Extended thromboprophylaxis in heart failure patients; the unmet need.

Heart failure (HF) is considered one of a leading cause of cardiovascular morbidity and mortality worldwide. The association between HF and venous thromboembolism (VTE) has been reported in several studies owing to many physiological and thromboembolic risk factors. Thus, the need for extended thromboprophylaxis during the post-discharge period in HF patients has been evaluated. Most guidelines do not recommend extended thromboprophylaxis because of its uncertain benefits and increased risk of bleeding. However, recent evidence in HF patients revealed no increased risk of bleeding with extended thromboprophylaxis, which highlights the importance of identifying ideal candidates who might benefit from extended thromboprophylaxis. Several risk assessment models (RAMs) have been developed to identify patients at a high risk of VTE who would benefit from in-hospital and post-discharge prophylactic anticoagulation therapy based on the risk-benefit principle. However, their accuracy in predicting VTE is questionable, and none have a standardized approach for evaluating the risk of VTE in HF patients. In this review, we provided an overview of the incidence and pathophysiology of VTE in HF patients, a summary of guideline recommendations for VTE prevention, and a summary of studies evaluating the use of extended thromboprophylaxis, with a focus on subgroup or post-hoc analyses of HF patients. We also discussed the need to design an ideal RAM that can identify candidate patients for extended thromboprophylaxis by stratifying the risk of VTE and identifying the key risk factors for bleeding in medically ill patients, including those with HF.

Abelacimab: A leap forward in anticoagulation with FXI and FXIa Inhibition.

Direct Oral Anticoagulants (DOACs) have revolutionized the treatment of thromboembolic disorders, offering targeted, effective, and safer alternatives to traditional anticoagulants like heparins and vitamin K antagonists (VKAs). Despite their benefits, DOACs have drawbacks, including an increased risk of gastrointestinal bleeding and unsuitability for patients with mechanical heart valves. Recent research has highlighted Factor XI (FXI) as a promising anticoagulation target due to its significant role in pathological thrombosis and minor involvement in normal hemostasis. Abelacimab, an antibody that inhibits FXI, has shown potential in transforming anticoagulation therapy by sparing hemostasis. This review provides a comprehensive analysis of abelacimab, examining its clinical pharmacology and its pharmacokinetic and pharmacodynamic properties. It scrutinizes abelacimab's safety profile and key monitoring parameters. The current evidence supporting its use and potential future research strengthening its position in anticoagulant therapy is also discussed. The objective is to enhance understanding and contribute to discussions around developing safer anticoagulants, particularly for patients at risk for thrombosis.

Comparison of Early Versus Late Adjunctive Vasopressin and Corticosteroids in Patients With Septic Shock.

BACKGROUND: Vasopressin (VP) and hydrocortisone (HC) have been shown to improve outcomes in patients with septic shock. However, there is very little literature addressing the impact of the timing of the combination. OBJECTIVE: This study was conducted to evaluate the impact of early versus late initiation of both VP and HC on time to shock reversal in septic shock patients. METHODS: This was a retrospective study conducted at a tertiary academic medical center. Data were collected from system-generated reports, which were used to identify patients with septic shock who were admitted to an intensive care unit (ICU) and received both VP and HC. The primary endpoint was time to shock reversal. Patients were divided into the "early" group if both VP and HC were initiated within 12 hours of vasopressor initiation or into the "late" group if either VP or HC (or both agents) were initiated after 12 hours of vasopressor initiation. RESULTS: A total of 122 patients were included in the analysis. Early initiation was associated with a shorter time to shock reversal (34 hours vs 65 hours; P = 0.012) compared to late initiation. There were no differences in ICU length of stay, mortality, the number patients requiring renal replacement therapy, or the duration of mechanical ventilation in either group. CONCLUSION AND RELEVANCE: Our study addressed a major gap in the literature and suggests that adding the combination of VP and HC within 12 hours of septic shock may be associated with improved patient outcomes.

Persistence of Symptoms Following Infection With COVID-19 Among Patients With Type 1 and Type 2 Diabetes Mellitus in Saudi Arabia.

