Vancomycin in ICU Patients with Gram-Positive Infections: Initial Trough Levels and Mortality.

BACKGROUND: Vancomycin is one of the most common therapeutic agents for treating gram-positive infections, particularly in critically ill patients. The aim of this study was to identify factors associated with initial therapeutic vancomycin trough levels and mortality in a tertiary-care intensive care unit (ICU). METHODS: This retrospective study evaluated 301 adult ICU patients admitted to King Abdulaziz Medical City in Riyadh between October 1, 2017 and December 31, 2018 with confirmed gram-positive infections and received intravenous vancomycin. Vancomycin trough levels of 15-20 mg/L for severe infections and 10-15 mg/L for less severe infections were considered therapeutic. RESULTS: The patients were relatively older with a mean age of 60 (SD ±20) years. Initial vancomycin trough levels were therapeutic in 168 (55.8%). Factors associated with initial therapeutic vancomycin trough levels were female gender (adjusted odds ratio [aOR]=2.575), older age (aOR=1.024), receiving a loading dose (aOR=2.445), having bacteremia (aOR=2.061), and high platelet count (aOR=1.003). On the other hand, the increase of estimated glomerular filtration rate (eGFR) (aOR=0.993) and albumin levels (aOR=0.944) were associated with lower odds of initial therapeutic vancomycin trough levels. Factors associated with higher mortality were female gender (adjusted hazard ratio [aHR]=2.630), increased body weight (aHR=1.021), cancer (aHR=3.451), and high APACHE II score (aHR=1.068). CONCLUSION: The study identified several factors associated with achieving initial therapeutic vancomycin trough levels (i.e. older age, female gender, receiving a loading dose, bacteremia, high platelets count, low eGFR and albumin level). These factors should be considered in the dosing of vancomycin in critically ill patients with gram-positive infections.

Prevalence of Prediabetes, Diabetes and Its Predictors among Females in Alkharj, Saudi Arabia: A Cross-Sectional Study.

BACKGROUND/OBJECTIVE: The prevalence of prediabetes and diabetes is reaching epidemic proportions across the globe. Therefore, this study aims to determine the prevalence of prediabetes and diabetes, together with its accompanying risk factors, among young females. METHODS: An exploratory cross-sectional survey was conducted with 638 Saudi females in Alkharj, Saudi Arabia. Statistical analysis was carried out using STATA version 14. Odds ratios for the risk of diabetes and associated factors were calculated using log-binomial and multinomial logistic regression. Standardized prevalence and strata-specific prevalence of diabetes and prediabetes for different risk factors were also calculated. FINDINGS: The study revealed that nondiabetics and prediabetics were more prevalent between the ages of 18 and 24 years, while diabetic patients were consistently between 25 to 44 years of age. The average value for HbA1c in females was 5.44. Regression analysis shows that being older, married, obese, a smoker or less educated significantly increases the risk for both prediabetes and diabetes. Mutivariable analysis revealed obesity had a significant association with both prediabetes and diabetes. Prediabetics were 2.35 times more likely to be obese as compared to nondiabetics, with 95% CI (1.38-3.99). Similarly, diabetics were 6.67 times more likely to be obese compared to nondiabetics 95% CI (1.68-26.42). CONCLUSION: Our study shows the prevalence of diabetes and prediabetes among females from Al Kharj was 3.8% and 18.8%, respectively. The diabetic and prediabetic female participants had higher mean BMI and waist circumference, were older in age, were married, and smoked as compared to nondiabetics. In the context of the findings of our study, and keeping in view the the burden of this disease globally and in our population, it has now become extremely important to understand these factors and encourage health-promoting behaviors to construct effective interventions.

Prevalence of Prediabetes, Diabetes, and Its Associated Risk Factors among Males in Saudi Arabia: A Population-Based Survey.

