King Abdulaziz Medical City-Riyadh Research Articles

Survival Rate and Short-term Outcomes of Extremely Preterm Infants: A Tertiary Care Center Experience from the Private Sector

Background: Premature birth is one of the leading causes of death in the world. The global incidence of prematurity ranges from 5% to 11% of all births. The aim of this study was to assess the outcome of extremely preterm infants born below 29 weeks in our institution, with regard to survival and major short-term outcomes, and compare our results with national and international centers. This study is the first to be conducted in a private tertiary care hospital in Saudi Arabia. Materials and Methods: This was a retrospective descriptive cohort study that reviewed the medical records of preterm infants admitted to the neonatal intensive care unit at the International Medical Center, Jeddah, Kingdom of Saudi Arabia, between January 2014 and January 2020. We compared our results to the national data from King Faisal Specialist Hospital and Research Center-Riyadh, King Abdulaziz Medical City (KAMC)-Jeddah and KAMC Riyadh, King Abdulaziz Medical City-Alhasa, the National Institute of Child Health and Human Development Neonatal Research Network, and the Canadian Neonatal Network. Results: A total of 92 preterm infants were included: 3, 8, 17, 17, 29, and 18 infants with a gestational age of 23 weeks, 24 weeks, 25 weeks, 26 weeks, 27 weeks, and 28 weeks, respectively. The mean gestational age was 25 weeks and 5 days. Fifty-four infants (58.7%) survived to hospital discharge. In terms of short-term outcomes, 13% had bronchopulmonary dysplasia, hemodynamically significant ductus arteriosus was present in 27%, and retinopathy of prematurity was found in 13%, necrotizing enterocolitis was diagnosed in 5.4%, while late-onset sepsis was reported in 23.9% of infants. Conclusion: Our study represents outcomes of Extremely Preterm Infants in a single Private tertiary Care Center from Saudi Arabia with a comparison to national and international data. Though it cannot be generalized our data can be used as an add-value cohort toward establishing countrywide neonatal network to better plan regional resource allocation and utilization and facilitate ongoing audit, benchmarking, and overall quality improvement initiatives.

Retrospective Comparative Analysis of Neonatal Mortality and Morbidity in Preterm Singleton and Multiple Births -Single Center Experience.

Objective. To compare mortality and major neonatal morbidities between singleton preterm infants and preterm infants of multiple gestations born <33 weeks' gestation. Method. Case-control study of preterm multiples and singletons <33 weeks' born at King Abdul-Aziz Medical City Riyadh (KAMC-R) between January 2017 and December 2020. Out-born infants and infants with lethal congenital abnormalities were excluded from the study. Mortality and major neonatal morbidities including bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), sepsis and surgical necrotizing enterocolitis (NEC) were compared between preterm singletons and multiples. Results. A total of 803 preterm infants were included: 567 (70.6%) were singletons, 158 (19.6%) were twins and 36 (4.5%) infants were higher multiples. Adjusted mortality before hospital discharge was significantly higher among preterm infants of multiple gestations compared to preterm singletons (12.3% vs 7.9%; P = .003; AOR, 2.2; 95% CI, 1.3-3.7). Retinopathy of prematurity (ROP) needing treatment was significantly higher among preterm infants of multiple pregnancies compared to preterm singletons (11% vs 6.5%, P = .033, AOR 1.1, 95% CI, 1.04-2.99). In addition, the incidence of bronchopulmonary dysplasia (BPD) at 36 weeks post menstrual age (PMA) (29.7% vs 20.5%; P = .003; AOR, 1.7; 95% CI, 1.2-2.5) and culture positive sepsis (24.2% vs 17.5%; P = .044; AOR, 1.5; 95% CI, 1.01-2.2) were significantly higher among preterm infants of multiple pregnancy. There were no differences in mortality and adverse neonatal outcomes between twins and higher multiples. Conclusion. Preterm infants of multiple gestations suffered higher mortality and neonatal morbidities compared to preterm singleton infants despite a higher utilization of maternal antenatal steroids and better antenatal care.

The most common pulmonary diseases length of stay, and characteristics of patients admitted to pulmonary service.

