Audit of diabetic care in a saudi primary care setting.

OBJECTIVE: To audit the care offered to diabetic patients attending the Family and Community Medicine Clinic (FAMCO), King Faisal University, Kingdom of Saudi Arabia (KSA). DESIGN: A cross-sectional study of medical records of 45 diabetic patients who regularly visited the clinic during a one-year period from June 1997 to May 1998. SUBJECTS: Patients who presented at the clinic because of non-insulin-dependent diabetes mellitus (type II). RESULTS AND CONCLUSIONS: The level of care for diabetic patients was relatively inappropriate, and some important parameters were under-recorded. Specific measures to improve and promote diabetic care in FAMCO clinics need to be undertaken. These include formulating and using protocols for diabetes management and better training of health-care providers.

Studies of preventive nephrology: self-urinalysis as a feasible method for early detection of renal damage.

The ever expanding pool of ESRF patients is exerting considerable strain on the health care resources of all nations of the world. Rationing, in one form or the other has therefore become the norm for most countries. Because dialysis prolongs life and is more readily available, and because ethically acceptable donor kidneys remain in short supply, thus limiting the potential of renal transplantation, this rather exasperating situation is bound to continue unless the entry point into the pool can be actively tacked. As part of our initial effort in this direction, we have examined the feasibility of self urinalysis by the general population as an epidemiological tool for detecting evidence of early renal damage by a total population cross-sectional survey of Faizia East Primary Health District (FEPHD) of Buraidah, capital city of the Gassim region of Saudi Arabia. Out of a de facto population of 7,695, 75.37% (5,800) cooperated fully. Majority of those who could not cooperate (881 [11.44%]) were infants and children. A total of 969 subjects (12.59%), mostly males at work, were not available. Only 45 (0.58%) subjects refused to participate. Housewives were significantly more amenable to the organisation of family self-urinalysis than head of the family (92.2% vs 61.4%; chi square = 321.78; df: 3; P < 0.0001). The mean family size was 7.82 (+/- SD: 3.82). Above the age of 4 years, 66.5% of males (2108/3170) as against 81.7% of females (2,641/3232) were able to carry our self-urinalysis. 11.76% of boys and 8.5% of girls below the age of 5 years were able to carry out self-urinalysis. Only 0.05% of male subjects and 0.03% of females failed to interpret colour change for proteinuria correctly. Similar remarkable competence was demonstrated for glycosuria by the population. We conclude that self-urinalysis is quite feasible in the general population, even if illiterates, if young. It can form a sound foundation, if properly harnessed, for a renal registry.

Some aspects of the pattern of systemic hypertension in the adult population of Gassim, Saudi Arabia: age distribution of the subsets of hypertensives.

As part of our studies in prevent nephrology, we have recorded causal blood pressure during a total population cross-sectional survey of the Faizia East Primary Health District of Buraidah (FEPHD), capital of Gassim region of Saudi Arabia. Out of 5671 subjects whose blood pressure could be recorded, 2222 were above 19 years of age and constituted our adult population. For this report, hypertension have been defined as equal to and greater than 140/90 mm Hg. Total hypertensive population had been divided into three subsets, based on this basic definition, namely combined systolic and diastlic hypertension (S/DHPN), isolated systolic hypertension (ISHPN) and isolated diastolic hypertension (IDHPN), a format which is not generally clear in previous studies on the subject. The overall prevalence of systemic hypertension was found to be 23.58%, which is lower than the figure of 36% for USA (pre-primary prevention intensive campaign). It is assumed that all the three subsets mentioned above have been used in calculating the latter. Although males tended to be more hypertensive than females (OR = 1.22; Chi Square = 3.89; P = 0.05; C.I.: 1.00 < OR < 1.49), the marginal difference (25.7% vs 22.10%) was largely due to the IDHPN subset (OR = 1.73; Chi Square = 4.48; P = 0.034; C.I.: 1.01 < OR < 2.96). In both the S/DHPN and ISHPN: statistical significance was not achieved. Significantly, ISHPN subset constituted the bulk--56.68%--of the hypertensive population while IDHPN constituted the least--11.64%. When analysed into 10-year-age cohorts, ISHPN showed the steepest rise in prevalence with age. Rather suprisingly, the IDHPN did not rise with advancing age while the S/DHPN slope was in between the two. We are unable to identify this pattern in our literature search on the subject. We cannot assess its significance by this study, but we wonder whether or not it carries any prognostic significance in terms of target organ damage. It is possible that this pattern may be peculiar to the sub-region but it certainly is not spurious and in our view deserves further scrutiny. We wish to suggest that clear definition of the three subsets of hypertensive population should be mandatory when defining prevalence. This may provide some further clues in the prognosis and pathogenesis of target organ damage.

