Public attitude towards biomedical research at outpatient clinics of King Abdulaziz Medical City, Riyadh, Saudi Arabia.

The aim of this study was to determine the attitude of Saudi Arabians to research involving storage and use of human tissues from which genetic information may be derived and to assess their willingness to donate tissue samples to biobanks. In a cross-sectional interview study of 1051 outpatients at a hospital in Riyadh city, 68.8% had a positive attitude towards biomedical research and 78.4% were willing to allow use of excess surgical tissues for research purposes. Participants were less willing to allow the use of tissue or organs from a deceased relative. Logistic regression analysis found that predictors for a positive attitude to biomedical research and to use of tissue in research were: female sex, higher level of education, previous experience of blood testing and previous participation in health-related research. The attitudes towards biomedical research among the participants were satisfactory and comparable to findings from other countries.

Public attitude towards biomedical research at outpatient clinics of King Abdulaziz medical city, Riyadh, Saudi Arabia

The aim of this study was to determine the attitude of Saudi Arabians to research involving storage and use of human tissues from which genetic information may be derived and to assess their willingness to donate tissue samples to biobanks. In a cross-sectional interview study of 1051 outpatients at a hospital in Riyadh city, 68.8% had a positive attitude towards biomedical research and 78.4% were willing to allow use of excess surgical tissues for research purposes. Participants were less willing to allow the use of tissue or organs from a deceased relative. Logistic regression analysis found that predictors for a positive attitude to biomedical research and to use of tissue in research were: female sex, higher level of education, previous experience of blood testing and previous participation in health-related research. The attitudes towards biomedical research among the participants were satisfactory and comparable to findings from other countries

Epidemiologic shift in the prevalence of Hepatitis A virus in Saudi Arabia: a case for routine Hepatitis A vaccination.

This study aims to determine the seroprevalence of Hepatitis A among a selected group of Saudi children and thus, identify the best immunization strategy. A school-based seroprevalence study in children 4-18 years of age attending the National Guard schools was done. Of the 25,531 children attending the National Guard schools, 2399 (10%) were randomly selected through a stratified one-stage cluster survey. The overall prevalence of HAV-IgG was 28.9%. The prevalence was almost the same in male and female (28.2% versus 29.5%, respectively). There was a gradual increase in the HAV-IgG with 7% in children (< 8 years), 14% (8-11 years), 30% (12-15 years), and 52% (> 16 years) of age. Since a substantial proportion of this pediatric population confirms a continuing decrease in anti-HAV seroconversion rates, we recommend including Hepatitis A in the schedule of routine childhood vaccinations.

Intrafamilial clustering of Helicobacter pylori infection in Saudi Arabia.

AIM: To study the pattern of Helicobacter pylori infection among family members in the Saudi population. METHODS: A cross-sectional, population-based, seroepidemiological study of family members was undertaken in a Saudi population using saliva H pylori immunoglobulin (Ig) G antibodies (Helisal kit). RESULTS: A total of 42 families comprising 271 children and 84 parents were studied (355 subjects; mean age 23 years, SD 19 years) The overall frequencies of H pylori IgG antibodies in mothers, fathers and children were 67%, 64% and 23%, respectively. There was no significant difference in the infection rate between mothers and fathers, or between boys and girls. The infection rate among children increased when one or both parents were seropositive, and the infection rate among parents was proportionally related to the number of infected children per family. The frequency of H pylori antibodies was significantly higher in spouses of seropositive parents than in spouses of seronegative parents (45% compared with 19.2%). CONCLUSIONS: These data confirm that the intrafamilial clustering of H pylori infection in Saudi Arabia occurs in a similar pattern to that described in the developed countries, and that living conditions and social conditions lead to person to person transmission of H pylori infection.

Bioavailability of four ursodeoxycholic acid preparations.