Although chronic respiratory diseases are prevalent in Saudi Arabia, there are limited data on the patient burden and associated factors. The aim of this study is to identify the chronic respiratory diseases frequently admitted to pulmonary services and to determine the patient's characteristics, associated comorbidities readmission rate, and reason for a more extended stay in hospital. A prospective study was conducted over a 5-year period at King Abdulaziz Medical City-Riyadh, Saudi Arabia, in the Pulmonary Division, between March 2015 and December 2019. Data on demographics, comorbidities, and chronic respiratory diseases were collected. Total patients admitted were 1315 patients, female 54.2%, the mean age was 62.4 (SD±17.6), and the ages ranged from 14 to 98 years. Overall, chronic obstructive pulmonary disease was the most common respiratory disease requiring admission (17.9%), followed by interstitial lung disease (15.8%), bronchiectasis (11.9%), and obesity hypoventilation syndrome (10.8%). The most common comorbidities were obesity (42.5%), diabetes 49.1%, and hypertension 54.9%. Only 135 (10.3%) were readmitted within 30 days posthospital discharge. Among the patients who were readmitted, 103 (76.3%) were readmitted due to issues related to previous admission diagnosis, noncompliance 75 (55.5%), social reasons, and premature discharges in 51 (37.8%) and 29 (21.5%) of the cases, respectively. The respiratory disease varied significantly by gender, age, obesity status, comorbidities, length of stay (LOS), and admissions. Chronic respiratory diseases are prevalent in our population and are mainly influenced by gender, age, obesity status, comorbidities, LOS, and admissions. Policymakers and health professionals need to recognize the burden of chronic respiratory diseases on patients and health systems and implement effective prevention programs.

Characteristics, Management, and Outcomes of Community-Acquired Pneumonia Due to Human Rhinovirus-A Retrospective Study.

Human rhinovirus (HRV) can lead to a variety of respiratory illnesses; it is also an uncommon cause of community-acquired pneumonia (CAP). We described the characteristics and outcomes of patients hospitalized for CAP due to HRV. We retrospectively studied consecutive adult patients admitted to King Abdulaziz Medical City-Riyadh with CAP due to HRV between 2016 and 2019. The diagnosis was made by respiratory multiplex PCR within 48 hours of hospitalization. We compared patients requiring ICU admission to those who did not. One-hundred-and-six patients were studied (peak hospitalization between November and January, median age 71.5 years, hypertension 59%, diabetes 50%, and chronic respiratory disease 44.3%); 16 (15.1%) patients required ICU admission. The median pneumonia severity index score (PSI) was 107, with no significant difference between ICU and nonICU patients. ICU patients had a higher prevalence of tachypnea (62.5% vs. 26.7%, p=0.005), hemoptysis (12.5% vs 0%, p=0.001), and lymphopenia (71.4% vs 26.3%, p=0.01). Chest X-ray on presentation showed bilateral infiltrates in 47/101 (46.5%) patients and unilateral infiltrates in 26/101 (25.7%) patients. Systemic corticosteroids were used in 54.7% of patients (the median initial dose was 120 mg of prednisone equivalent and was higher in nonICU patients). Most (69.2%) ICU patients received mechanical ventilation (median duration of 8 days). Bacterial coinfection (6.6%) and superinfection (3.8%) were rare. The overall hospital mortality was 9.4% (higher for ICU patients: 37.5% vs. 4.4%, p < 0.001). Most patients with CAP due to HRV were elderly and had significant comorbidities. ICU admission was required in almost one in six patients and was associated with higher mortality.

Admission temperature and neonatal outcomes - single-centre experience in Saudi Arabia

This study aimed to investigate the association between admission hypothermia (AH), neonatal mortality and major neonatal morbidities in preterm infants <33 weeks' gestation. An additional aim of the study was to examine changes in the prevalence of admission hypothermia after the initiation of a thermoregulation quality improvement (QI) project. This is a retrospective cohort study of preterm infants < 33 weeks' gestation born at King AbdulAziz Medical City Riyadh (KAMC-R) between January 2017 to December 2020. Eight-hundred infants were born during the study period. Four hundred and one infants (50.1%) had an admission temperature of <36.5°C and a further 399 (49.9%) had an admission temperature of >36.5°C. The mortality before discharge was 15.7% in infants with AH compared to 4.8% among those with an admission temperature above 36.5°C. This remained statistically significant after adjustments for gestational age and maternal PET status on a multivariate analysis (P=.001, OR 2.7,95%CI 1.5-4.7). The need for mechanical ventilation (P=.005) and incidence of surgical NEC (P=.030) were significantly different between the two temperature groups. Mean (SD) admission temperature increased from 36.3°C to 36.6°C following the thermoregulation intervention program (P <.001). Admission temperature <36°C is associated with higher mortality in the first week (P=.001, OR 3.3,95% CI (1.7-6.6)) and increased incidence of cystic PVL (P=.04, OR 2.1, CI (1.03-4.3)). Preterm infants with AH suffered higher mortality and greater neonatal morbidities.

