Annals of Saudi Medicine最新文献

Background: During the induction of general anesthesia, hemodynamic instability is a common occurrence in elderly hypertensive patients with increased arterial stiffness, which can cause undesirable complications. Pulse wave velocity (PWV) is an important indicator of arterial stiffness.

Objectives: Investigate if preoperatively measured PWV is related to hemodynamic changes during induction of general anesthesia.

Design: Prospective, case control.

Setting: University hospital.

Patients and methods: The study was carried out between December 2018 and December 2019 in patients 50 years or older scheduled for elective otolaryngology with endotracheal intubation and who had an American Society of Anesthesiologists (ASA) score of I or II. Patients diagnosed with hypertension (HT) or receiving treatment for hypertension for systolic blood pressure (SBP) ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg were compared with non-hypertensive patients (non-HT) of matching age and gender.

Main outcome measures: PWV values between HT and non-HT patients and hypotension rates at the 30th second of induction, the 30th second of intubation, and the 90th second of intubation between the HT and non-HT groups.

Sample size: 139 (95 with HT and 44 non-HT) RESULTS: PWV was higher in the HT group than in the non-HT group (P<.001). Hypotension at the 30th second of intubation in the HT group was significantly more frequent than in the non-HT group (P=.025). PWV was higher in hypotensive (n=62) than in non-hypotensive patients but the difference was statistically significant only for PWV measured at 30th second of intubation (n=77) (P=.018).

Conclusions: The easily and non-invasively measured preoperative PWV may be an effective means of predicting hypotension during the induction of general anesthesia at the 30th second of intubation in HT patients.

Limitations: Numbers of patients in the groups were not the same, and the study was not sufficiently powered to investigate the effect of hypertensive medications on PWV and arterial stiffness.

Conflict of interest: None.

Background: Intraoperative lactate levels increase in patients undergoing craniotomy, but the reason is not yet fully known. High levels of intraoperative lactate are associated with mortality and morbidity in patients with septic shock and abdominal and cardiac surgery.

Objectives: Investigate whether intraoperative lactate elevation is associated with postoperative systemic and neurological complications and mortality in craniotomy.

Design: Retrospective study SETTING: University hospital in Turkey.

Patients and methods: In this study, we included patients who underwent elective intracranial tumor surgery in our hospital between 1 January 2018, and 31 December 2018. According to the level of intraoperative lactate, patients were divided into two groups: high (≥2.1 mmol/L) and normal (<2.1 mmol/L). The groups were compared by the presence of postoperative new neurological deficits, postoperative surgical and medical complications, mechanical ventilation duration, 30-day mortality, in-hospital mortality, and hospital stay length. Cox regression analysis was performed for the 30-day mortality outcome.

Main outcome measures: Association between intraoperative lactate levels and postoperative 30-day mortality.

Sample size: 163 patients with lactate data.

Results: While no significant difference was found between the groups regarding age, gender, ASA score, tumor location, operation time and pathology results, preoperative neurologic deficits were higher in the high intraoperative lactate group (P=.017). No statically significant difference was found between the groups for postoperative neurological deficit, need for prolonged mechanical ventilation, and hospital stay length. The postoperative 30-day mortality rate was higher in the group with high intraoperative lactate (P=.028). High lactate and medical complications were significant in the Cox analysis.

Conclusion: Intraoperative lactate elevation was associated with postoperative 30-day mortality in patients undergoing craniotomy. The intraoperative level of lactate is an important mortality predictor in patients undergoing craniotomy.

Limitations: Retrospective design and single-centered, missing most data for several variables.

Conflict of interest: None.

Background: Non-pharmaceutical interventions (NPIs) applied to limit the SARS-CoV-2 pandemic also affect the circulation and seasonal characteristics of other respiratory viruses.

Objectives: Assess the impact of NPIs on the spread and seasonal characteristics of non-SARS-CoV-2 respiratory viruses and examine viral respiratory co-infections.

Design: Retrospective cohort SETTING: Single center in Turkey.

Patients and methods: Syndromic multiplex viral polymerase chain reaction (mPCR) panel results of patients admitted to the Ankara Bilkent City Hospital with symptoms of acute respiratory tract infection between April 1, 2020 and October 30, 2022 were evaluated. Two study periods before and after 1 July 2021, when the restrictions were discontinued, were statistically analyzed and compared to determine the effect of NPIs on circulating respiratory viruses.

Main outcome measures: Prevalence of respiratory viruses as determined by syndromic mPCR panel.

Sample size: 11300 patient samples were evaluated.

