Challenges facing healthcare leadership in attaining accreditation of teaching hospitals.

PURPOSE: This paper aims to examine the challenges faced by health-care leadership in teaching hospitals in attaining accreditation for their institutions. DESIGN/METHODOLOGY/APPROACH: This paper is based on a study of current literature on health-care leadership, hospital accreditation and quality of patient care and identifies the challenges facing health-care leadership in attaining accreditation for teaching hospitals. FINDINGS: Based on a review and analysis of literature, infrastructure, finance, legal support, workforce recruitment and training, documentation and technology are identified as challenges faced by health-care leadership in teaching hospitals. The key challenges facing health-care leadership with respect to medical education and clinical research are found to be integration of education into hospital operations, compliance with all regulatory and professional requirements and adequacy of resources in executing research programs. ORIGINALITY/VALUE: This study draws the attention of health-care leadership in teaching hospitals on the challenges they face in obtaining accreditation for their institutions so that they may develop appropriate strategies to overcome them.

Implementation of Digital Health Technology at Academic Medical Centers in Saudi Arabia.

Academic Medical Centers (AMCs) in Saudi Arabia are dedicated to providing high-quality patient care and promoting the health and wellbeing of its citizens. Additionally, they provide medical education and conduct research in a wide range of clinical disciplines. A recent global trend in academic hospitals with mandates similar to those in Saudi Arabia is that they have started utilizing digital health technology in a bid to increase efficiency and improve the quality of patient care. This paper takes the position that such digital health technologies should also be utilized in AMC settings in Saudi Arabia. Electronic health records (EHRs), smartphones, video-imaging technologies, virtual desktop infrastructures, mobile EHR access, and smart-beds can help AMCs serve patients more effectively. Rural people can be connected to consultants at AMCs using these technologies using virtual self-care tools. Validation of new digital health devices can be performed in collaboration with digital health partners and serve to enrich the knowledge of medical students in the area of digital health. This review aims to draw the attention of stakeholders to the need to implement digital health technology in AMCs in Saudi Arabia and help improve the quality of healthcare.

Sarcoidosis with multiple organ involvement associated with necrotizing crescentic glomerulonephritis.

We report a case of a young Saudi male who presented with generalized body weakness and easy fatigability associated with fever, night sweating, loss of weight and appetite, and renal impairment. He was diagnosed as a case of sarcoidosis, and renal biopsy report was consistent with necrotizing crescentic glomerulonephritis (GN). Immunosuppressive medication was started to help halting the progression to renal failure and stabilize renal function. To the best of our knowledge, the association between sarcoidosis and crescentic GN has been reported in only few cases in literature.

Milk-Alkali syndrome induced by H1N1 influenza vaccine.

Milk-Alkali syndrome (MAS) consists of a triad of hypercalcemia, metabolic alkalosis, and acute renal failure. We hereby report a 75-year-old Indian gentleman who presented to our emergency department with a history of generalized weakness and easy fatigability. Investigations were consistent with MAS secondary to calcium carbonate and calcitriol treatment to prevent osteoporosis, aggravated by H1N1 influenza vaccine. The patient was treated with hemodialysis and zoledronate. To our knowledge, this is the first reported case of such association in the literature.

The Phantom of Metformin-Induced Lactic Acidosis in End-Stage Renal Disease Patients: Time to Reconsider with Peritoneal Dialysis Treatment.

♦ OBJECTIVE: Metformin continues to be the safest and most widely used antidiabetic drug. In spite of its well-known benefits; metformin use in end-stage renal disease (ESRD) patients is still restricted. Little has been reported about the effect of peritoneal dialysis (PD) on metformin clearance and the phantom of lactic acidosis deprives ESRD patients from metformin therapeutic advantages. Peritoneal dialysis is probably a safeguard against lactic acidosis, and it is likely that using this drug would be feasible in this group of patients. ♦ MATERIAL AND METHODS: The study was conducted on 83 PD patients with type 2 diabetes mellitus. All patients were on automated PD (APD). Metformin was administered in a dose of 500 - 1,000 mg daily. Patients were monitored for glycemic control. Plasma lactic acid and plasma metformin levels were monitored on a scheduled basis. Peritoneal fluid metformin levels were measured. In addition, the relation between plasma metformin and plasma lactate was studied. ♦ RESULTS: Mean fasting blood sugar (FBS) was 10.9 ± 0.5 and 7.8 ± 0.7, and mean hemoglobin A1-C (HgA1C) was 8.2 ± 0.8 and 6.4 ± 1.1 at the beginning and end of the study, respectively (p < 0.001). The mean body mass index (BMI) was 29.1 ± 4.1 and 27.3 ± 4.5 at the beginning and at the end of the study, respectively (p < 0.001). The overall mean plasma lactate level across all blood samples was 1.44 ± 0.6. Plasma levels between 2 and 3 mmol/L were found in 11.8% and levels of 3 - 3.6 mmol/L in 2.4% plasma samples. Hyperlactemia (level > 2 and ≤ 5 mmol/L) was not associated with overt acidemia. None of our patients had lactic acidosis (levels > 5 mmol/L). Age ≥ 60 was a predictor for hyperlactemia. No relationship was found between plasma metformin and lactate levels. ♦ CONCLUSION: Metformin may be used with caution in a particular group of ESRD patients who are on APD. Metformin allows better diabetic control with significant reduction of BMI. Information on the relationship between metformin and plasma lactate levels is lacking. Peritoneal dialysis appears to be a safeguard against the development of lactic acidosis in this group of patients.