Assessing health literacy among hypertensive patients attending primary healthcare clinics at King Abdulaziz Medical City, Riyadh, Saudi Arabia

Background: Inadequate health literacy is associated with worse health outcomes and carries high financial burden on both patients and healthcare system. There is insufficient data about health literacy among the hypertensive patients in Saudi Arabia. The aim of this study is to measure health literacy among hypertensive patients attending the primary health care clinics at King Abdulaziz Medical City, Riyadh (KAMC-R). Methodology: This study is a cross-sectional study that aims to identify the effect of various factors on health literacy among hypertensive patients attending the primary health care clinic at KAMC-R. Data was collected using a self-administered questionnaire shortly before the patient encountered their treating physician. The questionnaire is comprised of two parts. The first part deals with the patient’s characteristics and demographic data. The second part of the questionnaire assesses health literacy utilizing the Arabic version of the Single Item Literacy Screener (SILS). Results: In this study 395 responses were obtained, of which, 55.7 % were female patients. The data were collected from 3 different centers (Health Care Specialty Center (HCSC) 39% , Iskan clinics 31% and Um-Alhamam center 30%). Of the participants, 34.2 % reported that they never needed help with reading drug leaflet and medical instructions, while 33.4 % reported always needing help, 11.9 % sometimes need help, 10.4 % usually need help and 10.1 % rarely need help. The study showed that maleshad higher level of good health literacy with about 64.1 %, compared with 45.1 % of females (P=0.00). The health literacy among hypertensive patients is affected proportionally by education level, monthly income, and level of exercise and affected inversely by age. Conclusion: The study showed that a high percentage of hypertensive patients had low health literacy. Those who were females, less educated, old, and patients with sedentary lifestyle are more likely to have a low level of health literacy. We recommend that physicians should confirm that their patients have full understanding of the nature of the disease, and the correct timing and dosage of medications with frequent reassessment. Keywords: Health literacy, hypertensive patients, primary healthcare, Riyadh, Saudi Arabia

Blood and blood products to support allogeneic hematopoietic progenitor cell transplant recipients at king abdulaziz medical city-Riyadh – Transfusion medicine services

Hematopoietic progenitor cell transplant (HPCT) is found throughout the body. HPCT is a set of undifferentiated cells that are capable of indefinite self-renewal and generation of a functional progeny of highly specialized cells. Allogeneic HPCT presents a distinct set of challenges for blood banks and transfusion services. When considering transfusion for an HPCT recipient, one has to take into account not only the complexities associated with the patient's underlying condition, but also potential problems associated with recipient alloantibodies, donor passenger lymphocytes, and the conversion of blood group substance after successful allogeneic HPCT. For an allogeneic HPCT recipient, it is vital that the blood transfusion service keep a detailed record of the donor and recipient's that include donor blood group and antibody screening results and recipient's pre- and posttransplant blood group and antibody screening results. The management of nonidentical and incompatible HPCT requires a unique strategies when major, minor, and bidirectional differences exist which have the potentiality to improve patient outcomes and allow for effective management of the blood and blood products inventory.