OBJECTIVES: The study aims at determining the prevalence of prediabetes and diabetes and at ascertaining some concomitant risk factors among males in Saudi Arabia. METHODS: A population-based cross-sectional study including 381 Saudi adult males from different institutions was recruited. Odds ratios for diabetes risk and risk factors were calculated using log-binomial and multinomial logistic regression, using STATA version 12. RESULTS: The participants included 381 diabetic males with a median age of 45 years, average body mass index of 25 ± 40 kg/m2, whereas waist circumferences ranged from 66 to 180 cm in the male study population. In addition, 27.82% had normal BMI, 32.28% were overweight, and 36.22% were obese. Around 36% had higher waist circumference, that is, >102 cm. Age, BMI, marital status, and educational attainment were statistically significant predictors for prediabetes and diabetes. CONCLUSION: This study found that the prevalence of diabetes and prediabetes was 9.2% and 27.6%, respectively, for male Al-Kharj study population. The factors that increase the risk of diabetes and prediabetes include older age, obesity and overweight, being married, smoker, and having a civilian job and less education. All these factors were found statistically significant except smoking status and job type. In order to evaluate the causal relationship of these factors, prospective studies are required in future.

Etiology and clinical characteristics of pediatric acute pancreatitis in Saudi Arabia: a 20-year experience from a single tertiary center.

BACKGROUND: Cases of acute pancreatitis (AP) have increased among pediatric populations worldwide; however, the natural course of this condition in Saudi Arabia was unknown. AIM: To report the characteristics as well as outcomes of pediatric AP. PATIENTS AND METHODS: A retrospective chart review study was conducted to include acute pancreatitis in patients ≤ 19 years. The period was from 1994 until 2015. Demographic, clinical, laboratory, imaging and outcome data were collected and analyzed. RESULTS: 50 patients (n = 26; 52% males vs. n = 24; 48% females) were included. The mean age at diagnosis was 11.6 years. The mean length of hospital stay was 10.5 days. 9 (18%) patients had a recurrence of AP and 4 (8%) had complications. Idiopathic AP was the most frequent etiology (n = 21; 42%), followed by cholelithiasis (n = 11; 22%). 2 patients (4%) had drug-induced AP, where one was taking isoniazid and the other had taken a large amount of erythromycin, amoxicillin and ibuprofen. 2 choledochal cysts complicated by AP (4%). Pancreaticobiliary diseases, as a complete entity, accounted for 34% (n = 17). Clinically, abdominal pain (n = 47; 94%) and vomiting (n = 38; 76%) were most commonly encountered. KUB was non-diagnostic in all patients. No patient died during their admission. CONCLUSION: Although still relatively uncommon in Saudi Arabia, there are on average 2-3 cases of pediatric AP diagnosed annually in our institution. Idiopathic AP was the most common cause. Isoniazid and choledochal cysts are rare causes of AP and were reported in the study.

How safe is primary care? A systematic review.

IMPORTANCE: Improving patient safety is at the forefront of policy and practice. While considerable progress has been made in understanding the frequency, causes and consequences of error in hospitals, less is known about the safety of primary care. OBJECTIVE: We investigated how often patient safety incidents occur in primary care and how often these were associated with patient harm. EVIDENCE REVIEW: We searched 18 databases and contacted international experts to identify published and unpublished studies available between 1 January 1980 and 31 July 2014. Patient safety incidents of any type were eligible. Eligible studies were critically appraised using validated instruments and data were descriptively and narratively synthesised. FINDINGS: Nine systematic reviews and 100 primary studies were included. Studies reported between <1 and 24 patient safety incidents per 100 consultations. The median from population-based record review studies was 2-3 incidents for every 100 consultations/records reviewed. It was estimated that around 4% of these incidents may be associated with severe harm, defined as significantly impacting on a patient's well-being, including long-term physical or psychological issues or death (range <1% to 44% of incidents). Incidents relating to diagnosis and prescribing were most likely to result in severe harm. CONCLUSIONS AND RELEVANCE: Millions of people throughout the world use primary care services on any given day. This review suggests that safety incidents are relatively common, but most do not result in serious harm that reaches the patient. Diagnostic and prescribing incidents are the most likely to result in avoidable harm. SYSTEMATIC REVIEW REGISTRATION: This systematic review is registered with the International Prospective Register of Systematic Reviews (PROSPERO CRD42012002304).