Reproductive and gynaecological issues in Saudi women with end stage renal disease.

Women with End Stage Renal Disease (ESRD) have hormonal imbalance leading to gynaecological and reproductive disturbances. The objective of this study was to see the reproductive and gynaecological problems associated with ESRD. Forty Saudi Arabian women with a diagnosis of ESRD for a period of 60 months were interviewed at the dialysis unit of King Fahd University Hospital, Al Khobar.The average age was 51.5 +/- 17.1 years with a range of 19-90 years. Eighteen (45%) were premenopausal with a mean age of 36.5 +/- 11.1 years. Diabetes mellitus and Hypertension was the cause of ESRD in 29 (72.5%). Out of 18 menstruating women 11(61.1%) had irregular periods. Only 2 had children after ESRD was diagnosed. Thirty-three (82.5%) women did not have their regular mammograms and 25 (73.5%) had no pap smears. Our study shows that majority of women with ESRD have gynaecological and reproductive issues which are being neglected.

Intraperitoneal pressure and intra-abdominal pressure: are they the same?

BACKGROUND: In peritoneal dialysis (PD), a standard therapy for patients with end-stage renal disease (ESRD), the effects of using the peritoneum as an exchange membrane and of dialysate dwelling within the peritoneal cavity creates some mechanical changes, including an increase in intraperitoneal pressure (IPP) that might lead to intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). The diagnosis of IAH and ACS depend on intra-abdominal measurement of IAP by an indirect technique. There is no clear distinction between IPP and intra-abdominal pressure (IAP). Our objective in this study was to find if there is real difference between IPP and IAP. METHODS: This study was conducted at the PD unit of King Fahd Hospital of the University, Al-Khobar, between July 2008 and January 2009. To be included, patients had to have known ESRD for at least 5 years, to be 18 years of age or older at enrollment, with stable body weight and blood pressure, and with no clinical signs of overhydration. Patients with congestive heart failure III and IV (New York Heart Association criteria) and severe pulmonary disease, psychiatric illnesses, neurogenic bladder, known history of peritonitis, or medical or surgical abdominal intervention in the preceding 3 months were excluded. We measured IAP by the direct technique through the peritoneal catheter and by an indirect technique using an intravesical catheter. RESULTS: The 25 patients who met the inclusion criteria included 13 men and 12 women, with a mean age of 53 ± 2 years (range: 18 - 76 years). The predominant causes of ESRD were diabetes mellitus and glomerulonephritis. Mean IPP in the dry state (supine) was 9.49 ± 5 mmHg, and mean IAP was 9.4 ± 5.4 mmHg (p = 0.9). In the dry state (erect), the mean IPP increased to 16.9 ± 7.2 mmHg, and the mean IAP, to 16.4 ± 6.9 mmHg (p = 0.8). In the filled state (supine), mean IPP was 12.6 ± 4.7 mmHg, and mean IAP, 12.8 ± 4.8 mmHg (p = 0.88); the erect pressures were 21.4 ± 7 mmHg and 21.6 ± 6.9 mmHg respectively (p = 0.9). CONCLUSIONS: Our findings indicate that there is no statistical difference between IPP and IAP in either the erect or the supine position.

Bone mass measurement using quantitative ultrasound in healthy Saudi women. A cross-sectional screening.

OBJECTIVE: To study the prevalence of osteopenia and osteoporosis in healthy Saudi women, a community-based screening was carried out. METHODS: Three thousand and two hundred sixty-nine women in the young women in peak bone mass (PBM) age group and 3131 in the postmenopausal age (PMA) group were screened using Achilles Insight (GE, USA). Subjects included in the study were healthy and residents of eastern province. The screening was conducted between January 2006 and December 2007. The study took place in King Fahd University Hospital, Al-Khobar, Kingdom of Saudi Arabia. RESULTS: In the PBM age group, 2090 (63.9%) were normal, 791 (24.2%) were osteopenic and 388 (11.9%) were osteoporotic. Osteopenia was more common in single urban women compared to those who were married and living in rural areas (p<0.01 and p<0.001). Women with college education had significantly normal bone mass than women with less than high school education (p<0.01). In the PMA, 948 (30.3%) were osteopenic and 720 (23%) were osteoporotic. Osteopenic was more common in women in urban areas as compared to industrial and the rural areas (p<0.01). Those women whose education was less than primary had significantly more osteoporosis when compared to women with college education (p<0.001). CONCLUSION: In the PBM, 11.9% were osteoporotic and in PMA group 23% were osteoporotic. Factors that influenced the risk for osteopenia and osteoporosis included level of education, number of children, and place of living.