AACE2021-A-1087: Prevalence of Celiac Disease in Saudi Patients with Type 1 Diabetes Mellitus

The objective of our study is to determine the prevalence of celiac disease (CD) in adolescents and adults with type 1 diabetes mellitus (T1DM) using anti-tissue transglutaminase (anti-tTG) antibodies and/or endoscope, This study is a chart review retrospective study involving all adolescents and adults with T1DM who were screened for CD at king Abdulaziz medical city Riyadh between 2010 and 2019. The sample size was calculated to be 537 patients based on estimated prevalence of 10% of celiac disease. The study sample wad randomly selected from all patients diagnosed with T1DM and who had CD screening test in the institution. The software SPSSv22 was used for the sample selection. The study variables include age, sex, age of diagnosis with T1DM, age of positive celiac screening, glycated hemoglobin HBA1c, total daily dose, diabetes ketoacidosis (DKA) frequency and other autoimmune diseases. Ethical approval was obtained by ethical board committee with study number: RC19/295/R. A total 539 patients’ records were reviewed. The prevalence of positive celiac screening in our sample is 11.5% ( 4.1% males and 7.4% females). CD prevalence based on positive screening test was equal (5.7%)in young patients (age groups 10-19 years) and older patients (age group 19-65 years). About 8% of positive CD patients in this study diagnosed with T1DM after documented positive celiac screening test. Moreover; around 16% of them developed T1DM and screened positive at the same year. The rest of the patients were found to have positive CD screening after they were diagnosed with T1DM. Regarding A1C, 69.35% of positive screened celiac patients had A1C level between 7-10%. The rest of the patients with positive CD screening had their A1C level of > 10 and represents around 24% and only 6.45% have A1C less than 7%. Around 51% of the patients with CD positive screening never had DKA. The amount of total daily dose was significantly lower in positive CD patients compared to negative CD patients. There was no statistical significant difference between patients with CD screening positive or negative regarding A1C, microvascular complication of diabetes or thyroid disorder. Regarding histopathological confirmation of CD; only 37% Of those screened positive underwent endoscopy; of which 43% were found to have normal endoscopic biopsy findings, 21.7% found to have partial villous atrophy and 34.7% were found to have total villous atrophy. This study highlighted the importance of screening for CD in T1DM patients. CD prevalence is significantly high in patients with T1DM despite the likelihood of under diagnosis of the problem. Additional Saudi studies with different age groups and methods are required. In addition, a unified national strategy to diagnose CD in T1DM patients is highly advisable.

Birth prevalence of orofacial cleft in a tertiary hospital in Riyadh, Saudi Arabia: A retrospective audit

AimThe present study aimed to calculate the birth prevalence of orofacial cleft patients in King Abdulaziz Medical City (KAMC) Tertiary Care Hospital in Riyadh City, KSA. Material and methodsThe data utilized in this retrospective study were obtained from the birth data registry at the hospital covering the period between January 2014 and December 2018. The data collected for the orofacial cleft patients pertained to the birth year, type of cleft, gender, and associated syndromes. ResultsThe total number of documented orofacial cleft cases born between 2014 and 2018 was 78, with a birth prevalence of 1.8 per 1000 live births and no gender bias. Cleft palate (CP) represented the most common type at 38.5% (n = 30), followed by cleft lip at 26.9% (n = 21) and unilateral cleft lip and palate at 24% (n = 19). The least common type was facial cleft, at 3.4% (n = 6). Syndrome association was seen in 15.4% (n = 12) of the cases. ConclusionThe birth prevalence of orofacial clefts in KAMC Riyadh city is in accordance with the worldwide ratio and similar to the birth prevalence reported in the Middle East area. CP showed more prevalence than the other orofacial cleft types, and the association with syndromes was significantly low.

Infection prevention and control standards and associated factors: Case study of the level of knowledge and practices among nurses in a Saudi Arabian hospital.

SummaryIntroductionHealthcare-associated infection is a significant public health issue in both developed and developing countries. This study was performed to assess the knowledge and practices of infection prevention and control (IPC) of nurses working in a Saudi hospital, and to examine their associations with the nurses’ sociodemographic characteristics and work/training experience.MethodsA self-administered questionnaire survey was conducted with participation of male and female nurses of all nationalities who had direct contact with patients while providing healthcare services at King Abdulaziz Medical City-Riyadh (KAMC-R). Sociodemographic characteristics, and work/training experience were reported; IPC knowledge and practices were assessed by questionnaire. Data of 308 valid responses were analyzed. Percentage of correct responses to nine IPC knowledge questions and frequent adherence to 11 IPC practices were calculated. IPC knowledge and practice scores were developed by using principal component analyses; individual scores were classified into high/low level of knowledge or practices by the median of the scores. Logistic regression analysis was performed to evaluate associations between IPC knowledge or practice scores and sociodemographic or work/training variables.ResultsMajority of the participants were females (89.3%). Significant associations between high education level and high level of IPC knowledge (AOR = 2.72, 95% CI = 1.45-5.10) and practices (AOR = 3.66, 95% CI = 1.90-7.05) were observed, after controlling the influence of sociodemographic and work/training variables.ConclusionHigh scores for IPC knowledge and IPC practices were independently associated with nurses’ high level of education, regardless of their nationality or previous working experience. Further studies to develop effective programs for IPC regardless of the nurses’ educational attainment are recommended.