Results: At least one respiratory tract virus was detected in 6250 (55.3%) patients. Of these, at least one respiratory virus was detected in 5% in the first period (between April 1, 2020 and June 30, 2021, when NPIs were applied), and in 95% in the second period (between July 1, 2021 and October 30, 2022, when NPIs were relaxed). After the removal of NPIs, there was a statistically significant increase in hRV/EV, RSV-A/B, Flu A/H3, hBoV, hMPV, PIV-1, PIV-4, hCoV-OC43, PIV-2 and hCoV-NL63 (P<.05). In the 2020-2021 season, when strict NPIs were applied, all respiratory viruses evaluated did not have the usual seasonal peak and there were no seasonal influenza epidemics during this period.

Conclusions: NPIs resulted in a dramatic decrease in the prevalence of respiratory viruses and notable disruption of seasonal characteristics.

Limitations: Single-center study and retrospective.

Conflict of interest: None.

Background: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) can mutate frequently and many new strains have emerged thus far. The clinical and epidemiological characteristics differ with each dominant strain.

Objectives: Obtain an understanding of the clinical characteristics of patients infected with the Omicron variants of the SARS CoV-2.

Design: Retrospective cohort SETTINGS: Teaching hospital in China.

Patients and methods: Data on sociodemography, signs/symptoms, hospital stay, viral shedding period, comorbidities, treatment options and final outcome were retrieved from hospital electronic medical record. We collected nasopharyngeal samples, laboratory data, and clinical data from patients admitted to the hospital with SARS CoV-2.

Main outcome measures: Clinical characteristics of the patients infected with Omicron variant of SARS CoV-2.

Sample size: 445 patients RESULTS: The median age was 43.0 years with a range from 2 to 75 years. Two-thirds of the participants were male and one-third were female. Almost half of the participants (51.9%) had no symptoms, whereas 48.1% had at least one symptom. Of symptomatic patients, 26.7% had mild symptoms and 21.3% had moderate symptoms. No patients were admitted with severe or critical symptoms. All patients discharged from the hospital after complete recovery without any serious complications or death. The most common symptom was cough followed by sore throat and fever. Less common symptoms were having sputum, stuffy nose, and muscle pain. Rare symptoms were weakness, headache, diarrhea, hemoptysis and nausea/vomiting.

Conclusions: All patients had mild to moderate symptoms. Shortness of breath was not a common symptom among the study group. No patients needed invasive oxygen therapy in this cohort.

Limitations: Single center and retrospective design.

Conflict of interest: None.

Background: Cancer patients are highly prone to develop bacterial bloodstream infections (BSI) and are also at risk of neutropenia. Knowledge of the prevalence of these infections and whether neutropenia is associated with a change in mortality is important to more effective management and reducing mortality and morbidity.

Objectives: Estimate the prevalence of bacterial BSI among oncology inpatients and assess the associations of 30-day mortality with Gram stain results and neutropenia.

Design: Retrospective cross-sectional SETTING: University hospital in Saudi Arabia.

Patients and methods: We retrieved records of oncology inpatients at King Khalid University Hospital, excluding patients without malignancy and with non-bacterial BSI. The number of records included in the analysis was reduced based on a sample size calculation and systematic random sampling used to select patients to include in the study.

Main outcome measures: Prevalence of bacterial BSI and association between neutropenia and 30-day mortality.

Sample size: 423.

Results: The prevalence of bacterial bloodstream infections was 18.9% (n=80). Gram-negative bacteria were more prevalent (n=48, 60.0%) than gram-positive bacteria, with the most common being Escherichia coli (n=20, 25.0%). The 23 patients (28.8%) who died included 16 (69.6%) with gram-negative infections and 7 (30.4%) with gram-positive infections. There was no statistically significant association of bacterial BSI-related 30-day mortality with Gram stain (P=.32). Of 18 patients (22.5%) who were neutropenic, only one (5.6%) died. Sixty-two (77.5%) patients were non-neutropenic, of whom 22 (35.50%) died. We found a statistically significant association between the presence of neutropenia and bacterial BSI-related 30-day mortality (P=.016), with mortality being lower among neutropenic patients.

Conclusions: Gram-negative bacteria are more prevalent in bacterial BSI than gram-positive bacteria. No statistically significant association of Gram stain result with mortality was found. However, the 30-day mortality rate was lower among neutropenic patients than among non-neutropenic patients. We recommend further investigation with a larger sample size in multiple regions to further unravel the association of neutropenia with bacterial bloodstream infection-related 30-day mortality.

Limitations: Lack of regional data and sample size.

Conflict of interest: None.

Background: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are surgical methods used for rectal neuroendocrine tumors (NETs) with diameters of ≤ 10 mm. However, which method has a higher performance remains uncertain.