BACKGROUND: Ursodeoxycholic acid (UDCA) is the drug of choice for treating primary biliary cirrhosis and dissolving cholesterol gallstones. OBJECTIVES: The objective of this study was to compare the bioavailability of four commercially available ursodeoxycholic acid formulations in standardized doses. METHODS: Twenty-four healthy subjects were studied in groups of four, and received each of the different UDCA preparations in random order, with a 1-week washout or more in-between. Serum UDCA levels were determined for a 6-h period. The mean area under the curve (AUC), Cmax and Tmax were determined for each drug formulation, and the results compared. Dose proportionality was determined using the Canadian Ursofalk tablet using either 250 mg, 500 mg or 750 mg dosing. The intraparticipant variability was assessed by asking each participant to repeat the last drug that they took the second time, 1 week later. RESULTS: The mean AUC was 68.99 micromol/1.6 h-1 for the USA UDCA tablet, 59.34 micromol/1.6 h-1 for the Canadian UDCA tablet, 55.55 micromol/1.6 h-1 for Ursolvan capsules, and 46.66 micromol/1.6 h-1 for Actigall capsules. The mean Cmax values were 24.29, 17.85, 16.63 and 413.32 nmol/mL, respectively. The mean Tmax was 1.82, 2.3, 2.79 and 3.39 h, respectively. Linear aggression analysis assessing the direct proportionality of AUC on the dose for the Canadian UDCA tablet gave an estimate of 0.063 + 0.0164 (standard error, P-value=0.0117), e.g. if the dose increases from 250 mg to 500 mg, the serum ursodeoxycholic acid increases by 250 x 0.063=15.75. There was excellent reproducibility for the AUC for the North American tablets (0.97, 0.88) compared to the two capsules (0.32, 0.15). CONCLUSIONS: The significantly higher AUC and Cmax and shorter Tmax for the Canadian Ursofalk tablets compared to the UDCA capsule preparations supports better bioavailability.

Hepatitis C Virus infection in Saudi Arab patients with B-cell non-Hodgkin's lymphoma.

OBJECTIVE: The objective of the current study is to determine the prevalence of Hepatitis C virus infection in Saudi Arab patients with B-cell non-Hodgkin's lymphoma. METHODS: Fifty-six unselected Saudi Arab patients with B-cell non-Hodgkin's lymphoma were tested for the presence of Hepatitis C virus antibodies using Elisa immunoabsorbant assay 2.0. Positive and indeterminate results were subjected to confirmatory testing using RIBA-Hepatitis C virus 2.0. Two control groups were utilized for comparison; the first is a group of randomly selected general medical patients and healthy blood donors; and the 2nd is a cohort of patients with hematological neoplasms other than B-cell non-Hodgkin's lymphoma. Patients with previous history of blood transfusion or liver disease were excluded from the study. RESULTS: Twelve of the 56 B-cell non-Hodgkin's lymphoma patients (21%) tested positive for Hepatitis C virus antibodies. Only 3 out of 104 (3%) and 2 out of 41 (5%) patients tested positive for Hepatitis C virus antibodies in the first and 2nd control groups. CONCLUSION: The results of this study indicate a higher prevalence of Hepatitis C virus infection in Saudi Arab patients with B-cell non-Hodgkin's lymphoma than in the control groups. The prevalence of Hepatitis C virus infection in the 2 control groups, in turn, seems to fall within the estimated prevalence in the general population.

Helicobacter pylori and intestinal metaplasia with its subtypes in the gastric antrum in a Saudi population.

