Annals of Saudi medicine最新文献

Background: Errors in clinical laboratory tests can have a detrimental effect on healthcare delivery. The pre-analytical phase accounts for most laboratory errors, known as pre-analytical errors (PAEs).

Objective: This study investigated the causes and frequencies of PAEs occurring within a laboratory of a tertiary care hospital.

Design: A single-center, retrospective, observational study.

Setting: King Abdul-Aziz Specialist Hospital, Taif, Saudi Arabia.

Materials and methods: All laboratory test orders and repeated or rejected specimens in the Laboratory Information System (LIS) during 2021. The data consisted of the types of PAEs, their distribution across laboratory sections, the patient source among hospital departments, and the working shift during which PAEs were recorded.

Main outcome measures: The causes and frequencies of PAEs across laboratory sections, hospital departments, and work shifts were analyzed.

Sample size: 2104 PAEs from a total of 3 346 199 test orders.

Results: Of the 3 346 199 test orders, 3137 were recorded as either repeated or rejected. Of these, 2104 (67.1%) were attributed to PAEs, representing a rate of 0.063% (95% CI: 0.060-0.066%) of the total test orders. 'Clotted specimens' (32%) and 'insufficient quantity' (31%) were the most frequent PAEs. Significant differences were identified in the error rate and type of PAEs across laboratory sections, hospital departments, and working shifts (P<.001 for each). The highest error rate was in the blood bank (0.4%). The hematology section accounted for the largest proportion of errors (48.4%). Most PAEs were test orders from the inpatient department (47.3%), with a majority occurring in the morning shift (58.2%).

Conclusion: Our study revealed a low overall PAE rate of 0.063%. 'Clotted specimens' and 'insufficient quantity' were the most frequent errors. Importantly, we identified significant differences in the types of PAEs across laboratory sections, hospital departments, and working shifts, indicating their multifaceted and context-dependent nature.

Limitations: A retrospective, single-center study.

Background: Follicular cell-derived thyroid carcinomas (FCTC) are common, with stable mortality rates but significant recurrence risks. Extrathyroidal extension (ETE) affects recurrence risk and staging. The 8th edition of the AJCC/TNM classification excludes microscopic ETE from upstaging but considers gross ETE a significant factor in older patients.

Objective: This study examines clinical outcomes and disease-free survival (DFS) in FCTC patients with and without ETE, evaluating the modifying effects of age and tumor size on incomplete response risk.

Design: A single-center retrospective chart review was conducted at King Abdulaziz University Hospital, Jeddah, Saudi Arabia.

Setting: King Abdulaziz University Hospital.

Patients and methods: Patients aged ≥13 years diagnosed from January 2017 to December 2021 with long-term follow-up (≥18 months) were included. Medullary and anaplastic thyroid cancers were excluded. Data on demographics, tumor characteristics, risk stratification, and clinical outcomes were collected. Response to therapy was categorized per the 2015 ATA guidelines. Chi-square and Multivariable analysis assessed interactions between age, tumor size, and ETE in predicting incomplete response. Kaplan-Meier curves visualized survival differences.

Main outcome measures: Identifying the interactions between age and tumor size with ETE to predict the risk of incomplete response to therapy among patients with FCTC.

Sample size: 255 patients. The median follow-up duration was 4 years.

Results: Patients with ETE were present in (n=38) 15.7% (8% microscopic, 7% gross). Older patients (≥55 years) with ETE had 26.47-fold higher odds of incomplete response than younger patients. Tumor size independently predicted incomplete response, but its interaction with ETE was not significant. Patients with ETE had a significantly higher incomplete response rate (58% vs. 17%, P=.0001).

Conclusion: Older patients with ETE face a markedly higher risk of incomplete response. Tumor size is an independent risk factor in those patients. Management should be stratified by age, advocating more aggressive management for older patients with ETE.

Limitations: Retrospective, and single-center design.

Background: Hypoparathyroidism (HPT) is a significant potential complication following thyroidectomy. Identifying predictors can aid in risk stratification, management, and potentially prevention.

Objective: To determine clinical and biochemical predictors of permanent HPT in post-thyroidectomy patients.

Design: Single-center, retrospective cohort study.

Settings: Tertiary care center in Saudi Arabia.

Patients and methods: We conducted a retrospective analysis of 1085 patients who underwent total thyroidectomy from 2015 to 2022. Patients who developed postoperative HPT were categorized into transient and permanent HPT groups. Demographic, surgical, and biochemical variables were analyzed. Multivariable logistic regression was used to identify independent predictors of permanent HPT, using transient HPT as the reference.