Objectives: Evaluate which of the two methods shows a higher performance.

Design: Systematic review and meta-analysis METHODS: Data from PubMed, Embase, Cochrane Library, and Web of Science were searched from inception to 12 April 2022. Outcomes, including complete resection, en bloc resection, recurrence, perforation, bleeding, and procedure time, were pooled by 95% confidence intervals (95% CI) using a fixed- or random-effects model.

Main outcome measures: Complete resection, en bloc resection, and recurrence.

Sample size: 18 studies, including 1168 patients were included in the study.

Results: Eighteen retrospective cohort studies were included in this meta-analysis. There were no statistical differences in the rates of complete resection, en bloc resection, recurrence, perforation, and bleeding rates between EMR and ESD. However, a statistical difference was detected in the procedure time; EMR had a significantly shorter time (MD=-17.47, 95% CI=-22.31 - -12.62, P<.00001).

Conclusions: EMR and ESD had similar efficacies and safety profiles in resectioning rectal NETs ≤ 10 mm. Even so, the advantages of EMR included a shorter operation time and expenditure. Thus, with respect to health economics, EMR outperformed ESD.

Limitation: Most of these studies are retrospective cohort studies instead of RCTs.

Conflict of interest: None.

Background: The COVID-19 pandemic has affected many aspects of life as well as hospital admissions. We hypothesized that many infectious diseases and hospitalizations in the pediatric age group might have decreased during the pandemic period.

Objective: Evaluate patients admitted to the general pediatric wards during the pandemic in comparison with the pre-pandemic period.

Design: Retrospective cross-sectional SETTING: General pediatrics wards of a tertiary hospital in Istanbul PATIENTS AND METHODS: The study included patients aged 0-18 years who were followed up while hospitalized in the general pediatrics wards between 11 March 2019 and 11 March 2021. The hospitalizations were grouped as pre-pandemic and pandemic based on the date when COVID-19 was declared a pandemic (11 March 2020).

Main outcome measures: Hospital admissions, length of stay, diagnoses, gender, age.

Sample size and characteristics: 4343 hospitalizations.

Results: Of the total 4343 hospitalizations meeting the inclusion criteria, 2786 (64.1%) occurred before the pandemic and 1557 (35.9%) during the pandemic, a 44% decrease. The distribution of all hospitalization diagnoses during the two years was as follows: respiratory tract diseases, 1768 (40.7%); neurological diseases, 946 (21.8%); gastrointestinal diseases, 550 (12.7%); hematological and oncological diseases, 514 (11.8%); genitourinary system and nephrological diseases, 504 (11.6%); and soft tissue infections, 255 (5.9%). During two years, there were 1418 (32.7%) patients with lower respiratory tract infections, 316 (7.3%) with gastroenteritis, and 440 (10.1%) with urinary system infections. The median hospital stay was 6 days before the pandemic and 4 days during the pandemic (P<.0001). During the pandemic, the rate of respiratory diseases decreased from 48.7 to 26.5%, and that of lower respiratory tract infections decreased from 40.5 to 18.6% (P<.0001).

Conclusion: Both previous studies and our results indicate that many infectious diseases in the pediatric age group significantly decreased, especially in the first months of the COVID-19 pandemic.

Limitations: Single-center study.

Conflict of interest: None.

Background: Early detection of iron overload in transfusion-dependent thalassemia (TDT) patients is critical to prevent complications and improve survival.

Objectives: Evaluate the utility of serum ferritin (SF) in the prediction of hepatic and myocardial iron overload (HIO and MIO) compared to T2*-MRI.

Design: Retrospective SETTINGS: Governmental hospitals.

Patients and methods: Patients with TDT who had T2*-MRI examinations between January 2016 to October 2019 were included. The predictive value of SF for detection of HIO and MIO was assessed by measuring area under the curve (AUC). A sample size of 123 cases was calculated to detect a correlation of 0.25 with 90% power and a two-sided type I error of 0.05.

Main outcome measures: The correlation between SF and estimated hepatic iron concentration.

Sample size: 137 TDT patients who required regular blood transfusions.

Results: The predictive value of SF was excellent for detection of HIO (AUC=0.83-0.87) but fair for detection of MIO (AUC=0.67). The two independent predictors of MIO were age and SF. The log of (age × SF) enhanced the SF predictive value for MIO (AUC=0.78). SF values of 700 and 1250 mg/L effectively excluded mild and moderate HIO with a sensitivity of 97.8% and 94.2%, respectively (LR-=0.1). While SF values of 1640 and 2150 mg/L accurately diagnosed mild and moderate HIO with a specificity of 95.55% and 96.4%, respectively (LR+>10). A log of (age × SF) cut-off value of 4.15 effectively excluded MIO (LR-=0.1), while a value of 4.65 moderately confirmed MIO (LR+=3.2).

