Annals of Saudi Medicine最新文献

Background: Emergency departments (EDs) are typically the first medical contact for seizure patients, and early diagnosis and treatment is primarily the responsibility of emergency physicians.

Objectives: Demonstrate the efficacy of bedside ocular ultrasonography for optic nerve sheath diameter (ONSD) measurement in differentiating provoked seizure from unprovoked seizure in the ED.

Design: Prospective observational study SETTINGS: Tertiary care hospital PATIENTS AND METHODS: Patients presenting to the ED with seizure were divided into two groups according to medical history, physical examination, laboratory results, cranial computed tomography findings and electroencephalography results. Patients with seizures that did not have a specific cause (unprovoked) were compared with patients who had seizures caused by underlying pathology (provoked). The measurement of the ONSD was taken at the bedside within 30 minutes of arrival. The study compared the ONSD values, age, sex, type of seizure, and Glasgow Coma Score between the two groups.

Main outcome measure: Efficacy of ONSD to distinguish between provoked and unprovoked seizures.

Sample size: 210 patients RESULTS: One hundred and fourteen (54.3%) patients were in the provoked seizure group and 96 (45.7%) were in the unprovoked seizure group. The ONSD measurements were significantly higher in the provoked seizure group compared with the unprovoked seizure group (median 6.1 mm vs. 5.2 mm, P<.001). The cut-off value of ONSD higher than 5.61 was significantly associated with the prediction of the provoked seizure (P<.001). The area under the curve value was 0.882 (95% CI: 0.830-0.922) with a sensitivity of 86.5 and specificity of 78.9%.

Conclusions: Bedside ONSD measurement by means of ocular ultrasound is an effective method for differentiating provoked seizure from unprovoked seizure.

Limitations: Statistical significance of age on ONSD and exclusion of pediatric patients.

Conflict of interest: None.

Background: Although obstetric morbidity and mortality have decreased recently, rates are still high enough to constitute a significant health problem. With the COVID-19 pandemic, many obstetric patients have required treatment in intensive care units (ICU).

Objectives: Evaluate critical obstetric patients who were treated in an ICU for COVID-19 and followed up for 90 days.

Design: Medical record review SETTING: Intensıve care unit PATİENTS AND METHODS: Obstetric patients admitted to the ICU between 15 March 2020 and 15 March 2022 and followed up for at least 90 days were evaluated retrospectively. Patients with and without COVID-19 were compared by gestational week, indications, comorbidities, length of stay in the hospital and ICU, requirement for mechanical ventilation, blood transfusion, renal replacement therapy (RRT), plasmapheresis, ICU scores, and mortality.

Main outcome measures: Clinical outcomes and mortality.

Sample size and characteristics: 102 patients with a mean (SD) maternal age of 29.1 (6.3) years, and median (IQR) length of gestation of 35.0 (7.8) weeks.

Results: About 30% (n=31) of the patients were positive for COVID-19. Most (87.2%) were cesarean deliveries; 4.9% vaginal (8.7% did not deliver). COVID-19, eclampsia/preeclampsia, and postpartum hemorrhage were the most common ICU indications. While the 28-day mortality was 19.3% (n=6) in the COVID-19 group, it was 1.4% (n=1) in the non-COVID-19 group (P<.001). The gestational period was significantly shorter in the COVID-19 group (P=.01) while the duration of stay in ICU (P<.001) and mechanical ventilation (P=.03), lactate (P=.002), blood transfusions (P=.001), plasmapheresis requirements (P=.02), and 28-day mortality were significantly higher (P<.001). APACHE-2 scores (P=.007), duration of stay in ICU (P<.001) and mechanical ventilation (P<.001), RRT (P=.007), and plasmapheresis requirements (P=.005) were significantly higher in patients who died than in those who were discharged.

Conclusion: The most common indication for ICU admission was COVID-19. The APACHE-2 scoring was helpful in predicting mortality. We think multicenter studies with larger sample sizes are needed for COVID-19 obstetric patients. In addition to greater mortality and morbidity, the infection may affect newborn outcomes by causing premature birth.