COVID-19 Infection Prevention and Control Guidelines for Pharmacy Personnel in King Abdulaziz Medical City-Riyadh, Kingdom of Saudi Arabia

Background: Since the outbreak of coronavirus disease 2019 (COVID-19) was announced in Wuhan City (China) on 31st December 2019, pharmacists worldwide have been playing a vital role in minimizing the adverse effects of the pandemic on healthcare systems. Objective: The guideline aims to provide clear, relevant, and comprehensive instructions for pharmacy staff on how to manage different medication processes during the COVID-19 pandemic. Method: This editorial discusses the development of a guideline named “CORONA VIRUS (COVID-19) Infection Prevention and Control Guidelines for Pharmacy Personnel in the Hospital Setting” by Pharmaceutical Care Services in King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia. Result: Pharmaceutical Care Services established the guideline in March 2020, which was then updated in June 2020 by Pharmaceutical Care Services in King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia to respond rapidly to the urgent need for a comprehensive approach to manage medication processes during the COVID-19 pandemic and monitor the implementation overall the hospital. Conclusion: This guideline is a reliable and comprehensive source of information and can be implemented by any pharmacy department within the Kingdom of Saudi Arabia and internationally. To the best of our knowledge, this work might be the first in the field of management of medication processes.

The Performance of Equations That Estimate Glomerular Filtration Rate against Measured Urinary Creatinine Clearance in Critically Ill Patients.

The performance of glomerular filtration rate- (GFR-) estimating equations was studied against creatinine clearance measured by 24-hour urine collection (CrCl24h-urine) in critically ill patients. Methods. In this substudy of the PermiT trial (https://clinicaltrials.gov/ct2/show/ISRCTN68144998), patients from King Abdulaziz Medical City-Riyadh who had CrCl24h-urine were included. We estimated GFR using Cockroft–Gault (CG), modification of diet in renal disease study (MDRD), chronic kidney disease epidemiology collaboration (CKD-EPI), and Jelliffe equations. For the CG equation, we entered the actual weight in one calculation (CGactual-wt), and if BMI ≥30 kg/m2, we entered the ideal body weight (CGideal-wt) and the adjusted body weight (CGadjusted-wt) in two calculations. We calculated the MDRD equation based on 4 (MDRD-4) and 6 variables (MDRD-6). The performance of these equations was assessed by different ways including Spearman correlation, bias (difference between estimated GFR and CrCl24h-urine), precision (standard deviation of bias), and Bland–Altman plot analysis. Results. The cohort consisted of 237 patients (age 45 ± 20 years, males 75%, mechanically ventilated 99% with serum creatinine 101 ± 94 µmol/L and CrCl24h-urine 108 ± 69 ml/min/1.73 m2). The correlations between the different equations and CrCl24h-urine were modest (r: 0.62 to 0.79; p < 0.0001). Bias was statistically significant for CGactual-wt (21 ml/min), CGadjusted-wt (12 ml/min), and MDRD-6 (-10 ml/min) equations. Precision ranged from 46 to 54 ml/min. The sensitivity of equations to correctly classify CrCl24h-urine 30–59.9 ml/min/1.73 m2 was 17.2% for CGactual-wt, 30.0% for CGideal-wt, 31.0% for CGadjusted-wt, 31.0% for MDRD-4, 39.1% for MDRD-6, 13.8% for CKD-EPI, and 34.5% for Jelliffe equation. Conclusions. Commonly used GFR-estimating equations had limited ability to properly estimate CrCl24h-urine and to correctly classify GFR into clinically relevant ranges that usually determine dosing of medications.

The effects of the COVID-19 lockdown on severe asthma in patients taking biologic therapy and air pollution in Riyadh.

