Acetylsalicylic Acid Compared with Enoxaparin for the Prevention of Thrombosis and Mechanical Ventilation in COVID-19 Patients: A Retrospective Cohort Study.

BACKGROUND AND OBJECTIVE: Low-dose acetylsalicylic acid (ASA, aspirin) is a well-known and frequently studied drug for primary and secondary prevention of disease due to its anti-inflammatory and coagulopathic effects. COVID-19 complications are attributed to the role of thrombo-inflammation. Studies regarding the use of low-dose ASA in COVID-19 are limited. For this reason, we propose that the use of low-dose ASA may have protective effects in COVID-19-related thromboembolism and lung injury. This study was conducted to assess the efficacy of low-dose ASA compared with enoxaparin, an anticoagulant, for the prevention of thrombosis and mechanical ventilation. METHODS: We conducted a retrospective cohort study on COVID-19-confirmed hospitalized patients at the Mansoura University Quarantine Hospital, outpatients, and home-isolated patients from September to December 2020 in Mansoura governorate, Egypt. Binary logistic regression analysis was used to assess the effect of ASA compared with enoxaparin on thromboembolism, and mechanical ventilation needs. RESULTS: This study included 225 COVID-19 patients. Use of ASA-only (81-162 mg orally daily) was significantly associated with reduced thromboembolism (OR 0.163, p = 0.020), but both low-dose ASA and enoxaparin, and enoxaparin-only (0.5 mg/kg subcutaneously (SC) daily as prophylactic dose or 1 mg/kg SC every 12 hours as therapeutic dose) were more protective (odds ratio [OR] 0.010, OR 0.071, respectively, p < 0.001). Neither ASA-only nor enoxaparin-only were associated with a reduction in mechanical ventilation needs. Concomitant use of low-dose ASA and enoxaparin was associated with reduced mechanical ventilation (OR 0.032, 95% CI 0.004-0.226, p = 0.001). CONCLUSIONS: Low-dose ASA-only use may reduce the incidence of COVID-19-associated thromboembolism, but the reduction may be less than that of enoxaparin-only, and both ASA and enoxaparin. Concomitant use of ASA and enoxaparin demonstrates promising results with regard to the reduction of thrombotic events, and mechanical ventilation needs.

Influences of Gender on Intravenous Nalbuphine Actions After Major Abdominal Surgery: A Multicenter Study.

INTRODUCTION: Nalbuphine, a synthetic kappa-opioid receptor (KOR) agonist and a partial µ-opioid receptor (MOR) antagonist, has been used for years as an effective analgesic. It has been shown to have a better safety profile than morphine. Considering the long history of use of this drug, it is interesting that only a limited amount of information exists on how gender differences influence nalbuphine responses. In this randomized double-blind comparative trial after major abdominal surgery, the analgesic effects of two doses of continuous intravenous infusion of nalbuphine were evaluated based on gender. METHODS: Enrolled patients were divided into four groups (two females and two males with 32 patients in each group). Two of them (groups A1 and A2), one male and one female, received postoperative continuous intravenous infusions of nalbuphine at 2 mg/h via patient-controlled analgesia (PCA). Each patient had the potential of receiving a rescue bolus of 1 mg of nalbuphine with a lock out time of 15 min. The other two groups (groups B1 and B2) received half the infusion dose, 1 mg/h, and half the nalbuphine rescue dose with the PCA pump, 0.5 mg maximum every 15 min as needed. Patients' vital signs, numerical pain rating scores, rescue nalbuphine, and incidence of side effects were assessed immediately after the operation, and every 3 h during the first 12 h. RESULTS: Nalbuphine 2 mg/h dosing led to significantly lower pain scores amongst females compared to males at 6, 9, and 12 h; while the 1 mg/h infusion pain scores were only lower at the 9-h time period. Females receiving the nalbuphine 2 mg dose at 6 h, and the 1 mg dose at 6, 9, and 12-h measurements needed significantly lower doses of rescue nalbuphine. Females on the 1 mg dose experienced significantly more nausea, vomiting, and sedation at the 6-, 9-, and 12-h measurement times. In the multivariate analysis, female gender was a negative predictor at all measurement times. CONCLUSIONS: The current study supports the hypothesis that although nalbuphine was found to be an effective and well-tolerated analgesic after major abdominal surgery, females were statistically more responsive than males. TRIAL REGISTRATION: The study was registered at the Pan African Clinical trials Registry PACTR201304000486309, and approved for the Ethical aspects.

Impact of an integrated care program on glycemic control and cardiovascular risk factors in patients with type 2 diabetes in Saudi Arabia: an interventional parallel-group controlled study.