Limitations: Retrospectıve, single-center, small population size.

Conflict of interest: None.

Background: Thyroid carcinoma is one of the most common malignancies worldwide. More than 70%-80% are papillary thyroid carcinoma (PTC). Many factors influence the PTC pathway of development such as genetic mutations, growth factors, and radiation. More biological understanding of the genetic and molecular pathways is needed in PTC to determine tumor behavior, and initial clinical assessment.

Objectives: Investigate the relation of COX-2 immunostaining in thyroid carcinoma with clinicopathological parameters to assess whether immunostaining results have prognostic significance.

Design: Retrospective study SETTING: Pathology department, tertiary care center METHODS: Records of PTC were retrieved and tissue microarrays were constructed. Tissue sections were stained using anti-human COX-2 monoclonal antibody. Immunostaining results were recorded and analysed.

Main outcome measures: Relationship of COX-2 immunostaining in thyroid carcinoma with clinicopathological parameters.

Sample size: 139 tissue samples from 139 patients RESULTS: High versus low COX-2 immunostaining showed no significant differences for most clinicopathological parameters. However, high COX-2 immunostaining showed borderline association with tumor multifocality (P=.05), lower overall (log-rank=8.739 and P=.003), and disease-free survival (log-rank=7.033, P=.008).

Conclusion: The study showed a positive association of high COX-2 immunostaining with lower survival outcomes in PTC. COX-2 immunostaining could be a potential prognostic factor for survival in PTC. Additional molecular and clinical investigations are needed for further understanding the molecular pathways of COX-2 in PTC and the feasibility of using inhibitors of COX-2 as adjuvant therapy along with current chemotherapy.

Limitations: Relatively low number of PTC variants, and no testing of other thyroid carcinomas.

Conflict of interest: None.

Background: Inflammatory bowel disease (IBD) is an important cause of morbidity in Saudi Arabia.

Objectives: Determine the incidence, clinical profile, course and outcomes of IBD in Riyadh, Saudi Arabia.

Design: Medical record review SETTING: Tertiary care center PATIENTS AND METHODS: Data were extracted from the medical records of all patients with IBD admitted to King Abdulaziz Medical City, Riyadh, from 1 January 2009 to 31 December 2019. The complications of IBD were classified as gastrointestinal or extraintestinal. Comorbidities were classified as either systemic diseases or gastrointestinal diseases.

Main outcome measures: Epidemiology, clinical manifestations and complications of IBD.

Sample size and characteristics: 435 patients with IBD, median (IQR) age at presentation 24.0 (14.0) years, 242 males (55.6%) RESULTS: The study population consisted of 249 patients with Crohn's disease (CD) (57.2%) and 186 with ulcerative colitis (UC) (42.8%). Nearly half were either overweight or obese. Abdominal pain, diarrhea and vomiting were the most common presenting symptoms. The most common extraintestinal manifestations were musculoskeletal (e.g., arthritis and arthralgia). Colorectal cancer was diagnosed in 3.2%. Patients with other gastrointestinal (GI) comorbidities were at higher risk of developing GI complications of IBD (P≤.05). Biological agents were used to treat 212 patients (87%) with CD and 102 patients (57%) with UC.

Conclusions: The number of patients diagnosed with IBD and their body mass index increased each year over the period of interest. However, the rate of surgical intervention and number of serious complications fell. This improvement in outcomes was associated with a higher percentage of patients receiving biological therapy.

Limitations: Incomplete data. Some patients diagnosed and/or followed up at other hospitals.

Conflict of interest: None.

Background: Prescribing habits during admission have largely contributed to the opioid epidemic. Orthopedic surgeons represent the third-highest opioid-prescribing specialty. Since more than half of body fractures in Saudi Arabia have been lower extremity fractures, it is imperative to understand opioid administration patterns and correlates among opioid-naïve inpatients.

Objectives: Assess opioid administration patterns and correlates among opioid-naïve inpatients with lower extremity fractures.