BACKGROUND:The curfews and lockdowns imposed during the COVID-19 pandemic may decreased the volume of traffic and reduced air pollution. In addition, social distancing measures may contribute to reducing infection and asthma exacerbation.OBJECTIVE:The objective of this study was to assess asthma control and asthma medication use among severe asthmatics on biologics before and after the COVID-19 pandemic.METHODS:This is a cross-sectional survey study of patients with severe asthma receiving biologic therapy at King Abdulaziz Medical City-Riyadh, Saudi Arabia. We looked at the effects of the COVID-19 lockdown on this cohort of severe asthmatics on biologic therapy from March till June 2020 over a period of 12 weeks. We investigated changes in patients’ symptoms and asthma control using the asthma control test (ACT) score and other parameters including emergency department visits, hospitalizations, use of oral prednisolone, changes in inhaler therapy, frequency of bronchodilator use, and patient perception of their symptoms before and after the lockdown period.RESULTS:A total of 56, Female 39 (69%), mean age ± SD 47.4 ± 13.8 years. The duration of bronchial asthma since diagnosis ranged from 4 to 30 years. Most patients had been treated with omalizumab (47, 84%); the rest received mepolizumab (7, 12.5%) and dupilumab (2, 3.6%). All these patients had been on biologic therapy for 5 months, ranging from 5 to 120 months. Most of the patients (45, 80.4%) agreed that their symptoms of asthma had improved with biologic therapy. Most of the patients felt that overall asthma symptoms are better after curfew and lockdown 28 (50%). Less use of bronchodilators postcurfew was reported in 38% of the patients. Asthma control (≥20) using ACT score was significantly higher among patients in postcurfew and lockdown period compared to precurfew period 34 (61.7%) and 23 (41%) (P = 0.001), respectively.CONCLUSIONS:Asthma control was better postcurfew and lockdown. A decrease in air pollution and social distances may be a contributing factor.

Risk Assessment of Repeated Suicide Attempts Among Youth in Saudi Arabia.

IntroductionAlthough the incidence of suicide attempts continues to increase among youth in Saudi Arabia, no risk assessment tool has been established for suicide attempt repetition in the country’s youth population. The objective of the study was to develop risk assessment of suicide attempt repetition among youth in Saudi Arabia.MethodsThis is a retrospective study of youth (10–24 years) with intentional suicide attempt(s) who presented to the emergency departments (ED) at King Abdullah Specialist Children’s Hospital (KASCH) and King Abdulaziz Medical City-Riyadh (KAMC-R), Saudi Arabia between 1 January 2015 and 31 December 2017. We excluded youth having unintentional suicide attempts. Data were retrieved for the 157 eligible as having attempted suicide.ResultsForty-one of 157 (26.1%) had repeated suicide attempts (95% confidence limits: 19.433.7%). Four independent factors were identified that were associated with an increased risk of repeated suicide attempts: age (adjusted odds ratio [aOR] = 1.147, 95% confidence interval (CI) = 11.015–1.297, P=0.028), family problems (aOR = 4.218, 95% CI = 1.690–10.528, P=0.002), psychiatric disorders (aOR = 3.497, 95% CI = 1.519–8.051, P=0.003), and hospitalization (aOR = 5.143, 95% CI = 1.421–18.610, P=0.013). This risk model showed adequate utility with an area under the receiver operating characteristic (ROC) curve (AUC): 77.9%, 95% CI: 69.486.3% with optimism-corrected AUC = 71.8%. Youden index defined a probability of ≥0.38 to predict a high risk of repeated suicide attempts.ConclusionThe risk of repeated suicide attempts among Saudi youth was high, compatible with what has been reported among youth in England and in France. Age, family problems, psychiatric disorders, and hospitalization are risk factors for repeated suicide attempts. A prevention program for suicide attempts in youth may take into account family problems, screening for psychiatric disorders, and suicidal behavior.

The Utilization of Spironolactone in Heart Failure Patients at a Tertiary Hospital in Saudi Arabia.