Conclusions: SF is an excellent predictor of hepatic IO in TDT. Age adjustment enhanced its myocardial IO predictive accuracy. Likelihood ratio-based SF cut-off values may help clinicians in risk stratification and treatment decision-making.

Limitations: The laboratory data were gathered retrospectively and although the risk of selection bias for T2*-MRI examination is thought to be low, it cannot be ignored.

Conflict of interest: None.

Background: Stomas are associated with multiple complications including dehydration which ultimately affects renal function. These complications begin with changes in the estimated glomerular filtration rate (GFR).

Objectives: Evaluate changes in GFR after stoma creation by stoma type and identify how different types of stoma affect GFR.

Design: Retrospective, analytical cohort SETTING: Tertiary care center in Saudi Arabia PATIENTS AND METHODS: The colorectal surgery database was reviewed for all adult patients who underwent stoma creation (permanent and temporary ileostomies and colostomies) or reversal in 2000-2015. GFR was estimated at the first encounter, before the index surgery, at the time of stoma reversal, and upon the last follow-up. Patients with renal impairment, including low GFR before stoma creation, patients who had a temporary stoma converted to a permanent stoma, and patients who died with a stoma were excluded. We studied the association of several demographic and clinical factors on changes in GFR by univariate and multivariate analysis.

Main outcome measures: Estimated GFR at the last clinic visit for the permanent stoma group and at stoma closure for the temporary stoma group.

Sample size: 394 patients (149 ileostomates, 245 colostomates) RESULTS: Thirty-three (8.4%) of the 394 patients had a low GFR: 11 (7.4%) in the ileostomy group and 22 (9%) in the colostomy group (P= .579). The rate of readmissions with ileostomies was higher (11.4%) than with colostomies (3.3%) (P≤.001). The number of temporary ileostomies (n=9, 7.0%) differed from temporary colostomies (n=2, 1.9%) but the difference was not statistically significant (P=.06). In the multivariate analysis, stoma permanency, hypertension, chemotherapy and nephrotoxic drugs were risk factors associated with low GFR.

Conclusion: Ileostomies were not associated with a high rate of renal function deterioration in comparison to colostomies, but had a significantly higher rate of readmission due to dehydration and electrolytes imbalance possibly due to the hot climate in Saudi Arabia.

Limitations: Retrospective nature and limited sample size which may have resulted in a type 2 statistical error.

Conflicts of interest: None.

Background: Emergency medical services (EMS) play an essential role in treating and transporting patients to hospitals or between hospitals. EMS providers must be distributed wisely across all regions of the country to meet healthcare needs during normal times and disasters. No previous study has investigated the characteristics and distribution of the EMS workforce in Saudi Arabia.

Objectives: Examine the characteristics and distribution of the EMS workforce in Saudi Arabia to identify gaps and areas in need of improvement. Also, explore the sociodemographic and educational characteristics of licensed EMS providers in Saudi Arabia.

Design: Cross-sectional SETTINGS: EMS in Saudi Arabia METHODS: We included all licensed EMS providers in Saudi Arabia as of 23 December 2020 who were registered in the Saudi Commission for Health Specialties (SCFHS) database. Sociodemographics, where they earned certification, and their job affiliations were collected and categorized.

Main outcome measures: EMS workforce distribution, gender, and EMS provider-to-population ratio.

Sample size: 18 336 EMS providers; 8812 (48.1%) with documented job affiliations.

Results: The EMS provider-to-population ratio is very low. In Saudi Arabia, in general, the ratio is 1:3871 (based on n=8812 providers), which is low compared to the 1:1400 ratio for Australian EMS provider-to-population, for example. That makes it a challenge for EMS providers to meet the population's needs, especially in times of disaster. The low ratio may have contributed to the delayed response time in Saudi Arabia (13 minutes for critical cases) which does not meet the international standard response time (8 minutes maximum). Also, only 3.5% of the total EMS providers registered were females, and the clear majority of all EMS providers were technicians.

Conclusions: The growth in the EMS workforce, including the recruitment of more females into the workforce and more EMS specialists compared to EMS technicians and health assistants, is critical to reaching a satisfactory EMS provider-to-population ratio.

Limitations: Most noteworthy of the limitations of this research are the insufficient statistics describing EMS distribution in Saudi Arabia, the lack of previous studies on the research topic in Saudi Arabia, and job affiliation not accurately recorded in the SCFHS database.

Conflict of interest: None.