BACKGROUND: There is a close association between intestinal metaplasia (IM) and the development of gastric cancer as well as a relationship between Helicobacter pylori, IM, and gastric cancer. Our aim was to study the frequency and subtypes of IM in a Saudi population with dyspepsia, a population with a low prevalence of gastric cancer. METHODS: Endoscopic antral biopsy specimens were histologically studied for the presence of IM and H. pylori in consecutive patients who underwent upper gastrointestinal endoscopy for evaluation of dyspepsia. Hematoxylin and eosin and Giemsa stain were used to study IM, inflammation, and H. pylori, whereas Alcian blue, pH 2.5/periodic acid-Schiff and high iron diamine/Alcian blue, pH 2.5, were used to study IM subtypes. RESULTS: Seven hundred and seventy-eight consecutive patients were recruited in this study, 415 men and 363 women, with a mean age of 43 +/- 17.6 years. Of the 778 patients, IM was identified in 118 (15.2%). The mean ages of patients with IM (48.8 +/- 18.7) and without IM (41.9 +/- 17.4) were statistically significant (P < 0.0001), whereas the patients' sex did not influence the presence of IM. Most had type-I IM (59.3%), whereas 26.3% and 14.4% had types II and III, respectively. The overall rate of infection with H. pylori was 75.4%. There was no difference in the frequency of IM in patients with or without H. pylori (15.5% versus 14.1%; P = 0.65). Of the 118 patients with IM, the 91 patients (77.1%) who also had H. pylori were older (55 +/- 23 years) than those without H. pylori (47 +/- 17 years, P = 0.05). CONCLUSION: This study has documented mainly that the prevalence of IM and IM subtype III is low in our population. Furthermore, we found no significant relationship between a high rate of H. pylori infection with either IM in general or with IM subtype III in particular, possibly accounting for a low incidence of gastric cancer in the Saudi population.

Randomized trial of ligation versus combined ligation and sclerotherapy for bleeding esophageal varices.

BACKGROUND: Endoscopic band ligation combined with sclerotherapy has been postulated to be superior to ligation alone for the treatment of esophageal variceal bleeding. METHODS: A randomized trial of ligation versus combined ligation and sclerotherapy was designed to determine whether combined therapy results in faster eradication of varices compared to ligation alone. Sixty patients were randomized to undergo band ligation or ligation combined with injection of 1 to 2 mL of polidocanol (1%) into each variceal column immediately proximal to the previously placed bands. Therapy was repeated at 1- or 2-week intervals until variceal eradication was achieved. Follow-up endoscopy was performed at 3 months and then at 6-month intervals. RESULTS: The demographic and clinical characteristics of the 31 patients who underwent ligation were similar to those of the 29 who received combined treatment. Sixty percent of the patients had cirrhosis due to viral hepatitis. No significant differences were found between the combined and ligation alone groups in arresting active bleeding [9 of 9 (100%) vs. 6 of 7 (86%)], units of blood transfusion (3 +/- 0.8 vs. 2 +/- 0.6), number of sessions required to eradicate varices (3.8 +/- 0.5 vs. 3.6 +/- 0.4), treatment failure [2 (17%) vs. 4 (14%)], esophageal varix recurrence [6 (21.%) vs. 2 (6%)], gastric varices formation [4 (14%) vs. 1 (3%)], stricture [1 (3%) vs. 0 (0%)], recurrent bleeding [5 (17%) vs. 7 (23%)], other complications [10 (34%) vs. 9 (29%)], or death [3 (10%) vs. 7 (23%)] during a follow-up period of up to 36 months. CONCLUSIONS: Combined ligation and sclerotherapy does not reduce the number of endoscopic treatment sessions required for variceal eradication and offers no benefit over ligation alone. Because of the lack of benefit, the added procedure time, and the cost, we do not advocate combination therapy, and ligation alone remains the best endoscopic treatment.

Duodenal ulcer and Helicobacter pylori infection at high altitude: experience from southern Saudi Arabia.