BACKGROUND: In Saudi Arabia, information on the persistence of COVID-19-related complications in diabetic patients, their associations with the type of diabetes mellitus (DM), and the role of uncontrolled DM in the complications remains elusive. This study aims to fill this gap. This study aimed to examine the persistence of COVID-19 complications in diabetic patients. METHOD: A simple randomized, cross-sectional, questionnaire-based study among patients with type 1 and 2 DM following infection with COVID-19 in Saudi Arabia. RESULT: In the present study, a total of 674 participants were included. Among the COVID-19 symptoms, fatigue (65.6%) was reported the most frequently, followed by headache (62.3%) and cough (59.8%). About 44% of patients reported high blood sugar levels, including 25.5% with elevated fasting (>126 mg/dL) and 18.5% with elevated postprandial (>200 mg/dL) glucose levels. We also report that age > 55 years [OR= 1.66 (1.01-2.56), p=0.045], anti-diabetic medications [OR= 2.10 (1.82-3.91), p=0.022], multiple comorbidities [OR= 3.21 (1.98-4.85), p=0.005], chest pain [OR= 2.54 (0.96-3.81), p=0.003], and joint pain [OR= 1.64 (0.73-2.94), p=0.025] were independently associated with COVID-19-related complications in diabetic patients. CONCLUSION: The most common persistent symptoms in diabetic patients with COVID-19 infection are fatigue, headaches, and cough. Advanced age and use of antidiabetic medications were independently associated with COVID-19-related complications in diabetic patients.

Assessing the Perception of Pharmacy Students on Launching a Doctor of Pharmacy/Master of Public Health Dual Degree Program in Saudi Arabia: A Multi-Institutional Cross-Sectional Study.

There is a lack of Doctor of Pharmacy (PharmD) and Master of Public Health (MPH) dual degree programs in Saudi Arabia. This study aims to examine current pharmacy students' perceptions regarding establishing such a program and the perceived limitations and advantages of pursuing such a degree. We conducted a cross-sectional web-based short survey to assess the feasibility of establishing a PharmD/MPH dual degree program in several randomly selected pharmacy schools in Saudi Arabia. Our cohort consisted of 657 students. Almost 56% were males, and nearly 58% were fourth-year pharmacy students. Close to 85% had a "very well" or "well" understanding regarding the pharmacist's role in the public health area, and almost 70% stated that they see themselves playing a role in public health as a future pharmacist. Nearly 93% reported that they are either "very likely" or "likely" to enroll in such a program if given the opportunity. Almost 80% felt it would increase their job opportunities. On the other hand, close to 70% felt it would increase workload and stress. This study highlights pharmacy students' positive perceptions regarding establishing a PharmD/MPH dual degree program in Saudi Arabia. The study results could be utilized as the starting point to propose and establish this program to health education policymakers in Saudi Arabia.

Comparative Risk of Acute Kidney Injury Following Concurrent Administration of Vancomycin with Piperacillin/Tazobactam or Meropenem: A Systematic Review and Meta-Analysis of Observational Studies.

The study aims to comparatively assess the nephrotoxicity of vancomycin when combined with piperacillin-tazobactam (V + PT) or meropenem (V + M) in adult patients hospitalized in general wards or intensive care units. We searched MEDLINE, Google Scholar, and Web of Science for observational studies evaluating incidences of AKI in adult patients receiving V + PT or V + M for at least 48 h in general wards or intensive care units. The primary outcome was AKI events, while the secondary outcomes were hospital length of stay, need for renal replacement therapy (RRT), and mortality events. The odds ratio (OR), or mean difference for the hospital length of stay, with a corresponding 95% confidence interval (CI) from the inverse variance weighting random-effects model were estimated for the risk of AKI, RRT, and mortality. Of the 112 studies identified, twelve observational studies were included in this meta-analysis with a total of 14,511 patients. The odds of having AKI were significantly higher in patients receiving V + PT compared with V + M (OR = 2.31; 95%CI 1.69-3.15). There were no differences between V + PT and V + M in the hospital length of stay, RRT, or mortality outcomes. Thus, clinicians should be vigilant while using V + PT, especially in patients who are at high risk of AKI.

Real-World Effectiveness and Safety of Apixaban versus Warfarin in Patients with Acute Venous Thromboembolism: Experience of a Large Tertiary Hospital in Saudi Arabia.