Introduction: Heart failure (HF) has high morbidity and mortality rates. Spironolactone has shown a 30% reduction in all-cause mortality, reduction in hospitalizations, and sudden death. However, data shows low use of spironolactone in HF patients. We aim to assess spironolactone utilization in HF reduced Ejection Fraction (HFrEF) patients and to identify the factors affecting its prescribing.Methods: A retrospective cross-sectional study of patients diagnosed with HF from January 2016 to January 2017 conducted at King Abdulaziz Medical City-Riyadh. Inclusion criteria: all adult HFrEF <40% who are eligible for spironolactone with New York Heart Association (NYHA) class II-IV. Serum creatinine should be <2.5 mg/dL in men or <2.0 mg/dL in women, or estimated glomerular filtration rate (eGFR) >30 mL/min/1.73m2 and potassium <5.0 mEq/L. Exclusion criteria: pediatrics, end-stage renal disease, primary aldosteronism, and allergy to spironolactone.Results: We screened around 5000 HF patients, of whom 368 were included. Among 195 patients who were not on spironolactone, 121 patients were eligible to use it; however, they did not receive it. One hundred seventy-three patients were on spironolactone, of whom 30 received the drug although they did not meet the eligibility criteria. The mean age of patients on spironolactone was 61±14 and the mean age of patients not on spironolactone was 66.6±15.6. Two hundred seventy-seven patients in the study population were male. Regarding comorbidities, 265 patients were diabetic. As for laboratory findings, the mean potassium for patients on spironolactone was 4.3 mEq/L; the creatinine and eGFR for patients on spironolactone were 82 umol/L (0.9 mg/dl) and 88 mL/min/1.73m2 while those not on spironolactone had higher creatinine at 93 umol/L (1 mg/dl) and eGFR 80 mL/min/1.73m2. Using multivariate regression, we found many factors affecting spironolactone utilization, including EF before spironolactone, serum creatinine, angiotensin-converting enzyme inhibitors (ACEI), angiotensin-II receptor antagonists (ARBs), furosemide, statin, and stroke.Conclusions: Spironolactone for HFrEF is underutilized. EF before spironolactone, serum creatinine, ACEI, ARBs, furosemide, statin, and stroke significantly affect spironolactone utilization. Further studies are warranted to identify barriers affecting spironolactone utilization in HF patients from prescribers' perspectives.

The Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Outbreak at King Abdul-Aziz Medical City-Riyadh from Emergency Medical Services Perspective.

Middle East Respiratory Syndrome Coronavirus (MERS-CoV) is a form of an infectious respiratory disease, discovered in November 2012 in Saudi Arabia. According to the World Health Organization (WHO; Geneva, Switzerland) reports, a total of 2,519 laboratory-confirmed cases and 866 MERS-CoV-related deaths were recorded as of March 5, 2016.1 The majority of reported cases originated from Saudi Arabia (2,121 cases). Also, MERS-CoV is believed to be of zoonotic origin and has been linked to camels in the Arabian area.1,2 In this report, the authors discuss the lessons learned from the MERS-CoV outbreak at King Abdul-Aziz Medical City-Riyadh (KAMC-R) from August through September 2015 from the Emergency Medical Services (EMS) perspective. The discussion includes the changes in policies and paramedic's practice, the training and education in infection control procedures, and the process of transportation of these cases. The authors hope to share their experience in this unique situation and highlight the preparedness and response efforts that took place by the division of EMS during the outbreak.

Embolic Stroke of Undetermined Source in Saudi Arabia: Prevalence, Patient Characteristics, and Outcomes

Background: Embolic stroke of undetermined source (ESUS) is a newly introduced clinical construct to better characterize cryptogenic stroke. It is associated with considerable morbidity and mortality and a high recurrence rate. It has not previously been investigated in Saudi stroke patients. We aimed to conduct a descriptive analysis of ESUS in Saudi Arabia, including its frequency among patients with acute stroke, characteristics, and outcomes. Methods: We reviewed all ischemic stroke patients admitted to the stroke unit at King Abdulaziz Medical City-Riyadh, Saudi Arabia, from February 2016 to July 2018. We applied the criteria proposed by the Cryptogenic Stroke/ESUS International Working Group, which defines ESUS as a radiologically confirmed nonlacunar brain infarct without (a) extracranial or intracranial atherosclerosis causing ≥50% stenosis in arteries supplying the ischemic area, (b) a major-risk cardioembolic source, (c) any other specific cause of stroke. We compared ESUS patients with the other stroke patients. Study was approved by local institutional review board. Results: Of the 736 patients admitted with ischemic stroke, 147 (20%) had ESUS. Patients with ESUS had fewer vascular risk factors compared to patients without ESUS. Nearly third were either dead or dependent at discharge. There were no significant differences between ESUS and other types of ischemic strokes in mortality rate and independence at discharge. Conclusion: ESUS is common in Saudi stroke patients. Despite of the lack of definite etiology, it is associated with considerable morbidity and mortality.