OBJECTIVE: To study the clinical presentation, endoscopic features and prevalence of Helicobacter pylori in duodenal ulcer (DU) patients in southern Saudi Arabia, located 3150 m above sea level, and to compare results with those from low altitude regions of the Kingdom. METHODS: Prospective study of patients with proven DU referred for upper gastrointestinal endoscopy at Asir Central Hospital, Abha, southern Saudi Arabia over an 18-month period. RESULTS: Of 126 patients with proven DU, 72% were men and mean age was 40.4 years (range 18 to 68). Twenty-eight per cent were smokers and only 5% used nonsteroidal anti-inflammatory drugs. Thirty-eight patients (30%) presented with hematemesis or melena, and the majority had a single ulcer. Nineteen per cent of patients with dyspepsia had DU and 96% had H pylori. These results are comparable with those reported from the low altitude, warmer regions of Saudi Arabia. CONCLUSIONS: Age of patients and the male:female ratio were similar to those in developing countries. The frequency of smoking is lower than in western countries and no patient in this report consumed alcohol. High altitude did not affect the prevalence of DU or the frequency of H pylori because the results were comparable with those from the low altitude areas of the Kingdom of Saudi Arabia and other lowland developing countries. Although great socioeconomic changes have increased the incidence of heart disease, the patterns of DU and H pylori infection assume those in developing nations.

The validity of the Reflotron as a screening tool for blood cholesterol.

Screening for blood cholesterol levels has become an essential need in many countries. The aim of this study was to evaluate the performance of Reflotron analyzer in screening for blood cholesterol in terms of its precision and accuracy. We have compared the results obtained by the Reflotron with those obtained by a standard hospital laboratory procedure for the same samples. An optimal precision that met the 1992 LSP standards for precision was observed (CV = 2.27%). On the other hand, a suboptimal accuracy of Reflotron was detected, where more than 80% of the Reflotron values differed from the reference laboratory values by more than 5%. As a consequence, 21% of individuals were misclassified as normal due to the very low sensitivity in spite of the optimum specificity observed for the Reflotron. Using the receiver operating characteristic curve analysis, the optimum cut-off points giving the best validity values for the test were 170 mg/dl and 190 mg/dl (4.4 mmol/L and 4.9 mmol/L) for the border-line and true hypercholesterolemia, respectively. At these levels, sensitivity was 0.89 and 0.86, specificity 0.93 and 0.93, and positive predictive value was 0.91 and 0.82, respectively. Considering some limitations of the study, it is concluded that the Reflotron could be of more potential validity for the use in cholesterol measurement surveys when the recommended cut-off points are used.

Etiology of ascites and the diagnostic value of serum-ascites albumin gradient in non-alcohol liver disease.

This study was designed to determine the different etiologies of ascites and the diagnostic value of serumascites albumin gradient (SAAG) in patients with ascites of non-alcoholic liver disease in Southern Saudi Arabia. A total of 132 patients with ascites (96 males and 36 females, mean age 58.8+/-15.9 years) were studied for the different causes of ascites. In 55 patients with liver disease and 22 patients with nonliver disease (malignancy and peritoneal tuberculosis), we compared SAAG with the three usual parameters of ascitic fluid biochemical analysis used in the differential diagnoses of ascites. The nonliver disease group showed higher ascitic fluid total protein (aTP) concentration (4.77+/-2.05 versus 1.98+/-1.56 g/dL), ascitic to serum ratio of total protein (a/sTP) concentration (0.75+/-0.43 versus 0.26+/-0.19), ascitic fluid lactic dehydrogenase (aLDH) level (565.4+/-353.4 versus 254.1+/-205.03 U/L) and a lower SAAG (0.6+/-0.30 versus 1.71+/-0.61). P7lt;0.0001 for all parameters. The positive predictive values for aTP, a/sTP, aLDH and SAAG to detect ascites due to liver disease were 68%, 76%, 67%, and 80%, respectively, while the negative predictive values were 96%, 96%, 84%, and 98%, respectively. Liver causes accounted for 69.7% of cases, followed by peritoneal tuberculosis 10.6%, malignancy 9.1%, congestive heart failure 7.6%, and nephrotic syndrome 3.0%. SAAG is a useful diagnostic parameter which can be used to separate ascites of liver disease (nonalcoholic) from other causes of ascites, with an efficiency of 91%. SAAG should replace the traditional parameters (aTP, a/sTP, and aLDH) used in the differential diagnosis of ascites. In our series, liver disease is the major cause of ascites, followed by peritoneal tuberculosis.