Blood pressure pattern in Saudi population of Gassim.

Blood pressure pattern for the Kingdom of Saudi Arabia has not been defined. In a total cross-sectional population survey of the Faizia East Primary Health District of Buraidah, capital of Gassim region, Saudi Arabia, 5671 subjects out of a de facto population of 7695 got their blood pressure recorded. The study district consisted of an urban section and a rural sector. Mean systolic and diastolic blood pressure were computed for the total population in conventional 5-year age cohorts as well as in an arbitrary functional age groups. The curve pattern and trends of the percentiles, were defined. Mean blood pressure (systolic and diastolic) was found to rise with age in both genders (male SBP: r = 0.66, P < 0.000001: female SBP: r = 0.58, P < 0.00001; male DBP: r = 0.53, P < 0.00001; female DBP: r = 0.45, P < 0.00001) and to correlate significantly with BMI. Both systolic and diastolic values were consistently higher in females than males. Overall means (+/- SD) were: for SBP, male 109.9 (+/- 21.57) vs female 114.33 (+/- 21.22) mm Hg; df: 5669: P < 0.00000; CI: -5.5, -2.0; for DBP, male 62.85 (+/- 16.89) vs female 64.67 (+/- 14.99) mm Hg; df: 5669; P < 0.0000; CI: -2.65, -0.989. Proteinuria (macroalbuminuria) was found to correlate positively and very significantly with both systolic and diastolic blood pressure: for SBP: r = 0.074, P < 0.0001; DBP: r = 0.055, P < 0.0001. Perhaps more significantly, in the context of preventive nephrology, is the observation that the intercept of the regression line with blood pressure was below the level conventionally regarded as hypertensive, suggesting that nephron damage may have occurred at this lower level. Overall mean diastolic blood pressure but not systolic was found to be significantly higher in the rural environment than the urban setting: mean rural DBP: 66.43 (+/- 15.699) vs urban: 62.78 (+/- 78); P < 0.00001; rural SBP: 113.71 (+/- 23.95) vs urban: 112.69 (+/- 19.87), P = NS. No discernible effect of consanguinity in marriage on blood pressure could be detected in this study but we believe that further details are required before a definite statement can be made on this important subject. The percentiles presented can only be regarded as foundation figures requiring further validation before they can be useful in determining cut-off levels for hypertension for the Saudi population.

Body mass index (BMI) in the Saudi population of Gassim.

In a total cross-sectional population survey of the Faizia East Primary Health District of Buraidah, Gassim region of Saudi Arabia, 6,044 (2727 male and 3317 females) subjects out of a de facto population of 7695 got their BMI computed because infants and restless or bedridden subjects could not be examined. Mean (+/- SD) and percentiles (25th & 75th) were calculated in the conventional 5-year age cohorts as well as in functional age groups, namely, 0-5, 6-12, 13-49, 50-69 and 70+ years. 5th, 10th, 25th, 50th, 75th, 90th and 95th percentiles were computed only for the functional age groups. In general, the trend was for BMI to increase with age in both genders but the curve pattern showed some plateauing from about the age of 50 with slight decline in later life. Females had significantly higher indices than males, this becoming quite prominent from the 10-14 year age cohort. This difference persisted irrespective of the types of age grouping or residential location. Overall means (+/- SD) were 20.14 +/- 5.98 vs 22.22 +/- 7.21 for males and females respectively; df: 5771; p = 0.0000; 95% CI: -2.43, -1.735. Subjects in the urban living environment had significant higher indices than their rural counterpart: (21.666.92 vs 20.446.33: df: 5771; P = 0.0000; 95% CI: 1.595, -0.840). From the age of 15 about one quarter of females are overweight (BMI at the 75th percentile > 25) and from 30 years the same proportion are frankly obese (BMI > 30). Both systolic and diastolic blood pressure were significantly positively correlated with BMI in both genders: male SBP: r = 0.22, P < 0.0001; male DBP: r = 0.21, P < 0.00001; female DBP: r = 0.18, P < 0.00001.

