screening at the two hospitals were 53, 55, 18 and 46, 39, 35 % respectively. For lipid profile, those who achieved the NICE targets for total cholesterol and LDL-C for two hospitals were 54, 51 and 71, 75% respectively. CONCLUSION: NICE standards of diabetic care are not met in many of the patients in Saudi Arabia as well as United Kingdom, indicating that these standards are easy to recommend than to achieve. There is a need to investigate the reasons for this failure so as to adopt realistic targets and better multidisciplinary approach to achieve them.

Clinical characteristics of patients with atrial fibrillation at a tertiary care hospital in the central region of Saudi Arabia.

OBJECTIVE: To report on the clinical presentation, etiology, and laboratory features of acute and chronic atrial fibrillation (AF) in a tertiary hospital in Riyadh, Saudi Arabia. MATERIALS AND METHODS: We retrospectively studied records of 720 patients with AF seen in outpatients and inpatients departments at King Abdulaziz Medical City, Riyadh, during the period of 1 January 2002 to 31 August 2008. RESULTS: Documented acute and chronic AF was present in 157 (21.8%) and 563 (78.1%) patients, respectively. Palpitations, dizziness and syncope were the most frequent symptoms in acute AF, while dyspnea and palpitations were the most common symptoms in the chronic type. Acute respiratory problems and acute myocardial infarction were significantly more common in acute AF, while congestive heart failure and acute respiratory problems (chest infection, bronchial asthma, and pulmonary embolism) were significantly more common in chronic AF. The most common causes of both types of AF were diabetes mellitus (DM) in 68.8%, hypertension (HTN) in 59.3%, chronic lung diseases (bronchial asthma, chronic obstructive pulmonary disease and interstitial lung disease) in 31.8%, valvular heart disease in 23.6%, and ischemic heart disease (IHD) in 23.1%. In 9 (1.3%) patients, no cause was detected. The echocardiographic findings of left ventricular hypertrophy, valve lesions, and depressed left ventricular function were significantly more common in chronic AF (P<0.01). CONCLUSIONS: Nowadays, DM, HTN, and IHD are becoming the most common predisposing factors for AF in the central region of Saudi Arabia and require prevention and control.

Extremely elevated erythrocyte sedimentation rate: etiology at a tertiary care center in Saudi Arabia.

OBJECTIVE: To evaluate the etiology of extremely elevated erythrocyte sedimentation rate (ESR) in adolescents and adults at a tertiary care center. METHODS: This retrospective, cross-sectional, observational study was carried out at King Abdulaziz Medical City, Riyadh, Saudi Arabia using the Westergren method of determining ESR in adolescents and adults aged >or=12 years. The patients included inpatients and outpatients with medical, surgical, and gynecological problems. During a period from June 2007 to October 2008, consecutive, non-repetitive patients with ESR >or=100 mm/hour were evaluated for possible etiology by checking the electronic and paper data file of each patient. RESULTS: During the study period, out of the 44,366 ESR tests carried out at this center, 1864 (4.2%) had an ESR >or=100 mm/hour belonging to 567 patients. Out of 508 patients fulfilling the study criteria, the main associated causes included: infections (38.6%), autoimmune diseases (15.9%), malignancy (15.4%), miscellaneous causes (10.2%), ischemic tissue injury or trauma (8.7%), and renal diseases (8.4%). Ten common individual causes included: rheumatoid arthritis (7.3%), osteomyelitis (6.9%), tuberculosis (5.5%), trauma (5.3%), lymphoma and sepsis of unknown origin (5.1%) each, urinary tract infection (4.7%), septic arthritis (3.1%), abscesses (2.8%), and pregnancy (2.2%). Fourteen (2.4%) patients had no known cause. CONCLUSION: Most of the patients with extreme ESR elevation have an underlying cause and a focused evaluation of such patients needs to be carried out to reach a diagnosis.

Oral lesions in Saudi renal transplant patients.

Renal transplantation has evolved as the best treatment option for patients with end-stage renal disease. Different oral problems arise in these patients, either as a direct consequence of drug-induced immunosuppression or pharmacokinetics. To determine the prevalence of intra-oral lesions in a group of medically stable Saudi renal transplant patients (RTP) and to identify possible risk factors, in comparison with age and sex-matched healthy control subjects (HCS), we studied 58 RTP and 52 HCS. All subjects had a thorough oral examination and oral lesions were diagnosed according to the clinically accepted criteria. Gingival overgrowth (GO), erythematous candidiasis (EC) and hairy leukoplakia (HL) were diagnosed in RTP with prevalence of 74.1%, 15.5%, and 8.6%, respectively. The severity of the gingival overgrowth significantly correlated with the use of cyclosporine and nifedipine combination therapy, serum cyclosporine, and serum creatinine level. In conclusions, the finding of our study strongly propose that RTP should undergo routine and regular comprehensive oral examination, and any suspicious lesion must be investigate and treated.

Acute myeloblastic leukemia in a patient with primary antiphospholipid syndrome.

Antiphospholipid syndrome is characterized by venous and arterial thrombosis, recurrent pregnancy loss and the presence of the lupus anticoagulant, anticardiolipin antibodies or both. Antiphospholipid syndrome may occur as a primary disease or in patients with systemic lupus erythematosus or other autoimmune, infectious or neoplastic disorders. In this paper we report a 29-year-old Saudi female, a known case of antiphospholipid syndrome, presented with complaints of fever, breathlessness and generalized fatigue. Further investigations confirmed her as a case of myeloblastic leukemia (M1, French-American-British classification). Acute myeloblastic leukemia is not described to be associated with primary antiphospholipid syndrome in the literature to date. This is the first case report of such association.