PURPOSE: The main objective of this study was to evaluate the effectiveness and safety of apixaban versus warfarin in patients with venous thromboembolism (VTE) in a "real-world" setting. PATIENTS AND METHODS: A retrospective cohort study was conducted using data from a large tertiary hospital in Saudi Arabia. Patients were included if they were adults (≥18 years), diagnosed with VTE, and treated with either apixaban or warfarin between January 2016 and September 2018. Patients who had received anticoagulation therapy within three months of the date of the index event were excluded. The effectiveness outcomes were incidence of VTE recurrence (ie, deep vein thrombosis DVT or pulmonary embolism [PE]), while the safety outcome was incidence of any major bleeding (MB) event within 90 days of follow-up. RESULTS: Among the 492 patients included for study, 212 (43.1%) received apixaban and 280 (56.1%) received warfarin. The mean age of patients was 53.6±19.1 years and 62% of the cohort was female. Comparable rates of VTE recurrence were observed for apixaban and warfarin treatment groups during follow-up (adjusted odds ratio (AOR) =0.95; 95% CI 0.53-1.68), including DVT (AOR=1.06; 95% CI 0.52-2.17) and PE (AOR=0.78; 95% CI 0.31-1.96). However, apixaban was associated with significantly fewer MB events than warfarin (AOR=0.18; 95% CI 0.04-0.83). CONCLUSION: The use of apixaban for the treatment of Saudi patients with acute VTE is associated with a VTE recurrence rate comparable to that of warfarin, with significantly fewer MB events.

Knowledge and Awareness of Authorship Practices Among Health Science Students: A Cross-Sectional Study.

BACKGROUND: The International Committee of Medical Journal Editors has published clear guidelines on the authorship of scientific papers. It is the research team's responsibility to review and ensure those guidelines are met. Authorship ethics and practices have been examined among healthcare professionals or among particular health science students such as medical students. However, there is limited evidence to assess the knowledge of authorship roles and practices among health science students. METHODS: We conducted a cross-sectional study to assess the knowledge of authorship guidelines practices among health science students at King Saud bin Abdulaziz University for Health Sciences in Riyadh, Saudi Arabia. A survey was developed and distributed. It covered several domains, including demographic characteristics, participant's knowledge and attitude of authorship practices, knowledge and experience with ghost and guest authorships, and knowledge of institutional authorship policies. Moreover, a score was computed to reflect the respondents' knowledge about authorship practices. RESULTS: Among the 321 participants who agreed to take the survey, two-thirds agreed with and supported that multi-authored articles' credit allocation should be based on the most significant contribution and contributions to the manuscript writing. Almost 47% agreed that team relationships would influence authorship allocation. The majority of the participants were not aware of their institutional research and publication policies. Also, around 50% of participants were not aware of guest or ghost authorships. Finally, the knowledge score about authorship credits, allocation, contribution, order, and guidelines was higher among students who were assigned as corresponding authors and those who were aware of their institutional authorship guidelines and policies. CONCLUSION: In conclusion, our findings suggest that health science students may have limited knowledge about authorship guidelines and unethical behaviors involved in a scientific publication. Universities and research centers should make more efforts to raise the awareness of health science students regarding authorship guidelines while ensuring that they comply with those guidelines.

Safety and efficacy of dual versus triple antithrombotic therapy (DAT vs TAT) in patients with atrial fibrillation following a PCI: a systematic review and network meta-analysis.

OBJECTIVE: Creating an appropriate antithrombotic therapy for patients with atrial fibrillation (AF) who have undergone percutaneous coronary intervention (PCI) remains a dilemma. Several clinical trials compared the use of a dual antithrombotic therapy (DAT) regimen with a direct oral anticoagulants including (apixaban, dabigatran, edoxaban or rivaroxaban) and a P2Y12 inhibitor versus a triple antithrombotic therapy (TAT) that includes a vitamin K antagonist plus aspirin and a P2Y12 inhibitor in patients with AF who have undergone PCI. However, there are no head-to-head trials comparing the DAT regimens to each other. We aimed to compare the efficacy and safety of DAT regimens using a network meta-analysis (NMA) approach. DESIGN: A systematic review and NMA of randomised clinical trials. METHODS: We conducted a systematic literature review to identify relevant randomised clinical trials and performed a Bayesian NMA for International Society on Thrombosis and Haemostasis (ISTH) major or clinically relevant non-major (CRNM) bleeding, all-cause mortality, stroke, myocardial infarction (MI) and stent thrombosis outcomes. We used NetMetaXL V.1.6.1 and WinBUGS V.1.4.3 for the NMA and estimated the probability of ranking the treatments based on the surface under the cumulative ranking curve. RESULTS: The comparison between DAT regimens showed no significant difference in the safety or efficacy outcomes. Apixaban regimen was ranked first as the preferred therapy in terms of ISTH major or CRNM bleeding and stroke, with a probability of 52% and 54%, respectively. Rivaroxaban regimen was the preferred therapy in terms of MI and stent thrombosis, with a probability of 34% and 27%, respectively. Dabigatran regimen was ranked first in terms of all-cause mortality, with a probability of 28%. CONCLUSION: The DAT regimens are as safe and effective as TAT regimens. However, ranking probabilities for the best option in the selected outcomes can be used to guide the selection among these agents based on different patients' conditions.