Studies on preventive nephrology: Systemic hypertension in the pediatric and adolescent population of Gassim, Saudi Arabia.

Casual blood pressure was recorded for subjects of Faizia East Primary Health District during a cross-sectional population survey. Valid information was obtained from 5671 subjects, out of which 3299 (1561 males and 1738 females) were between the ages of three and 18, constituting therefore the pediatric/adolescent (P/A) sector of our study population. The prevalence of hypertension (HPN), defined as A(3) 95th percentile for total HPN population (mild and severe) and A(3) 99th percentile for severe, was calculated for the three-year age cohorts suggested by the Task Force on Blood Pressure Control in Children (1987). The three subsets of HPN were derived from the suggested cut-off levels without any modifications. Overall prevalence of HPN was, for the P/A, found to be 10.65% (351/3299). Females in all the age cohorts were significantly more hypertensive than males, overall gender prevalence being 7.94% (124/1561) for males against 13.06% (227/1738) for females: P=0.0000019; CI: 0.45

Utilization of laboratory investigations in primary health care centers in Al-khobar, saudi arabia.

OBJECTIVE: The objective of this study was to determine the pattern of utilization of laboratory investigations in the Al-Khobar area of Saudi Arabia. MATERIAL AND METHODS: A two-stage sampling design was used to select a Family Health Records checklist. At the first stage, 5 Primary Health Care Centers were selected out of 9 using a random sampling method. A Family Health Records checklist was selected using a systematic sampling design from each selected Primary Health Care Center at the first stage. RESULTS: The results showed that laboratory investigations were used for 49% of the sample population tested. Of these, 84% recorded a maximum of 3 laboratory tests. In over half of the cases, the tests were inappropriately utilized, 37.8% were underutilized and 13.2% were over-utilized. There was no significant difference in the pattern of utilization between males and females and between Saudi and non-Saudi patients. However, laboratory services were utilized more for patients above the age of 40 years, where an average of 2.1 tests per patient was recorded. CONCLUSION: There was a significant difference between primary health care centers regarding pattern of laboratory utilization. Respiratory disease accounted for the majority of the health problems, followed by diabetes mellitus and hypertension. Microbiology was the most heavily used investigation followed by biochemistry and hematology. Urinalysis was the most frequently requested test followed by blood glucose and complete blood count (CBC). This study highlighted the problems in the utilization of laboratory investigations and led to a number of solutions and recommendations.

Contrasting influence of the living environment and gender on systemic hypertension in Saudi population of Gassim, Saudi Arabia.