Main outcome measures: Identification of independent predictors associated with permanent HPT.

Sample size: 1085 patients, 264 with postoperative HPT.

Results: We had 264 patients (24.3%) who developed postoperative HPT: 207 (19.1%) had transient and 57 (5.2%) had permanent HPT. Independent predictors of permanent HPT included thyroid cancer (Odds ratio, OR 2.08, 95% Confidence Interval, CI 1.03-4.17), autoimmune thyroid disease (OR 2.01, 95% CI 1.00-4.08), increased thyroid weight (OR 1.52 per 1 SD increase, 95% CI 1.08-2.14), and longer hospital stay (≥7 days) (OR 3.53, 95% CI 1.87-6.68). Preoperative vitamin D deficiency was identified as the only modifiable risk factor (OR 2.25, 95% CI 1.17-4.32). A postoperative parathyroid hormone (PTH) level ≤1.52 pmol/L within 24 hours was strongly associated with the risk of permanent HPT.

Conclusion: Permanent HPT is significantly associated with preoperative vitamin D deficiency, thyroid malignancy, autoimmune thyroid disease, and greater thyroid weight. A postoperative PTH level ≤1.52 pmol/L is a reliable early biochemical predictor. Risk-based stratification may support individualized patient management and follow-up planning.

Limitations: This was a single-center, retrospective study, limiting generalizability, in addition to the heterogeneity in surgeon experience and the time of PTH measurements post-operatively.

Background: Anthracyclines are widely used in cancer treatment and cause dose-dependent cardiotoxicity 2 different by increasing oxidative stress and RAS activation. Angiotensin converting enzyme inhibitors (ACEIs) show promise in reducing this damage.

Objectives and design: This systematic review and meta-analysis evaluated the efficacy and safety of ACEIs in preserving left ventricular function and reducing cardiotoxicity associated with anthracycline therapy.

Methods: A comprehensive search of databases up to May 2024 included randomized controlled trials (RCTs) that assessed ACEIs to prevent cardiotoxicity. Random-effects meta-analysis was applied.

Main outcome measures: The primary outcome was changes in left ventricular ejection fraction (LVEF). Secondary outcomes included cardiac event incidence and adverse events.

Sample size: Nine RCTs were included, encompassing 869 patients (440 ACEI group, 429 control group).

Results: ACEIs significantly improved LVEF at six months (mean difference of 7.93%; 95% CI 3.18-12.67%; P=.001) but not at 12 months. Moreover, ACEIs were associated with non-statistically significant lower rates of heart failure and arrhythmia development compared to the control, with no significant differences noted in adverse events.

Quality of evidence: Evidence quality was high for short-term LVEF improvement and moderate-to-low for other outcomes. Egger's regression test indicated a low risk of publication bias for LVEF.

Heterogeneity: High (I²=97%) for LVEF at 6 months.

Conclusion: ACEIs prevent cardiotoxicity in the short term without increasing adverse events. More extensive trials are needed to confirm long-term benefits.

Limitations: The small number of RCTs and high heterogeneity limit the study. Inconsistent reporting of baseline cardiovascular factors and confounders also hindered accurate assessment of treatment effects.

Registration: PROSPERO CRD42024555546.

Background: The coronavirus disease 2019 (COVID-19) pandemic disrupted cancer care, resulting in significant diagnostic delays.

Objectives: While prior studies have examined shifts in clinical stage, limited data exist on the pandemic's effect on histopathological features and long-term survival in gastric cancer (GC). We aimed to address this gap through a comprehensive comparative analysis.

Design: Retrospective cohort study.

Setting: Tertiary-care center.

Patients and methods: This single-center study included 317 participants newly diagnosed with GC, divided into pre-pandemic (March 2018-March 2020) and pandemic (March 2020-March 2022) groups. Demographic, clinical, and detailed histopathological characteristics and 1- and 3-year overall survival (OS) rates were compared between groups.

Main outcome measures: Comparison of clinical stage, treatment modality, histopathological features, and 1- and 3-year overall survival between GC patients diagnosed before and during the COVID-19 pandemic.

Sample size: 317 patients.

Results: The pandemic group exhibited a significantly higher rate of metastasis at diagnosis (38.0% vs. 26.9%; P=.035), lower rate of surgical resection (54.0% vs. 65.3%; P=.041), and higher rate of palliative therapy (44.0% vs. 31.1%; P=.018). Histopathologically, this cohort had a greater proportion of high-grade (G3) tumors (P=.014), lower median number of dissected lymph nodes (P=.002), and poorer response to neoadjuvant therapy (P=.025). Both 1- and 3-year OS were significantly lower in the pandemic group (P=.009 and .045, respectively).

