Realistic simulation case scenario as a vertical integration teaching tool for medical students: A mixed methods study.

Realistic simulation-based learning has recently become an integral part of medical education and can provide several advantages if applied effectively. This study aimed to develop and validate a realistic simulation case scenario (RSCS) as a novel teaching tool for preclinical medical students. Furthermore, we aimed to evaluate student perception of this tool as a teaching strategy, as well as to acquire an in-depth understanding of student perspectives. We employed the mixed methods approach to explore how clinical reasoning develops through a validated RSCS. This study, which included 50 third-year medical students, was conducted at the College of Medicine, Dar Al Uloom University, KSA between November 2021 and February 2022. Most of the participants (94%) were satisfied with the RSCS method and 92% of the participants reported RSCS as more effective in terms of achieving learning objectives. Many advantages of RSCS have been reported, including the provision of realistic knowledge relating to critical care management, encouraging student participation in the learning process, and enhancing interpersonal and problem-solving skills. In conclusion, RSCS is an effective and dynamic teaching approach that aids in knowledge consolidation with a significant impact on the emotions and cognitive abilities of students.

Tocilizumab Outcomes in Critically Ill COVID-19 Patients Admitted to the ICU and the Role of Non-Tocilizumab COVID-19-Specific Medical Therapeutics.

BACKGROUND: Tocilizumab is a monoclonal antibody proposed to manage cytokine release syndrome (CRS) associated with severe COVID-19. Previously published reports have shown that tocilizumab may improve the clinical outcomes of critically ill patients admitted to the ICU. However, no precise data about the role of other medical therapeutics concurrently used for COVID-19 on this outcome have been published. OBJECTIVES: We aimed to compare the overall outcome of critically ill COVID-19 patients admitted to the ICU who received tocilizumab with the outcome of matched patients who did not receive tocilizumab while controlling for other confounders, including medical therapeutics for critically ill patients admitted to ICUs. METHODS: A prospective, observational, multicenter cohort study was conducted among critically ill COVID-19 patients admitted to the ICU of 14 hospitals in Saudi Arabia between 1 March 2020, and October 31, 2020. Propensity-score matching was utilized to compare patients who received tocilizumab to patients who did not. In addition, the log-rank test was used to compare the 28 day hospital survival of patients who received tocilizumab with those who did not. Then, a multivariate logistic regression analysis of the matched groups was performed to evaluate the impact of the remaining concurrent medical therapeutics that could not be excluded via matching 28 day hospital survival rates. The primary outcome measure was patients' overall 28 day hospital survival, and the secondary outcomes were ICU length of stay and ICU survival to hospital discharge. RESULTS: A total of 1470 unmatched patients were included, of whom 426 received tocilizumab. The total number of propensity-matched patients was 1278. Overall, 28 day hospital survival revealed a significant difference between the unmatched non-tocilizumab group (586; 56.1%) and the tocilizumab group (269; 63.1%) (p-value = 0.016), and this difference increased even more in the propensity-matched analysis between the non-tocilizumab group (466.7; 54.6%) and the tocilizumab group (269; 63.1%) (p-value = 0.005). The matching model successfully matched the two groups' common medical therapeutics used to treat COVID-19. Two medical therapeutics remained significantly different, favoring the tocilizumab group. A multivariate logistic regression was performed for the 28 day hospital survival in the propensity-matched patients. It showed that neither steroids (OR: 1.07 (95% CI: 0.75-1.53)) (p = 0.697) nor favipiravir (OR: 1.08 (95% CI: 0.61-1.9)) (p = 0.799) remained as a predictor for an increase in 28 day survival. CONCLUSION: The tocilizumab treatment in critically ill COVID-19 patients admitted to the ICU improved the overall 28 day hospital survival, which might not be influenced by the concurrent use of other COVID-19 medical therapeutics, although further research is needed to confirm this.

Machine learning decision tree algorithm role for predicting mortality in critically ill adult COVID-19 patients admitted to the ICU.