Perceptions of postoutbreak management by management and healthcare workers of a Middle East respiratory syndrome outbreak in a tertiary care hospital: a qualitative study

ObjectivesThis study examines perceptions of the operational and organisational management of a major outbreak of Middle East Respiratory Syndrome (MERS) caused by a novel coronavirus (MERS-CoV) in the Kingdom of...

Awareness, Concerns, and Protection Strategies Against Bloodborne Viruses Among Surgeons.

Background: Surgeons are at high risk of contracting infectious viruses such as human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) through exposure to patients’ blood. The purpose of this study was to assess the surgeons’ awareness of contracting bloodborne viruses. Methods: A cross-sectional study with a questionnaire distributed to 241 surgeons at King Abdulaziz Medical City - Riyadh (KAMC-R) during the period June 2017 through January 2018. Descriptive statistics were used to analyze data collected using Stata®, v14 (StataCorp LLC, College Station, Texas, USA). Categorical variables were analyzed using Pearson chi-square test. P-value of < 0.05 was considered significant.Results: A total of 241 surgeons answered the questionnaire, 179 (74.3%) surgeons were male and 62 (25.7%) were female. The mean age ± standard deviation (SD) of male surgeons was 35.8 ± 11.0 years while for females was 33.3 ± 9.1 years. The majority of our cohort were vaccinated for HBV (96% in males and 97% in females). Two-thirds of the study cohort did not know the conversion rate post-needlestick injury by HIV, HBV, and HCV. Two-thirds of the study cohort think there is a need for HIV screening before surgery. Mixed answers were received from the cohort when asked about their concern regarding contracting HIV infection from their patients; only one-third of the surgeons were extremely concerned. When asked about the risk of needlestick injury during treating patients positive for HBV, the majority of the surgeons said no. However, a significant difference between the female and male surgeons was found in which 12 of the 62 female surgeons answered yes (19.4%) compared to 11 of the 179 male surgeons (6.1%) (p = 0.002).Conclusion: The majority of our surgeons are vaccinated for HBV. However, female surgeons appear to be at higher risk of needlestick injury from HBV patients. This requires further investigation into the reasons for such high incidents. More education is needed about bloodborne viruses.

The prevalence and associated factors of viral hepatitis and cryptogenic related hepatocellular carcinoma at King Abdulaziz Medical city-Riyadh

Background: Worldwide, viral hepatitis is the major risk factor for HCC with hepatitis B (HBV) being more than hepatitis C (HCV). Saudi Arabia is one of the endemic areas of viral hepatitis. Cryptogenic HCC is thought to arias from unknown causes of liver cancers. Thus, the purpose of this study was to find the prevalence of viral and cryptogenic HCC in King Abdulaziz Medical City-Riyadh (KAMC-R).Methods: A retrospective chart review was performed for all HCC patients diagnosed between 2010 to 2017 at KAMC-R. Information regarding age, gender, comorbidity, alcohol consumption, serology tests, liver enzymes, body mass index, model for end-stage liver disease score, alpha-fetoprotein and Child-Turcotte-Pugh score were included. The Chi-square test was used to determine the differences between categorical data. A p&lt;0.05 was considered statistically significant.Results: Total of 294 patients with HCC charts were reviewed. HCV and HBV were found in 42.85% and 20.74% of the patients, respectively. Co-infection with HBV and HCV were reported in 1.7% whereas cryptogenic HCC was found in 32.65% of the patients. High BMI and DLP were noticeably higher in cryptogenic group (p=0.045 and p=0.022 respectively). Multiple lesions were noticed more in HCV group whereas single lesion was more in the cryptogenic group (p=0.0343). Also, large lesions (&gt;5 cm) were remarkably found more in cryptogenic HCC whereas small lesions were more in HCV group (p=0.006).Conclusions: Hepatitis C was the major risk factor associated with HCC, followed by Cryptogenic HCC. High BMI and DLP were common features of cryptogenic HCC.