Conclusions: The COVID-19 pandemic was associated with more advanced disease at diagnosis and significantly worse long-term survival for patients with GC. These outcomes appear to result from diagnostic and treatment delays rather than substantial changes in tumor biology. These findings underscore the need to establish resilient cancer care systems to reduce vulnerability during health crises.

Limitations: Single-center retrospective design and selection bias due to histopathological analyses being limited to surgically treated patients.

Background: Toxoplasmosis, an opportunistic intracellular protozoan infection caused by Toxoplasma gondii (T. gondii), and rubella, caused by the rubella virus (RV) are the two most common TORCH infections.

Objectives: To evaluate seroprevalence of T. gondii and rubella infection among child bearing age women.

Design: Retrospective design.

Settings: Multi-center study.

Patients and methods: The study included women of childbearing age living in the Western region of Saudi Arabia, who sought medical check-up in one of the governmental public hospitals. Electronic health records of eligible patients were reviewed during the period January 2017 to December 2021 from three major health care institutions.

Main outcome measures: Seroprevalence of T. gondii and rubella infection among women of childbearing age in the Western region of Saudi Arabia.

Sample size: 13 895 women were screened and 2117 women of childbearing age were eligible.

Results: Among the 2117 women, seropositive-antibodies-results for T. gondii were 148 (6.1%) for IgG antibodies anti-Toxo-IgG-antibodies, 16 (0.8%) for anti-Toxo-IgM-antibodies, and 14 (0.7%) for anti-Toxo-IgG and IgM-antibodies. Univariate analysis showed that the highest proportion of IgG+ women were recorded among 35-39 years of age followed by 25-29 years. The highest proportion of IgM+ was observed among 40-44 years old followed by 35-39 years. Among the women tested for rubella seroprevalence, 16 (0.8%) were IgM positive, 1346 (63.6%) were immune (IgG positive), and the remaining 755 (35.7%) were susceptible. Rubella immunity was moderately high (63.6%) but dropped significantly with increasing age.

Conclusion: The seroprevalence of Toxoplasmosis in our study appears to be lower than the global average. Nevertheless, it highlights the need for targeted educational programs and public health initiatives with interventions to raise awareness in the community. Rubella immunity, while moderately high overall, showed a notable decline with increasing age, highlighting regular assessment of rubella vaccination programs in the country to ensure effective prevention and control of the disease. The study highlights the need for future research focusing on the epidemiologic trends of TORCH infections, given their broader implications on public health in Saudi Arabia.

Limitations: The seroprevalence results were based on a small sample size living in the Western region of Saudi Arabia and may not reflect other regions in the country.

Background: Invasive Acinetobacter infection in children is associated with significant morbidity and fatality.

Objectives: Investigate the clinical characteristics, antimicrobial susceptibility, outcomes, and fatality-related risk factors of Acinetobacter bacteremia in children.

Design: A retrospective case series study.

Setting: King Faisal Specialist Hospital and Research Centre (KFSHRC), Riyadh, Saudi Arabia.

Patients and methods: The study included children (aged 0-14 years) with a positive blood culture for Acinetobacter species from January 2015 to December 2022.

Main outcomes measures: Clinical characteristics, antimicrobial susceptibility, case fatality rate, and fatality-related risk factors.

Sample size: 42 children.

Results: 17 girls (40%) and 25 boys (60%) with a median age of 10.5 months [interquartile range (IQR): 2-48]. The most common underlying conditions were hematologic/oncologic disease (n=15, 36%) and congenital heart disease (n=12, 29%). Thirty-three patients (79%) developed Acinetobacter bacteremia as a hospital-acquired infection. The predominant species were A. calcoaceticus-A. baumannii complex (n=34, 45%) and A. baumannii (n=15, 36%). Common exposures within 30 days prior to infection were previous hospitalization (n=32, 76%), antimicrobial therapy (n=26, 62%), central line insertion (n=19, 45%), mechanical ventilation (n=16, 38%), surgery (n=15, 36%), immunosuppressive therapy (n=9, 21%) and dialysis (n=9, 21%). Furthermore, 14 patients (33%) exhibited multidrug resistance, and one patient (2%) developed meningitis. Following treatment, 33 patients (79%) recovered with a median treatment duration of 15 days (IQR=12-21), two patients (5%) experienced relapse while on treatment, and two patients (5%) exhibited recurrent infection. The case fatality rate was 12% (5/42) and all died within 10 days post-infection. In the univariable analysis of fatality-related risk factors showed that younger age (median 2 months [IQR: 1-2]) (P=.025), congenital heart disease (P=.018), and dialysis within 30 days prior to infection were significantly associated with fatality (P=.005).