BACKGROUND: Coronavirus disease-19 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is currently a major cause of intensive care unit (ICU) admissions globally. The role of machine learning in the ICU is evolving but currently limited to diagnostic and prognostic values. A decision tree (DT) algorithm is a simple and intuitive machine learning method that provides sequential nonlinear analysis of variables. It is simple and might be a valuable tool for bedside physicians during COVID-19 to predict ICU outcomes and help in critical decision-making like end-of-life decisions and bed allocation in the event of limited ICU bed capacities. Herein, we utilized a machine learning DT algorithm to describe the association of a predefined set of variables and 28-day ICU outcome in adult COVID-19 patients admitted to the ICU. We highlight the value of utilizing a machine learning DT algorithm in the ICU at the time of a COVID-19 pandemic. METHODS: This was a prospective and multicenter cohort study involving 14 hospitals in Saudi Arabia. We included critically ill COVID-19 patients admitted to the ICU between March 1, 2020, and October 31, 2020. The predictors of 28-day ICU mortality were identified using two predictive models: conventional logistic regression and DT analyses. RESULTS: There were 1468 critically ill COVID-19 patients included in the study. The 28-day ICU mortality was 540 (36.8 %), and the 90-day mortality was 600 (40.9 %). The DT algorithm identified five variables that were integrated into the algorithm to predict 28-day ICU outcomes: need for intubation, need for vasopressors, age, gender, and PaO2/FiO2 ratio. CONCLUSION: DT is a simple tool that might be utilized in the ICU to identify critically ill COVID-19 patients who are at high risk of 28-day ICU mortality. However, further studies and external validation are still required.

Knowledge of non-healthcare individuals towards cardiopulmonary resuscitation: a cross-sectional study in Riyadh City, Saudi Arabia.

BACKGROUND: Most sudden cardiac arrests occur at home, with low rates of bystander cardiopulmonary resuscitation being performed. We aimed to assess knowledge of cardiopulmonary resuscitation among individuals in Riyadh City, Saudi Arabia, who are not involved in health care. METHODS: A community-based cross-sectional study was conducted between January and February 2020 in 4 different areas in Riyadh City: North, South, East, and West. The participants were surveyed using a validated self-administered questionnaire. The Statistical Package for Social Sciences version 25.0 was used for inferential statistics and binary logistic regression analysis. RESULTS: A total of 856 participants completed the questionnaire, 51.8% were unaware of cardiopulmonary resuscitation. Only 4.4% of the participants had attended a formal cardiopulmonary resuscitation training course, 5.1% were campaign attendees, and 38.7% acquired their experience through the media. Having a higher level of education was positively associated with having knowledge of cardiopulmonary resuscitation. The main concern among attendees of cardiopulmonary resuscitation training courses and campaigns was legal issues, whereas inadequate knowledge was the major barrier for those who had learned about cardiopulmonary resuscitation through the media. CONCLUSION: The level of knowledge of cardiopulmonary resuscitation among non-health care individuals in Riyadh City was found to be insufficient. Therefore, coordinated efforts among different authorities should be considered to implement a structured strategy aiming to increase awareness and knowledge of cardiopulmonary resuscitation among non-health care individuals.

Use of ultrasound guidance in central venous catheter placement by emergency physicians in Saudi Arabia.

OBJECTIVES: To determine the ultrasound guidance for central venous catheter (USG-CVC) placement rate of emergency physicians (EPs) in Kingdom of Saudi Arabia. METHODS: A cross-sectional survey study regarding the respondents' demographic profiles, formal and informal training in USG-CVC placement, experiences, and attitudes towards the procedure was emailed to all EPs registered with the Saudi Commission for Health Specialties (SCFHS) between October and December 2018. RESULTS: In total, 234/350 SCFHS-registered EPs completed the survey; the response rate was 66.9%. Most respondents (70.5%) were board-certified in emergency medicine (EM). Ninety percent indicated that US device for CVC placement assistance was available. Most EPs (78.2%) had performed USG-CVC placement; the US usage rate correlated significantly with recent graduation from residency (p=0.048). In total, 83.3% received formal training during residency. Of the 234 respondents, 53.8% felt extremely comfortable with CVC placement with USG and 19.7% without USG (p less than 0.01). Nevertheless, most respondents desired further USG-CVC training. CONCLUSION: Despite existing evidence and a consensus on its superiority over the landmark technique, USG-CVC placement has not been adopted by a small proportion of EPs into clinical practice. Formal training, education, and institutional provision of permanent onsite US machines may address any barriers.

