National Guidelines for Colorectal Cancer Screening in Saudi Arabia with strength of recommendations and quality of evidence

BACKGROUND: Colorectal cancer is the most common cancer among Saudi men and the third commonest among Saudi women. Given the predominance of colorectal cancer compared with other cancers in Saudi Arabia, context-specific guidelines are needed for screening. METHODS: Experts from the Saudi Society of Colon and Rectal Surgery, Saudi Gastroenterology Association, Saudi Oncology Society, Saudi Chapter of Enterostomal Therapy, Family Medicine and Department of Public Health at the Saudi Arabian Ministry of Health and a patient advocate was assembled by the Saudi Centre for Evidence-Based Healthcare, a subsidiary of the Saudi Arabian Ministry of Health. The panel collaborated with a methodological team from McMaster University, Canada to develop national guidelines for colorectal cancer screening. After identifying key questions, the panel conducted a systematic review of all reports on the utility of screening, the cost of screening for colorectal cancer in Saudi Arabia and on the values and preferences of Saudi patients. Meta- analyses, when appropriate, were performed to generate pooled estimates of effect. Using the GRADE approach, the panel used the evidence-to-decision (EtD) framework to assess all domains important in determining the strength and direction of the recommendations (benefits and harms, values and preferences, resource implications, equity, acceptability, and feasibility). Judgments related to the EtD domains were resolved through consensus or voting, if consensus was not reached. The final recommendations were developed during a two-day meeting held in Riyadh, Saudi Arabia in March 2015. Conflicts of interests among the panel members were handled according to the World Health Organization rules. LIMITATIONS: There is lack of national data on the incidence of adenomatous polyps or the age groups in which the incidence surges. There were no national clinical trials assessing the effectiveness of the different modalities of screening for colorectal cancer and their impact on mortality. CONCLUSION: The panel recommends screening for colorectal cancer in Saudi Arabia in asymptomatic Saudi patients at average risk of colorectal cancer. An infrastructure should be built to achieve that goal.(AU)

Characteristics, risk factors, and treatment practices of known adult hypertensive patients in saudi arabia.

Objective. To determine the prevalence, risk factors, characteristics, and treatment practices of known adult hypertensives in Saudi Arabia. Methods. Cross-sectional community-based study using the WHO stepwise approach. Saudi adults were randomly chosen from Primary Health Care Centers catchment areas. Data was collected using a questionnaire which included sociodemographic data, history of hypertension, risk factors, treatment practices, biochemical and anthropometric measurements. Collected data was cheeked, computer fed, and analysed using SPSS V17. Results. Out of 4719 subjects (99.2% response), 542 (11.5%) subjects were known hypertensives or detected by health workers in the past 12 months. Hypertension was significantly associated with age, gender, geographical location, education, employment, diabetes, physical inactivity, excess body weight, and ever smoking. Multiple logistic analysis controlling for age showed that significant predictors of hypertension were diabetes mellitus, ever smoking, obesity, and hypercholesteremia. Several treatment modalities and practices were significantly associated with gender, age, education, and occupation. About 74% were under prescribed treatment by physicians, 62% on dietary modification, 37% attempted weight reduction, 27% performed physical exercise, and less than 7% used herbs, consulted traditional healers or quitted smoking. Income was not significantly associated with any treatment modality or patient practices. Conclusion. Hypertension (known and undetected) is a major chronic health problem among adults in Saudi Arabia. Many patients' practices need changes. A comprehensive approach is needed to prevent, early detect, and control the disease targeting, the risk factors, and predictors identified.

Compliance to iron supplementation during pregnancy.