The role of hepatitis E virus infection among patients with acute viral hepatitis in southern Saudi Arabia.

We investigated the etiology of acute sporadic viral hepatitis in southern Saudi Arabia in a series of 132 patients admitted with acute viral hepatitis. Of these cases, 108 (81.8%) were due to acute hepatitis A virus infection, of which 11 (8.3%) patients had been previously exposed to hepatitis E virus, and another 10 (7.6%) were chronic carriers of hepatitis B virus. Three cases (2.3%) were acute hepatitis B virus infection. The overall prevalence of hepatitis E IgG antibodies was found to be 9.1%. The remaining 21 (15.9%) patients were tested for hepatitis E IgM, EBV-VCA IgM and hepatitis C IgG antibodies by sensitive enzyme immunoassays. In none of them could hepatitis E IgM, EBV-VCA IgM or hepatitis C IgG antibodies be demonstrated, and these patients were thus considered as acute non-A, non-B hepatitis. Acute hepatitis C virus infection, however, could not be ruled out from this group. We therefore concluded that the majority of clinically apparent viral hepatitis cases were due to HAV, while HBV accounted for a small proportion of the cases. Clinically apparent HEV infection does not appear to be common in the population studied, since even those with serologic evidence of previous exposure to HEV did not recall a history suggestive of acute viral hepatitis.

A second-generation method of genotyping hepatitis C virus by the polymerase chain reaction with sense and antisense primers deduced from the core gene.

A second-generation method of genotyping hepatitis C virus (HCV) was developed by the polymerase chain reaction (PCR) with sense as well as antisense primers deduced from the core gene. HCV RNA specimens extracted from sera were reverse-transcribed and amplified with universal primers in the first round of PCR to obtain fragments of 433 base pairs representing nucleotides 319-751. In the second round of PCR, portions of PCR products were amplified separately with sense and antisense primers specific for each of the five common genotypes prevailing across the world, i.e., I/1a, II/1b, III/2a, IV/2b and V/3a. The specificity of the method was verified by a panel of 177 HCV isolates of various genotypes in the genetic groups 1-9. It allowed clear differentiation of genotype I/1a from II/1b which was not always accomplished by the previous method. When 501 sera from blood donors and hepatitis patients with HCV viremia from various countries were genotyped by the second-generation method, 478 (95.4%) were classified into the five genotypes. HCV RNA samples from 23 (4.6%) sera were not classifiable into any of the five common genotypes and, by sequence analysis, 22 were found to be of four genotypes in group 4 and one of genotype 1c in Simmond's classification.

Interleukin-8 and granulocyte-macrophage colony-stimulating factor secretion in hepatocellular carcinoma and viral chronic active hepatitis.

Interleukin-8 (IL-8) and granulocyte-macrophage colony-stimulating factor (GM-CSF) are important mediators of inflammation and immune response in human disease. To demonstrate their importance in pathophysiological processes in liver disease, we measured the circulating levels of IL-8 and GM-CSF in patients with hepatocellular carcinoma (HCC) and chronic active hepatitis (CAH). IL-8 and GM-CSF levels in serum samples were determined with highly specific and sensitive enzyme-linked immunosorbent assays. IL-8 levels were more elevated in serum samples of patients with HCC and CAH associated with hepatitis C virus infection than HCC and CAH associated with hepatitis B virus infection. However, in all patients with autoimmune CAH and in some patients with HCC and CAH, GM-CSF levels were elevated over the baseline levels measured in all of the normals, but this difference was not statistically significant for any group. We conclude that IL-8 and GM-CSF are increased in some patients with liver diseases, and as such they may play a significant role in host defense and disease.