Correction to: Reliability and validity of the Hospital Anxiety and Depression Scale in an emergency department in Saudi Arabia: a cross-sectional observational study.

The original article [1] contains an incorrect affiliation.

Predictive value of high sensitivity C-reactive protein on progression to heart failure occurring after the first myocardial infarction.

Background: High sensitivity C-reactive protein (hsCRP) predicts myocardial dysfunction after acute coronary syndromes. We aimed to study the association of hsCRP estimation at first acute myocardial infarction (AMI) with myocardial dysfunction and heart failure. Methods: This research was carried out at the Department of Physiology and Department of Emergency Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia. In this prospective study, 227 patients were studied. hsCRP levels were estimated when patients came to the emergency department at AMI, 7 days post AMI, and at 12 weeks of follow up after AMI. The outcome was change in myocardial functions, especially heart failure, 12 months after the attack. Results: Based on a cutoff mean value of hsCRP levels at admission (10.05±12.68 mg/L), patients were grouped into high and low C-reactive protein (CRP.) The ejection fraction was significantly lower at follow up in the high CRP group (37.29±12.97) compared to the low CRP group (43.85±11.77, p<0.0198). hsCRP had significant inverse correlation with left ventricular ejection fraction (r=-0.283, p<0.01). About 38.1% patients showed heart failure, with 23.6% in the high CRP group and 14.5% in the low CRP group (OR 2.4, p=0.028). Receiver operating characteristic curve analysis showed that CRP levels at AMI had a specificity of 79% and sensitivity of 83% to predict heart failure. Conclusion: A high hsCRP level measured at first AMI predicts myocardial dysfunction and heart failure. It is suggested that hsCRP plays an important role in the development of heart failure after myocardial infarction.

The Levels of Tissue Factor Pathway Inhibitor in Sepsis Patients Receiving Prophylactic Enoxaparin.

OBJECTIVE: Sepsis syndrome is usually accompanied by activation of blood coagulation mechanisms. Earlier studies found deficiencies of the 3 main natural anticoagulants, antithrombin, protein C, and protein S. However, none of these inhibitors block tissue factor, the prime trigger of coagulation during sepsis that is controlled specifically by the tissue factor pathway inhibitor (TFPI). The aim of this study was to characterize the fluctuations in the levels of natural anticoagulants, particularly TFPI, in the course of sepsis and to find out their association with the anticoagulant action of the low-molecular-weight heparin enoxaparin. MATERIALS AND METHODS: We studied 51 consecutive patients with sepsis. Blood samples were collected from patients at baseline (0 h) and at 4, 12, and 24 h after enoxaparin administration. The following assays were undertaken using commercial kits: activated partial thromboplastin time, prothrombin time, thrombin time, total and free TFPI, protein C and protein S, antithrombin, fibrinogen, and anti-factor Xa. RESULTS: Before enoxaparin administration, there was significant prolongation of the prothrombin time and activated partial thromboplastin time, and this remained the case in the 3 subsequent samples. There was marked reduction in the levels of antithrombin, protein C, and total and free protein S to below control values throughout the study. In contrast, plasma levels of both total and free TFPI were markedly elevated and increased after enoxaparin therapy. Anti-factor Xa levels were within the therapeutic range throughout. There was no difference in TFPI levels between those patients who died and those who survived. CONCLUSION: Sepsis triggered marked release of TFPI from endothelial cells. This persisted and was increased further following the administration of enoxaparin. In contrast, there was marked consumption of the natural coagulation inhibitors antithrombin, protein C, and protein S. These results go some way towards explaining why the therapeutic use of recombinant TFPI fails to correct sepsis-associated coagulopathy.

Reliability and validity of the Hospital Anxiety and Depression Scale in an emergency department in Saudi Arabia: a cross-sectional observational study.