Design and settings: Retrospective cohort PATIENTS AND METHODS: Opioid naïve individuals aged 18 to 64 years, admitted due to lower extremity fracture from 2016 to 2020 were included. Data was collected from health records of the Ministry of National Guard Health Affairs (MNG-HA) at five different medical centers. The high-dose (≥50 MME) patients were compared with low dose (<50 MME) patients. Any association between inpatient factors and high-dose opioid use was analyzed by multiple logistic regression.

Main outcome measures: Opioids taken during inpatient admission as measured by milligram morphine equivalents (MME)/per day.

Sample size: 1520 patients RESULTS: Most of the 1520 patients (88.5%) received an opioid medication, while (20.3%) received high-dose opioids at a median daily dose of 33.7 MME/per day. The proportion of patients received naloxone (20.7%) was double among high-dose opioid inpatients. High-dose opioid patients during admission were two times more likely to receive an opioid prescription after discharge (odds ratio, 2.32; 95% confidence interval, 1.53, 3.51), and three more times likely to receive ketamine during admission (odds ratio, 3.02; 95% confidence interval, 1.64, 5.54).

Conclusion: Notable variabilities exist in opioid administration patterns that were not explained by patient factors. Evidence-based opioid prescribing practices should be developed for orthopedic patients to prevent opioid overprescribing and potential opioid overdose among orthopedic patients.

Limitations: Retrospective, unmeasurable confounders might have biased our results. Since based on National Guard employees, results may not be generalizable.

Conflict of interest: None.

Background: Healthcare in Saudi Arabia is under transformation from a national free health service to a system paid either by insurance or governmental funds. This change will impact the model of operation including dental services.

Objectives: Estimate the revenue of the Department of Dentistry based on an insurance-based billing system.

Design: Medical record review SETTING: An academic tertiary care hospital in Riyadh PATIENT AND METHODS: Data on outpatient visits for the period 2015-2019 was extracted from the electronic health records. The billing data was categorized by specialty and current procedure terminology (CPT) code. The revenue stream for each CPT code was estimated and compared between the actual cost of service for each CPT code billed price, and average price of the market leaders in private practice.

Main outcome measure: Revenue generated by the department.

Sample: 339 421 outpatient visits for 22 056 patients.

Results: Female and males made 179 555 (52.9%) and 159 858 (47.1%) outpatient visits, respectively. Outpatient divided by the age groups: ≤14,15-65, >65 years were 58 868 (17.3%), 251 552 (74.1%), 29 001 (8.5%), respectively. The visits divided by specialty were as follows: general dentistry 28.1%, pedodontics 12.5%, orthodontics 7.1%, endodontics 7.0%, oral and maxillofacial surgery 6.9%, prosthodontics 4.4% and periodontics 3.3%. Outpatient visits to the nursing clinic and hygienist amounted to 30.7%. The median number of visits per patient per year was 5 (range, 1-63), which increased to 6 (range, 1-110) in 2019. The annual revenue plateaued in 2019 at 13 983 538 SAR (3 728 943 USD) with only a 2.2% of increase from 2018. Out of 292 CPT codes, 44.8% were priced below the actual cost. Moreover, 28.4% showed pricing below actual cost, but higher than the price of the market leaders. There was an annual loss of revenue of 10.1% due to incorrect pricing of CPT codes. Average productivity of the dentist and hygienist amounted to 2263 and 760 visits per year, respectively.

Conclusions: There is a need for improvement in delivery of care, cost-containment, productivity and amendment of charge description master pricing.

Limitations: The sample did not include data from the period 2020-2022 due to the restriction of dental services due to the COVID-19 epidemic.

Conflict of interest: None.

Background: Many ophthalmological complications have been associated with hydrocephalus (HC), including ocular motility disorders, visual field defects, optic atrophy, and loss of visual acuity. No studies have investigated the prevalence of strabismus and visual outcomes of children with congenital HC after ventriculoperitoneal (VP) shunt in Saudi Arabia.

Objectives: Estimate the frequency of strabismic children diagnosed with HC who underwent a VP shunt procedure.