In a cross-sectional total population survey of Faizia East Primary Health District of Buraidah, which is divided into an "urban" and "rural" sections, casual blood pressure was recorded in 5671 subjects. 2222 (910 males) were adults (> 19 years). 3299 (1561 males) were between 3-18 years, making the paediatric/adolescent cohort of the population. The rest were below 3 years and were not included for calculations in this report. For adults, HPN was defined as > or = 140/90 mm Hg and P/A it was > or = 95th percentile for the age cohorts 3-5, 6-9, 10-12, 13-15 and 16-18 years as recommended by The Task Force for Blood Pressure Control in Children (1987). Each of the three subsets of HPN were derived from these basic definitions without modification. In the adults population, overall prevalence (S/DHPN + ISHPN + IDHPN) was 23.58% (524/2222) and gender prevalence was marginal in favour of males (25.71 vs 22.1% for males and females respectively; OR: 1.22, chi square = 3.89; p = 0.05; CI: 1.00 < OR < 1.49). By contrast, overall HPN prevalence in P/A was 10.64% (351/3299) and in all the age cohorts, girls were very significantly more hypertensive than boys. Overall figures were 13.06 vs 7.94% respectively for girls and boys; OR: 0.57; chi square = 22.65; p < 0000019; CI: 0.45 < OR < 0.73. Only in severe HPN (> or = 99th percentile) in 16-18 year age cohort did male preponderance become obvious. When the influence of the living environment was examined, in adult population (urban: 40,001; rural: 1670 subjects), for all age cohorts the rural environment which is largely inhabited by the unsophisticated Bedouins living close to their livestock, significantly predisposed to HPN as compared to the urban setting. Overall figures are 19.95 vs 32.60%, urban vs rural respectively: OR: 0.52; chi square = 40.4; p < 0.000000; CI: 0.42 < OR < 0.64. On the other hand, in the P/A population (2301 urban, 998 rural) for the age cohorts 3-5 and 6-9 years the urban environment significantly predisposed to HPN. At 10-12 years the prevalence was virtually even (12.65 vs 12.71%; OR: 0.99; p: NS). Thereafter, i.e. 13-15, 16-18 year cohorts, the rural environment became more dominant, just like the adult pattern. In other words whatever the factors in the unsophisticated Bedouin "rural" setting which predisposes to HPN does not become operative until after childhood--after 12 years. This contrasting gender and environmental influence in our study population seems unique, being reported for the first time. It may be pointing us in new direction in the elucidation of the pathogenesis of HPN and should deserve further studies.

Utilisation of health services by the primary health care centres-registered elderly people in burraidah city, saudi arabia.

OBJECTIVE: To assess the pattern of and factors associated with geriatrics' utilisation of health services. DESIGN: A cross-sectional, study involving a random sample of 266 elderly subjects registered in the primary health care centres in Burraidah city, Saudi Arabia. SETTING: The primary health care centres in Qassim Region, Saudi Arabia. METHODS: Data was collected from PHC centres-registered elderly subjects at their homes. Information including utilisation of primary health centres, hospital admissions and duration of hospital stay were recorded. RESULTS: The response rate was 96.7%. Twenty percent of the sample had not used any health services facility during the previous year. Two-thirds of subjects made visits to the primary health care centres, majority of them having made 6 visits or less. Significant factors positively associated with those visits were female, advancing age, and having a family. Three-quarters of the sample did not have hospital admissions. Significant factors positively associated with admissions were diabetes mellitus, hypertension, paralysis, advanced age, and living with a family. CONCLUSIONS: Geriatric health services utilisation by the study sample is affected by family ties and the high prevalence of chronic diseases. Subjects living alone or crippled by immobility may not be able to utilise available health services properly. Community based geriatrics services can help this vulnerable group.

Survival after stroke in saudis : a hospital based study.

BACKGROUND: Prognosis of stroke has been studied in various population. Factors adversely affecting short term survival include impaired consciousness, leg weakness and increasing age. AIM OF THE STUDY: In this study, the prognostic effects of age, sex, hypertension, diabetes mellitus and presentation in coma on the survival pattern of stroke patients presenting to a referral hospital, are reviewed. METHODOLOGY: The medical records of all patients hospitalized with definite stroke at King Fahd Specialist Hospital, Buraidah, for the period between June 1986 and June 1991, were reviewed. The Cranial CT Scans were also reviewed. RESULTS: One hundred and seventy four patients, 106 males and 68 females, with a mean age of 64 years who had definite stroke were studied to estimate overall survival and the various risk factors influencing it. The case records and cranial CT scans were reviewed. CONCLUSION: The factors adversely affecting survival in this study, were age above 60 (P<0.04), presentation in coma (P<0.003) and pre-existing heart disease (P<0.0009). There was no significant effect on survival due to sex, hypertension and/or diabetes mellitus.