Iron deficiency anaemia is the most common nutritional disorder in the world. Pregnant women are at especially high risk of iron deficiency and anaemia because of significantly increased iron requirements during pregnancy. Iron supplementation during pregnancy has been recommended for women in the developing world, since usually no basic changes occur in the composition of the diet. This is a retrospective cohort study carried out in Al-Yamamah Hospital, Riyadh, Saudi Arabia, comparing the outcome of haemoglobin levels in 308 pregnant women near term with compliance to iron supplementation during the preceding pregnancy stages. Data were collected using an interview-based questionnaire for assessment of supplementation compliance and the women were divided into three categories: strictly compliant; partially compliant; and non-compliant. Haemoglobin levels were extracted from the medical records for the first antenatal visit (before 13 weeks' gestation) and compared with the level at entrance to the study at 36 weeks' gestation. Both Epi-info 2002 version 3.2 and SPSS version 10 were used for data analysis. Our results show that 49.7% used iron supplements continuously during the second and third trimesters of pregnancy; 38.3% reported partial use and 12.0% used no iron supplements. Haemoglobin levels improved significantly only among strictly compliant pregnant women, by 0.3 g/dl; decreased among partially compliant women by, 0.36 g/dl and significantly decreased among non-compliant, by -1.4 g/dl. Factors associated with non-compliance were education with a simple linear protective effect from being non-compliant. The percentage of anaemic women increased from 29.6% in the first trimester to 34% in the third trimester. Anaemia was significantly associated with non-compliance with iron supplementation, the adjusted OR was 6.19 95% CI 2.55-15.02, p < 0.0001. Strategies to improve compliance and effective iron supplementation among pregnant women should be implemented.

Second trimester termination of pregnancy for fetal anomaly or death: comparing mifepristone/misoprostol to gemeprost.

OBJECTIVE: To assess the effect of changing the regimen for second trimester induction of labour from gemeprost to mifepristone/misoprostol. DESIGN AND SETTING: A retrospective study at a university teaching hospital over the 5-year period 1993-1997. SUBJECTS, METHODS and REGIMENS: 68 patients, 34 in the gemeprost group and 34 in the mifepristone/misoprostol group. The gemeprost group received 1mg vaginally every 3h to a maximum of five doses. The mifepristone/misoprostol group were pre-treated with 600 mg mifepristone orally followed by 800 microg misoprostol vaginally and then 400 microg orally every 3h to a maximum of four oral doses. MAIN OUTCOME MEASURES: Induction to abortion interval; delivery within 24h. RESULTS: The mifepristone/misoprostol group had a lower induction to abortion interval compared to the gemeprost group (median 8.9h versus 19.8h, respectively, p<0.01). The mifepristone/misoprostol regimen was more successful than the gemeprost regimen; 94% versus 68%, respectively, aborted without extra medical or surgical intervention, p=0.02. There were no significant differences in side effects, analgesia requirements or complications between the two groups. Three patients with previous Caesarean sections had a ruptured uterus; two from the gemeprost group and one from the mifepristone/misoprostol group. CONCLUSIONS: The new mifepristone/misoprostol regimen was more effective in second trimester induction of labour. Induction of labour with misoprostol or gemeprost should be used with care in patients with a previous Caesarean section.

The misoprostol third stage of labour study: a randomised controlled comparison between orally administered misoprostol and standard management.

OBJECTIVE: To compare misoprostol with standard oxytocic regimens in the prevention of postpartum haemorrhage. DESIGN: Randomised controlled trial. SETTING: Obstetric unit in a large teaching hospital. METHODS: One thousand women randomised to 500 microg misoprostol given orally or to standard oxytocic regimens of oxytocin, oxytocin with ergometrine, or ergometrine. MAIN OUTCOME MEASURES: Incidence of postpartum haemorrhage and the incidence and severity of side effects. RESULTS: Postpartum haemorrhage occurred in 12% of women given misoprostol and in 11% of women given standard oxytocic drugs (relative risk (RR) 1.10, 95% confidence interval (CI) 0.79, 1.55). Blood loss of 1000 mL or more occurred in 2% of women in each group. Nausea, headache, dizziness and tiredness were less frequent with misoprostol (RR (95% CI) 0.71 (0.59, 0.84); 0.53 (0.38, 0.74); 0.73 (0.61, 0.87) and 0.88 (0.83, 0.94) respectively). The main side effects of misoprostol were shivering (RR 1.95, 95% CI 1.69, 2.25) and a rise in temperature (difference in mean rise 0.34 degrees C, 95% CI 0.26, 0.42). CONCLUSION: Oral misoprostol for the prevention of postpartum haemorrhage was comparable to standard oxytocics. Many side effects were less common with misoprostol but shivering and pyrexia were more common. Larger randomised trials are needed before establishing the equivalence between misoprostol and standard oxytocic drugs in the prevention of postpartum haemorrhage.