Unresolved issues and current concepts in management of primary glomerulonephritis.

The successful treatment of primary glomerulonephritis (GN) presenting with nephrotic syndrome in adults depends heavily on an accurate diagnosis. A successful diagnosis depends on a correct approach, combining light microscopy, immunofluorescence, and other special staining of renal biopsy material examined by a trained nephropathologist. A good clinical history and serological tests easily rule out possible secondary causes (for example, infection, autoimmune, metabolic or toxic) in most cases. Unfortunately, these procedures are not put into practice in most cases in developing countries, resulting in missed diagnosis and unnecessary steroid and immunosuppressant therapy with its inherent morbidity. Following the emergence of IgA and IgM nephropathies as very common forms of glomerular disorders in some countries, immunofluorescence has become absolutely necessary for their diagnosis. Moreover, a recent meta-analysis has defined different treatment protocols for minimal change nephropathy, focal segmental glomerulosclerosis, membranous nephropathy, and IgA nephropathy for a better outcome. This article emphasizes and elaborates on these issues for proper management of primary GN.

Co-existence of tuberous sclerosis and the fanconi syndrome in two saudi male siblings: report on two cases.

In this report, we present two cases of familial tuberous sclerosis co-existing with the Fanconi Syndrome. Both cases presented with history of failure to thrive and mental retardation associated with hypokalemic metabolic acidosis. To our knowledge, the association between tuberous sclerosis and the Fanconi Syndrome has not been reported previously.

Obstructive sleep apnea syndrome among a snoring community.

OBJECTIVE: To evaluate the relation between snoring and the presence of obstructive sleep apnea (OSA) in terms of relevant health parameters and questionnaire responses. METHODS: Selective random sampling within a household survey in the cities of Al-Khobar and Dammam, Kingdom of Saudi Arabia over a 3 month period during the year 2000, was carried out. One hundred and fifty-two persons, aged 17-62 years, with a positive history of snoring as determined by the spouse or other members of the family were selected. RESULTS: The presence of OSA was determined using the Epworth sleepiness scale (ESS). The predictors included age, gender and body mass index. Snoring was found to be more associated with OSA as suggested by ESS in the study sample. The severity of snoring and its pattern are more associated with apneic patients. CONCLUSION: Snoring is common and may be a serious medical problem. This study revealed that snoring is associated with symptoms suggesting OSA syndrome as detected by ESS. The family doctor and his team should be aware of the condition, using simple screening test such as ESS, improves the patient care, and finding of suspected cases.

Research and research activities in a university in Eastern Saudi Arabia.

OBJECTIVES: The purpose of the present study was to obtain the views of faculty members regarding various aspects of scientific research, which is one of the essential functions of a University. METHODS: A cross-sectional study was conducted in the College of Medicine, King Faisal University, Dammam, Kingdom of Saudi Arabia, between January and June 2001, using a standardized questionnaire to obtain the views of faculty members in both basic and clinical departments on issues related to scientific research. The questionnaire consisted of 41 items and the responses were assessed on a 5 point scale. The variables included specified objectives for research by administration, quality of research, process of application for funding, available facilities for research, constraints to meaningful scientific research and mechanisms that would enhance its quality. RESULTS: The response rate was 67% (74 of the total available 110): Professors 22, Associate Professors 27, Assistant Professors 23 and Lecturers 2 in 24 departments (6 basic sciences, 18 clinical sciences). The number of completed research projects was judged inadequately by 50 (68%), and 31 (42%) thought the quality could be improved upon. The process of the application for funding was cumbersome. The major identified constraints were inadequate infrastructure, additional administrative duties (89%) and teaching schedule overload (82%). The major strategies suggested to enhance the quality of research included simplifying the process for application for research (approval and funding), provision of defined quality time for faculty members to engage in research and the establishment of adequate support and infrastructure facilities. CONCLUSIONS: Most faculty members aspire for a higher quality of biomedical research. The following were identified strategies to improve research goals and quality: Provision of starting seedling packages for new faculty members, simplifying research application processes, establishing efficient and adequate infrastructures, and providing protected research time.