Real-World Analysis of Potential Pharmacokinetic and Pharmacodynamic Drug Interactions with Apixaban in Patients with Non-Valvular Atrial Fibrillation.

PURPOSE: We conducted this study to assess the real-world prevalence, nature, predictors, and clinical necessity of apixaban pharmacokinetic (PK) and pharmacodynamic (PD) drug interactions in patients with non-valvular atrial fibrillation (NVAF) at a tertiary medical institution in Saudi Arabia. PATIENTS AND METHODS: An observational retrospective cohort analysis was conducted in adult patients diagnosed with NVAF receiving apixaban for stroke prevention from the period of June 2015 to May 2019. RESULTS: Of the 1271 patients included in the analysis, 611 (48.1%) patients had potential PD- or PK-drug interactions with apixaban. Of those, 490 (38.6%) patients had potential PD drug-drug interactions (DDIs) and 121 (9.5%) patients had potential PK-DDIs. PD-DDIs with apixaban were mainly with antiplatelet therapy followed by non-steroidal anti-inflammatory drugs and antidepressants. PK-DDIs with apixaban were mainly with combined P-gp/CYP3A4 inhibitors or inducers. History of minor bleeding was positively correlated with PD-DDIs with apixaban, ß coefficient = 0.455 (OR 1.58; 95% CI 1.01-2.45); p<0.05. History of acute coronary syndrome was positively correlated with PD-DDIs with apixaban, ß coefficient = 0.515 (OR 1.60; 95% CI 1.36-1.99); p<0.05. History of heart failure was positively correlated with PK-DDIs with apixaban, ß coefficient = 0.459 (OR 1.58; 95% CI 1.07-2.35); p<0.05. Almost 15% of the included patients had no clinical indication to receive the potential interacting drug with apixaban and about 20% of them were assuming an inappropriate apixaban dose according to the product package insert. CONCLUSION: Pharmacodynamics and pharmacokinetics interactions are common in more than half of the patients with NVAF receiving apixaban for stroke prevention in this real-world analysis. Some of these interacting medications are not indicated. Drug-drug interactions should always be considered and monitored with apixaban with a regular assessment of the need for any interacting medication.

Knowledge regarding Zika Virus Infection among Healthcare Providers in an Academic Tertiary Care Center in Riyadh, Saudi Arabia: A Cross-Sectional Survey Study.

BACKGROUND: Zika virus (ZIKV) has become a major concern across the world. It is highly necessary for healthcare providers (HCPs) to have sufficient knowledge about such a disease. The purpose of this study is to assess the knowledge regarding ZIKV among HCPs in Riyadh, Saudi Arabia. Materials and Methods. A cross-sectional survey study was conducted at a tertiary care center in Riyadh, KSA, during a two-month period from September 19, 2016 to November 19, 2016. Descriptive statistics were performed on data collected. For continuous variables, data were expressed as means ± standard deviations (SDs), medians, and ranges. Proportions were used to describe categorical variables. Knowledge scores were evaluated and compared by demographic characteristics including age, designation, years of practice, and gender, using the t-test/Mann-Whitney U test or the Kruskal-Wallis test, as appropriate. RESULTS: A total of 336 HCPs from different specialties (physicians, dentists, nurses, pharmacists, and nutritionists) completed the questionnaire. Significant differences in knowledge about ZIKV were observed by participant's age. Significantly higher knowledge levels were observed among older participants (45 years or more; p=0.011). A substantial difference in the knowledge level was observed by department, with pairwise comparisons showing significant differences in knowledge scores between all departments except for Pharmacy vs. Nutrition and Nursing vs. Internal Medicine. Knowledge scores were not significantly different by years of practice. CONCLUSION: Our study showed inadequate knowledge of HCPs from different specialties about ZIKV infection which needs to be improved in terms of infection prevention and control. Awareness about ZIKV infection should be ensured and maintained among HCPs to face any possible emergence in the region.