Design: Medical record review SETTING: Tertiary care center PATIENTS AND METHODS: We reviewed the files of all pediatric patients diagnosed with hydrocephalus before the age of 2 years and treated with shunts during the period 2010 to 2020 at our institution.

Main outcome measures: Strabismus types and ophthalmic assessment (visual state, outcomes, and ocular motility state).

Sample size and characteristics: 190 children; 98 (51.5%) males.

Results: Eighty-nine (46.8%) had congenital HC followed by intraventricular hemorrhage 36 (18.9%); 74 (38.9%) patients had regular follow-ups in ophthalmology. Sixty-five (34.2%) patients had no ophthalmic assessment or fundus examination records, while 63 (33.1%) were diagnosed with strabismus. At the initial assessment, 26 (13.6%) patients had exotropia (XT). At the final assessment, 7 (3.6%) patients had XT. The association between VP shunt and strabismus was statistically significant, (χ²=6.534, df=1, P<.01).

Conclusion: More than one-third of children diagnosed with HC who had surgical treatment in a tertiary hospital did not have any records of ophthalmic assessment, which highlights the need to implement a specific ophthalmological examination protocol in patients with HC. Further studies are needed to analyze the association between VP shunt and strabismus.

Limitations: Evaluating the ocular state and visual function before and after VP shunt was not possible.

Conflict of interest: None.

Background: Disease severity scores are important tools for predicting mortality in intensive care units (ICUs), but conventional disease severity scores may not be suitable for predicting mortality in coronavirus disease-19 (COVID-19) patients.

Objective: Compare conventional disease severity scores for discriminative power in ICU mortality.

Design: Retrospective cohort SETTING: Intensive care unit in tertiary teaching and research hospital.

Patients and methods: COVID-19 patients who were admitted to our ICU between 11 March 2020 and 31 December 2021 were included in the study. Patients who died within the first 24 hours were not included. SAPS II, APACHE II and APACHE 4 scores were calculated within the first 24 hours of ICU admission. A receiver operating characteristics (ROC) analysis was performed for discriminative power of disease severity scores.

Main outcome measure: ICU mortality SAMPLE SIZE AND CHARACTERISTICS: 510 subjects with median (interquartile percentiles) age of 65 (56-74) years.

Results: About half (n=250, 51%) died during ICU stay. Three disease severity scores had similar discriminative power, the area under the curve (AUC), SAPS II (AUC 0.79), APACHE II (AUC 0.76), APACHE 4 (AUC 0.78) (P<.001). Observed mortality was higher than predicted mortality according to conventional disease severity scores.

Conclusion: Conventional disease severity scores are good indicators of COVID-19 severity. However, they may underestimate mortality in COVID-19. New scoring systems should be developed for mortality prediction in COVID-19.

Limitation: A single-center study CONFLICT OF INTEREST: None.

Background: Chromosomal abnormalities are more common in first trimester recurrent miscarriages (RM). Chromosomal anomalies affect approximately 2%-8% of couples with RM.

Objectives: Evaluate the spectrum and the frequencies of chromosomal anomalies in RM.

Design: A retrospective hospital record-based descriptive study.

Setting: A tertiary care center in Turkey.

Patients and methods: We studied couples with RM between October 2020 and January 2022. Relevant family and medical history, clinical examination and the results of karyotype were statistically analyzed.

Main outcome measures: Prevalence and types of chromosomal aberrations in couples with RM. SAMPLE SİZE: 362 couples with a history of RM RESULTS: Among the 362 couples, 14 cases (3.86%) had chromosome abnormalities. Eight cases (57.14%) were structural anomalies and six cases (42.86%) were numerical chromosomal aberrations. We found five balanced translocations (67.5%) and three Robertsonian translocations (37.5%). The prevalence of polymorphic variants was 51/362 (14.1%).

Conclusions: This study supports the conclusion that clinicians should understand the importance of chromosome analysis in these couples and direct them to karyotyping after two abortions in order to exclude the possibility of a genetic cause of RM.

Limitations: Single-center study and retrospective.

Conflict of interest: None.