Utilization of laboratory investigations: study of knowledge, attitude and practice among primary care physicians.

OBJECTIVES: The aim of the study was to assess the physicians' knowledge, attitude and practice towards laboratory services in the primary health care (PHC) centers at Al-Khobar area. METHODOLOGY: Five primary health care centers were selected out of 9 (56%) from the Al-Khobar area. Twenty physicians (33%), in these primary health care centers were included. A questionnaire was given to all physicians to explore the knowledge, attitude and practice. RESULTS: All physicians considered laboratory investigations an essential service that contributed to the management of their patients most of the time. Knowledge and practice of most (80% of them) regarding laboratory investigations was between fair to good but the attitude of 80% of them was poor since postgraduation experience was the only factor which influenced their practice. CONCLUSIONS: There has been an increase in number of Saudi physicians working in the Primary Health Care Centers. The quality of the current laboratory services was deficient according to 30% of physicians. They considered that investigations were essential for primary health care centers. And finally the utilization of laboratory tests in the Kingdom of Saudi Arabia was higher than many developing countries.

Studies on preventive nephrology: pattern of the subsets of hypertension in the paediatric, adolescent and adult population of Gassim, Saudi Arabia.

As part of our studies in preventive nephrology, we have recorded the casual blood pressure during a total population cross-sectional survey of the Faizia East Primary Health District (FEPHD). A total of 5671 subjects had adequate records. Of these 2222 were adults (> 19 years). The prevalence of systemic hypertension (HPN) was calculated, using as cut-off levels, > or = 140/90 for the adult population and > or = 95th percentile as recommended by the Task Force for Blood Pressure Control in Children (1987) for the paediatric and adolescents (3-18 years). Using these definitions without modification, the three subsets of HPN viz. combined systolic/diastolic (S/DHPN), isolated systolic (ISHPN) and isolated diastolic (IDHPN) were derived for each of the age cohorts studied-10-year age cohorts for the adults and the Task Force 3-year age cohorts for the paediatric/adolescent (P/A) population. In both adult and P/A population ISHPN constituted the bulk of the hypertensive population (56.68% for the adults and 51.57% for P/A). the IDHPN subset was the least for adults making up 11.64% while the S/DHPN was in between constituting 31.68%: For the P/A population S/DHPN was the least, 15.95% and IDHPN (32.48%) was in between. When distributed into 10-year age cohorts for the adults, ISHPN showed the steepest gradient depicting increasing prevalence with advancing age. On the other hand, IDHPN did not rise with age; if at all, it tended to fall. The slope for S/DHPN was sandwiched in between. For the P/A population, for all the 3-year age cohorts, and for all the three subsets, there was an initial peak in childhood followed by a decline in adolescence. However, some variations were discernible in each subset. ISHPN in girls peaked at 10-12 before declining but in boys it virtually followed an even keel. IDHPN, in both boys and girls peaked sharply at 6-9 before a rapid decline in prevalence into adolescence. S/DHPN also peaked at 6-9 but both the upward slope and the subsequent decline were more gentle than the other subsets. When viewed together for our study population, assuming equivalence in cut-off levels for HPN, both ISHPN and S/DHPN seem to exhibit a bimodal curve, with one peak in childhood and a second rise in adulthood continuing into old age. IDHPN showed a unimodal curve, with the one peak in childhood followed by a continuing decline through adolescence into adulthood to virtual disappearance in old age. We believe these slopes may have prognostic significance which are not entirely clear at the moment but our findings reinforce the importance of the systolic blood pressure and that diastolic blood pressure alone should no longer be used as the index treatment or complication of high blood pressure.

Breast cancer in a low-risk population. The influence of age and menstrual status on disease pattern and survival in Saudi Arabia.