Modeling risk assessment for breast cancer in symptomatic women: a Saudi Arabian study.

BACKGROUND: Despite the continuing increase in the breast cancer incidence rate among Saudi Arabian women, no breast cancer risk-prediction model is available in this population. The aim of this research was to develop a risk-assessment tool to distinguish between high risk and low risk of breast cancer in a sample of Saudi women who were screened for breast cancer. METHODS: A retrospective chart review was conducted on symptomatic women who underwent breast mass biopsies between September 8, 2015 and November 8, 2017 at King Abdulaziz Medical City, Riyadh, Saudi Arabia. RESULTS: A total of 404 (63.8%) malignant breast biopsies and 229 (36.2%) benign breast biopsies were analyzed. Women ≥40 years old (aOR: 6.202, CI 3.497-11.001, P=0.001), hormone-replacement therapy (aOR 24.365, 95% CI 8.606-68.987, P=0.001), postmenopausal (aOR 3.058, 95% CI 1.861-5.024, P=0.001), and with a family history of breast cancer (aOR 2.307, 95% CI 1.142-4.658, P=0.020) were independently associated with an increased risk of breast cancer. This model showed an acceptable fit and had area under the receiver-operating characteristic curve of 0.877 (95% CI 0.851-0.903), with optimism-corrected area under the curve of 0.865. CONCLUSION: The prediction model developed in this study has a high ability in predicting increased breast cancer risk in our facility. Combining information on age, use of hormone therapy, postmenopausal status, and family history of breast cancer improved the degree of discriminatory accuracy of breast cancer prediction. Our risk model may assist in initiating population-screening programs and prompt clinical decision making to manage cases and prevent unfavorable outcomes.

Practices, awareness and attitudes toward self-medication of analgesics among health sciences students in Riyadh, Saudi Arabia.

BACKGROUND: Self-medication is a common practice among health sciences students in Saudi Arabia. It is known that inappropriate selfmedication may harm individuals due to increasing the risk of drug misuse or delaying a hospital visit by masking some symptoms. Thus, the aim of our study is to investigate and assess practices, awareness and attitudes toward analgesics self-medication among health science students in Riyadh, Saudi Arabia. METHODS: This is a cross-sectional study in a form of electronic survey that was conducted among health sciences students from different universities in Riyadh, Saudi Arabia in 2016. Two hundred and seventy-two students responded to the questionnaire. The electronic questionnaire survey covered demographics, self-medication practice and the analgesics consumption, attitude and awareness about the safety of self-medication practice of analgesics. RESULTS: Factors associated with high prevalence of self-medication were not significant except for age (P = 0.04). Health sciences students had adequate knowledge about the safety of analgesics consumption itself and simultaneous use of analgesics with other drugs, significantly different by college; 80% for Pharmacy, 71% for Medicine, 61% for Nursing and Dentistry, and 25% for Applied Medical Sciences and pre-professional students (p = 0.037). CONCLUSION: The occurrence of self-medication practices is distressingly high among health sciences students. It is necessary to educate the students about the side effects and drawbacks of irresponsible selfmedication.

Relationship of body mass index to sleep duration, and current smoking among medical students in Tabuk City, Saudi Arabia.