Association of HDL cholesterol efflux capacity with incident coronary heart disease events: a prospective case-control study.

BACKGROUND: Although HDL cholesterol concentrations are strongly and inversely associated with risk of coronary heart disease, interventions that raise HDL cholesterol do not reduce risk of coronary heart disease. HDL cholesterol efflux capacity-a prototypical measure of HDL function-has been associated with coronary heart disease after adjusting for HDL cholesterol, but its effect on incident coronary heart disease risk is uncertain. METHODS: We measured cholesterol efflux capacity and assessed its relation with vascular risk factors and incident coronary heart disease events in a nested case-control sample from the prospective EPIC-Norfolk study of 25 639 individuals aged 40-79 years, assessed in 1993-97 and followed up to 2009. We quantified cholesterol efflux capacity in 1745 patients with incident coronary heart disease and 1749 control participants free of any cardiovascular disorders by use of a validated ex-vivo radiotracer assay that involved incubation of cholesterol-labelled J774 macrophages with apoB-depleted serum from study participants. FINDINGS: Cholesterol efflux capacity was positively correlated with HDL cholesterol concentration (r=0·40; p<0·0001) and apoA-I concentration (r=0·22; p<0·0001). It was also inversely correlated with type 2 diabetes (r=-0·18; p<0·0001) and positively correlated with alcohol consumption (r=0·12; p<0·0001). In analyses comparing the top and bottom tertiles, cholesterol efflux capacity was significantly and inversely associated with incident coronary heart disease events, independent of age, sex, diabetes, hypertension, smoking and alcohol use, waist:hip ratio, BMI, LDL cholesterol concentration, log-triglycerides, and HDL cholesterol or apoA-I concentrations (odds ratio 0·64, 95% CI 0·51-0·80). After a similar multivariable adjustment the risk of incident coronary heart disease was 0·80 (95% CI 0·70-0·90) for a per-SD change in cholesterol efflux capacity. INTERPRETATION: HDL cholesterol efflux capacity might provide an alternative mechanism for therapeutic modulation of the HDL pathway beyond HDL cholesterol concentration to help reduce risk of coronary heart disease. FUNDING: US National Institutes of Health, UK Medical Research Council, Cancer Research UK.

The orthopaedic error index: development and application of a novel national indicator for assessing the relative safety of hospital care using a cross-sectional approach.

OBJECTIVE: The Orthopaedic Error Index for hospitals aims to provide the first national assessment of the relative safety of provision of orthopaedic surgery. DESIGN: Cross-sectional study (retrospective analysis of records in a database). SETTING: The National Reporting and Learning System is the largest national repository of patient-safety incidents in the world with over eight million error reports. It offers a unique opportunity to develop novel approaches to enhancing patient safety, including investigating the relative safety of different healthcare providers and specialties. PARTICIPANTS: We extracted all orthopaedic error reports from the system over 1 year (2009-2010). OUTCOME MEASURES: The Orthopaedic Error Index was calculated as a sum of the error propensity and severity. All relevant hospitals offering orthopaedic surgery in England were then ranked by this metric to identify possible outliers that warrant further attention. RESULTS: 155 hospitals reported 48 971 orthopaedic-related patient-safety incidents. The mean Orthopaedic Error Index was 7.09/year (SD 2.72); five hospitals were identified as outliers. Three of these units were specialist tertiary hospitals carrying out complex surgery; the remaining two outlier hospitals had unusually high Orthopaedic Error Indexes: mean 14.46 (SD 0.29) and 15.29 (SD 0.51), respectively. CONCLUSIONS: The Orthopaedic Error Index has enabled identification of hospitals that may be putting patients at disproportionate risk of orthopaedic-related iatrogenic harm and which therefore warrant further investigation. It provides the prototype of a summary index of harm to enable surveillance of unsafe care over time across institutions. Further validation and scrutiny of the method will be required to assess its potential to be extended to other hospital specialties in the UK and also internationally to other health systems that have comparable national databases of patient-safety incidents.