Data on 130 women with invasive breast cancer, seen at our institution between April 1981 and November 1990, were retrospectively reviewed to assess the influence of age and menstrual status on the pattern and prognosis of their disease. Patients were mostly young (median age 40 years) and in 21 patients (16%) the diagnosis was established at the age of 30 years or younger. Eighty-six patients (66%) were under 50 and 82 patients (63%) were pre-menopausal. Pre-menopausal patients were more numerous than expected in stage III and less numerous in stage II. On the other hand, the differences between observed and expected values for both stage I and stage IV in the 2 menopausal groups were not significant. Compared with post-menopausal patients, pre-menopausal patients with 1-3 or greater than 3 positive lymph nodes were more numerous than expected. Differences between pre-menopausal and post-menopausal patients have persisted after categorizing patients into 2 age-groups with a cut-off point at 50 years. Comparable initial assessment and therapeutic modalities were offered to the 2 menopausal groups. At the time of analysis (January, 1991) all patients had a complete follow-up. Over a median follow-up of 46 months, the overall median survival (+/- SE) was 85.7 (+/- 4.4) months with a survival probability (+/- SE) at 5 years of 62% (+/- 5%). The proportional hazard model of Cox has identified advanced stage (stages III and IV) and involvement of lymph nodes as the only independent adverse predictors of survival with estimated hazard rates of 2.9 and 2.8, respectively. Unadjusted analysis, adjusted analysis and stratified survival functions failed to reveal any survival difference based on age or menstrual status. We conclude that, in a low-risk population and despite apparent baseline differences in demographic and disease characteristics between pre-menopausal and post-menopausal breast cancer patients, neither age nor menopausal status had a significant influence on survival. Our results should guide future cancer-care programs in Saudi Arabia.

Community acquired acute bacterial and atypical pneumonia in Saudi Arabia.

BACKGROUND: Rational treatment of pneumonia requires knowledge of the likely aetiological diagnosis in any community. Little is known about the pattern and outcome of pneumonia in Saudi Arabia. METHODS: A total of 567 pneumonic episodes in adult patients from the Al-Qassim area were reviewed retrospectively. RESULTS: Patients had a mean age of 42.7 years, with 103 patients (18%) aged 13 to 20 years and 103 (18%) aged 60 or more. Almost two thirds of the episodes (64%) occurred in men. An aetiological diagnosis was established in 351 (62%) cases, with 145 episodes being due to pneumococcal infection and 129 to Mycoplasma pneumonia. Inhospital mortality was 6% (35 patients). Age over 60 years, aspiration pneumonia, and Gram negative infection were the only factors that independently predicted adverse outcome on adjusted mortality analysis. CONCLUSION: This analysis of pneumonia in the Al-Qassim area indicates the pattern and prognosis of acute bacterial and atypical pneumonia that requires admission to hospital in the central region of Saudi Arabia. It should provide a basis for developing rational treatment for community acquired pneumonia in Saudi Arabia.

Women's knowledge of and attitude toward breast cancer in a developing country: implications for program interventions--results based on interviewing 500 women in Saudi Arabia.

We interviewed 500 adult females without personal history of any type of cancer to assess their awareness and attitude toward various aspects of breast cancer. The mean age (SD) of participants was 31.6 (+/- 8.5) years with a range of 18 to 62 years. After control for level of education, age was not found to be a statistically significant factor that influenced participants' performance. Also not statistically significant was the history of having a relative who had cancer. Conversely, education was the only examined factor that correlated with interviewees' awareness and attitude. Individuals with university or higher education (level III) were more knowledgeable (statistically significant) than uneducated or those with only primary schooling (level I), or those participants who only had intermediate or high school education (level II). On the other hand, the responses of those individuals with education level I generally performed in a fashion similar to those at education level II. The general outcome of this exercise was that unacceptably high proportions of females at all education levels were either wrong or uncertain about some fundamental aspects of breast cancer etiology, risk factors, clinical features, detection methods, and management. Also shown was the relatively high percentages of those, particularly in education level I, who held misconceptions about unconventional management or the complications of conventional methods. We conclude that academic education alone is not enough to assure that recommended health behaviors will be adopted. For establishing cancer health education or cancer prevention and early detection programs, primary care physicians and community cancer centers should work jointly. Brief guidelines are proposed.