BACKGROUND: Depression and anxiety are prevalent psychiatric comorbidities that are known to have a negative impact on a patient's general prognosis. But screening for these potential comorbidities in a hospital's accident and emergency department has seldom been undertaken, particularly in Saudi Arabia and elsewhere in the Middle East. The Hospital Anxiety and Depression Scale (HADS) has been extensively used to evaluate these psychiatric comorbidities in various clinical settings at all levels of health care services except for the accident and emergency department. This study therefore aimed to assess the reliability and validity of the HADS for anxiety and depression among patients at a hospital accident and emergency department in Saudi Arabia. METHODS: This cross-sectional observational study was conducted from January to December 2012. The participants were 257 adult patients (aged 16 years and above) who presented at the accident and emergency department of King Khalid University Hospital, Riyadh, Saudi Arabia, who met our inclusion criteria. We used an Arabic translation of the HADS. We employed factor analysis to determine the underlying factor structure of that instrument in assessing reliability and validity. RESULTS: We found the Arabic version of the HADS to be acceptable for 95% of the subjects. We used Cronbach's alpha coefficient to evaluate reliability, and it indicated a significant correlation with both the anxiety (0.73) and depression (0.77) subscales of the HADS, thereby supporting the validity of the instrument. By means of factor analysis, we obtained a two-factor solution according to the two HADS subscales (anxiety and depression), and we observed a statistically significant correlation (r = 0.57; p < 0.0001) between the two subscales. CONCLUSION: The HADS can be used effectively in an accident and emergency department as an initial screening instrument for anxiety and depression. It thus has great potential as part of integrated multidisciplinary care.

Out-of-hospital adult cardiac arrests in a university hospital in central Saudi Arabia.

OBJECTIVES: To report the characteristics of adult out-of-hospital arrest patients and their outcomes in Riyadh, Saudi Arabia.   METHODS: This is a prospective descriptive study of out-of-hospital adult arrests incident transported to King Khalid University Hospital, Riyadh, Saudi Arabia between July 2012 and September 2013.   RESULTS: A total of 96 adult patients were enrolled in this study. Males represented 62.5% of the participants. The mean age of the study population was 58.9 years, and specifically 30.8 years for traumatic arrests, and 62.9 for non-traumatic. An over-all mortality rate of 95.8% was documented, as well as a low rate of bystander cardiopulmonary resuscitation being performed, and a family member transported most patients to the hospital.   CONCLUSION: A low survival rate for non-traumatic out-of-hospital adult arrest patients and a 100% mortality rate in traumatic arrests were discovered.

Attitude and practice of the health care professionals towards the clinical practice guidelines in King Khalid University Hospital in Saudi Arabia.

RATIONALE, AIMS AND OBJECTIVES: To explore the opinion and practice of the health care providers in King Khalid University Hospital (KKUH) towards clinical practice guidelines (CPGs). METHODS: A cross-sectional self-reported anonymous survey was distributed to 2225 health care professionals working in KKUH clinical departments. RESULTS: The response rate was 56.5%. The respondents had a positive attitude towards CPGs; 90% thought that CPG unify patients' care and 96% agreed that CPGs improve the quality of services provided. The respondents' practice in using CPGs concurred with their attitude and opinion. A total of 86.3% agreed that CPGs changed the way they manage their patients and 71.8% agreed with the statement that they have already used CPGs in the management of the patients. Compared to nurses, physicians were significantly less likely to use CPGs in practice (P < 0.05); moreover, the practice of using guidelines differs significantly according to the years of experience, with 71% of respondents with experience of 15 years or more using CPGs in the management of their patients, compared to 60% among respondents with less years of experience (P < 0.05). CONCLUSION: The health care providers at KKUH have positive practice and attitude towards CPGs in general, which could positively influence the future introduction and implementation of evidence-based CPGs.

Behavioural induced severe hypernatremia without neurological manifestations.

Hypernatremia is a relatively common entity and is more prevalent among the elderly and critically ill. A number of medical conditions are commonly associated with hypernatremia, and these differ substantially among children and adults. Severe hypernatremia is usually associated with central nervous system manifestations and carries a high mortality rate. We report a case of a female patient who presented to the emergency department of the King Khalid University Hospital, Riyadh, Saudi Arabia with severe hypernatremia and without any associated co-morbid conditions or neurological manifestations. We did not find any etiological background despite extensive evaluation other than under hydration due to decreased fluid intake, which was secondary to behavioural causes.