BACKGROUND: Being overweight is associated with cardiometabolic risk, and lifestyles including smoking and good sleep hygiene are also implicated. We aimed to assess the dietary habit, time spent on social media, and sleep duration relationship to body mass index (BMI) among medical students in Tabuk, Saudi Arabia. METHODS: A cross-sectional study was conducted among 147 clinical phase medical students in the Medical College, University of Tabuk (Saudi Arabia) from January 2018 to May 2018. A checklist questionnaire was used to measure variables such as age, sex, smoking, level of exercise, whether taking meals and snacks regularly, eating fast food, fruit and vegetable consumption, sleep duration, time spent on social media, and breakfast skipping. Data were analyzed by IBM-SPSS version 20, using one-way ANOVA and Pearson's production-moment correlation (r). A p-value of less than 0.05 was considered statistically significant. RESULTS: Participants consisted of 51% males, mean age (Mean ± SD) was 22.90±1.27 years, sleep duration was 7.50±2.17 hours, time spent on social media was 5.54±3.49 hours, body mass index was 24.8±5.19, and breakfast skipping, fast food consumption, smoking, and regular exercise were reported in 52.4%, 87.7%, 12.9%, and 36.1% respectively. A significant negative correlation was evident between BMI and sleep duration (r= -0.185, p=0.025), cigarette smokers were more likely to be obese compared to their counterparts (27.28±6.85 vs. 24.10±4.98, p=0.018). No significant statistical relationship was evident between BMI, breakfast skipping, fast food, fruit and vegetable intake, and time spent on social media. CONCLUSION: BMI was higher among smokers and those with shorter sleep duration, there was no association between BMI and other students' characteristics. Measures to smoking quitting and good sleep hygiene are recommended.

Direct oral anticoagulants for the treatment of venous thromboembolism in patients with active malignancy: a systematic review and meta-analysis.

Low molecular weight heparins (LMWHs) are considered the standard of care for the treatment of venous thromboembolism (VTE) associated with cancer. We conducted a meta-analysis to evaluate the safety and efficacy of direct oral anticoagulants (DOACs) in patients with cancer. We systematically searched Medline for potential randomized-control clinical trials (RCTs) and post-hoc analyses. For each study, data on recurrent VTE, major or clinically relevant non-major bleeding (CRNMB), and major bleeding (MB) were extracted. Initially, a total of 1395 citations were identified. Eight studies met our eligibility criteria. The utilization of DOACs in patients with cancer showed a statistically significant reduction in the risk of VTE recurrence compared to LMWH or warfarin (RR = 0.64; 95% CI 0.46-0.88). Similar rates of major or CRNMB were observed between DOACs and LMWH or warfarin (RR = 1.00; 95% CI 0.75-1.33). There was no significant difference in the rate of MB between DOACs and LMWH or warfarin (RR = 1.31; 95% CI 0.71-2.44). Our results suggest that DOACs might reduce the incidence of VTE recurrence in patients with cancer without putting them at high risk for MB/CRNMB or MB. Our findings were mainly driven by the results of the Hokusai VTE Cancer trial. Given the level of investigated evidence, our findings should be interpreted with caution since the majority of the data were originated from sub-group analyses of large (RCTs). Future studies that are adequately powered are warranted to assess efficacy and safety data of DOACs for the treatment of VTE in patients with different types of cancer.

Exploring Factors Associated with Depression and Anxiety among Hospitalized Patients with Type 2 Diabetes Mellitus.

OBJECTIVES: The aims of the current study were to determine the prevalence and severity of anxiety and depression, and to explore associated factors among hospitalized patients with type 2 diabetes mellitus. SUBJECTS AND METHODS: All patients with type 2 diabetes (160 patients) who were admitted to the Internal Medicine Wards of the King Abdulaziz Medical City, Riyadh, Saudi Arabia, from January to August 2015 were asked to participate, and 158 patients agreed to do so. A self-administered questionnaire consisting of 2 parts was used. The first part was on sociodemographic information, and the second part was a validated screening tool for assessing depression and anxiety. The severity of anxiety and depression was classified as normal, mild, moderate, and severe. Logistic regression was carried out to identify variables that were independently associated with anxiety and depression. RESULTS: Using the screening tool, 85 (53.8%) and 80 (50.6%) study patients were identified as patients who suffered from depression and anxiety, respectively. The severity of distress was moderate/severe in 36 (42.4%) patients with depression and 41 (51.3%) patients with anxiety. The factors independently associated with the risk for anxiety in hospitalized patients with diabetes were physical inactivity and staying 8 days or longer in the hospital. On the other hand, factors that were independently associated with the risk for depression were older age, low income, and nephropathy. CONCLUSION: The majority of hospitalized patients with diabetes developed moderate/severe anxiety or depression, or both, during hospitalization. Hence, screening for anxiety and depression in high-risk hospitalized diabetic patients is recommended during hospitalization.