Conclusion: In this study, children with Acinetobacter bacteremia often had a history of prior hospitalization, antimicrobial therapy, invasive procedures, and chronic underlying comorbidities, specifically congenital heart disease and hematologic/oncologic disorders. Additionally, younger age, congenital heart disease, and recent dialysis were associated with fatality in the univariable analysis.

Limitations: Small sample size, lack of multivariable analysis, lack of molecular epidemiologic data.

Background: Recurrent laryngeal nerve injury (RLNI) is a wellknown complication of thyroidectomy that can lead to vocal cord palsy (VCP). Identifying risk factors and reducing the incidence of RLNI are essential for improving surgical outcomes.

Objectives: To assess the incidence of permanent VCP after thyroidectomy and evaluate its possible associated risk factors.

Design: A retrospective cohort study.

Setting: A multicenter study conducted in Makkah, Saudi Arabia.

Methods: The study assessed incidence of permanent RLNI and its associated risk factors in 314 patients who underwent thyroidectomy at our centers in Makkah, Saudi Arabia, between December 2014 and December 2024. The data were gathered on general characteristics, clinical findings, and surgical details. Statistical analyses were performed to identify significant risk factors.

Main outcomes measures: Incidence of permanent RLNI and the associated risk factors.

Sample size: 314 patients.

Results: Overall incidence of permanent VCP was 9 (2.9%). The left vocal cord was affected in 3 (1%) of cases, while the right vocal cord was affected in 6 (1.9%). Significant risk factors included age over 45 years (P=.043), male patients (P=.04), prior thyroid surgery (P=.006), and high cumulative doses of radioactive iodine (P=.008). However, no significant associations with factors such as family history of thyroid disease, carcinoma, or incidental disease onset.

Conclusion: Post-thyroidectomy VCP is influenced by several factors, including age, gender, previous thyroid surgery, and radioactive iodine dose. These findings highlight the importance of careful pre-operative risk assessment and the use of preventive measures, such as Intra-Operative Nerve monitoring, use of optical magnification and pre-operative predicting of thyroidectomy difficulty to reduce RLNI risk.

Limitations: Possibility of selection bias due to the retrospective design. In addition to lack of use of certain analytical tests and detailed subgroup analysis due to the moderate sample size.

Background: Candidozyma auris is resistant to many antifungals, spreads rapidly and causes deaths in patient groups with comorbid factors.

Objectives: The aim of this study was to determine the virulence of C. auris, antifungal resistance genes and clinical characteristics of the patients.

Design: Retrospective cohort.

Setting: Single-center.

Material and methods: This study was conducted between August 2022 and December 2023 at Ümraniye Training and Research Hospital. ITS1-5.8S-ITS2 and ITS1-ITS4 gene regions of the rDNA gene of C. auris isolates identified by VITEK MS v.3.2 were amplified by polymerase chain reaction (PCR) method. These regions were partially sequenced using the Sanger method. The presence of C. auris specific CDR1, ERG11, MDR1, ACT1, SAP5, HYR3, ALS5, IFF4, FUR1, PLB3, PGA26 and PGA52 gene regions were determined by PCR. Antifungal susceptibility testing of C. auris was performed with VITEK 2 Compact AST YS08 and SYO.

Main outcome measures: Variations in C. auris isolates, antifungal resistance and clinical characteristics of patients.

Sample size: Forty-four isolates from 31 patients.

Results: According to gene regions, nine different variations were identified in our hospital, with VAR-1 being the most common. Twenty-five (80.6%) of the patients died and isolation of the causative agent was between days 1-30 in 13 (41.9%) patients. Antibiotic use, ICU admission rate, and central venous catheter use in patients were 29 (93.6%), 28 (90.3%), and 21 (67.7%), respectively. Hypertension, diabetes mellitus (DM) and septic shock were found in 14 (45.2%), 13 (41.9%) and 10 (32.3%) patients, respectively. Antifungal resistance rates of the isolates were determined as 97.7% and 84.1% for amphotericin B and fluconazole, respectively. No resistance to micafungin and caspofungin was detected. The survival rate with echinocandin use was 22% (4 patients).

Conclusion: Identification of gene regions is valuable in determining the pathogenicity of C. auris. Due to the presence of comorbidities in patients with C. auris, it is not possible to determine the exact proportion of deaths attributable to C. auris alone.

Limitations: Single center setting; gene regions could not be expressed.