BACKGROUND: Long intervals between patient visits and limited time with patients can result in clinical inertia and suboptimal achievement of treatment goals. These obstacles can be improved with a multidisciplinary care program. The present study aimed to assess the impact of such a program on glycemic control and cardiovascular risk factors. METHODS: In a randomized, parallel-group trial, we assigned 263 patients with poorly controlled type 2 diabetes mellitus (T2DM) to either a control group, standard care program, or a multidisciplinary care program involving a senior family physician, clinical pharmacy specialist, dietician, diabetic educator, health educator, and social worker. The participants were followed for a median of 10 months, between September 2013 and September 2014. Glycated hemoglobin (HbA1c), fasting blood glucose (FBG), lipid profiles, and blood pressure (BP) were measured. The assignment was blinded for the assessors of the study outcomes. The study registry number is. RESULTS: In the intervention group, there were statistically significant (p < 0.05) post-intervention (relative) reductions in the levels of HbA1c (-27.1%, 95% CI = -28.9%, -25.3%), FBG (-17.10%, 95% CI = -23.3%, -10.9%), total cholesterol (-9.93%, 95% CI = -12.7%, -7.9%), LDL cholesterol (-11.4%, 95% CI = -19.4%, -3.5%), systolic BP (-1.5%, 95% CI = -2.9%, -0.03%), and diastolic BP (-3.4%, 95% CI = -5.2%, -1.7%). There was a significant decrease in the number of patients with a HbA1c ≥10 (86 mmol/mol) from 167 patients at enrollment to 11 patients after intervention (p < 0.001). However, the intervention group experienced a statistically significant increase in body weight (3.7%, 95% CI = 2.9%, 4.5%). In the control group, no statistically significant changes were noticed in different outcomes with the exception of total cholesterol (-4.10%, p = 0.07). In the linear regression model, the intervention and the total number of clinic visits predicted HbA1c improvement. CONCLUSIONS: Implementation of a patient-specific integrated care program involving a multidisciplinary team approach, frequent clinic visits, and intensified insulin treatment was associated with marked improvement in glycemic control and cardiovascular risk factors of poorly controlled T2DM patients in a safe and reproducible manner. TRIAL REGISTRATION: ISRCTN Identifier: ISRCTN83437562 September 19, 2016 Retrospectively registered.

Potentially inappropriate medications prescribed for elderly patients through family physicians.

The elderly population is increasing throughout the globe, resulting in higher healthcare costs. Potential inappropriate medication (PIM) prescriptions are a major health problem affecting the elderly persons. Due to limited studies in PIM use in primary care and home healthcare in Saudi Arabia, we aim to examine the extent of PIM prescription for and use by elderly patients. This study was carried out with 798 elderly patients, arbitrarily selected from Prince Sultan Medical Military City through the patient register. The mean age of the patients were in the range of 75.2 ± 5.5; 37.8% were males and 62.2% were females. The elderly patients are affected majorly with diabetes (73.9%), hypertension (83.2%) and lipid abnormalities (73.8%). The maximum patients involved in this study were affected with lower hemoglobin levels i.e. 99.2%. Renal impairment was found in 64% and iron supplements were the most commonly used in 23.1%, followed by analgesics and opioids (17%). The 52.5% of participants were using one or more PIMs. Kidney was the only functions and had influence on prescribed decisions. This study indicates PIM is a concern in elderly patients attending clinics and home residents and commonly prescribed ones are atypical antipsychotics, iron overdose, benzodiazepines and opioids. Prescription of drug-drug interactions, cascades and inappropriate drug doses results in preventable adverse effects.

Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.

BACKGROUND: Fasting during the month of Ramadan could lead to acute complications and increased hypoglycemic risk of patients with type 2 diabetes. Therefore, diabetes is one of the diseases that need careful observation and special considerations during Ramadan including patients' education and counseling. OBJECTIVES: To evaluate the impact of Ramadan focused education program on acute complications and biomedical parameters. METHODS: A prospective nonrandomized interventional controlled design was run on three phases: before, during, and after Ramadan on 262 type 2 diabetes patients. The intervention group (n=140) received focused individualized diabetic education sessions and antidiabetic medications adjustment before and after Ramadan, while the control group (n=122) received standard diabetic care. A validated hypoglycemia questionnaire was used in both groups to assess the change of the risk. Patients were advised to adjust the dosage and timing of antidiabetic agents according to the recommendations for management of diabetes during Ramadan. Primary outcomes were postintervention change of hypoglycemia score and HbA1c over 6-month follow-up. Data were presented as mean ± standard deviation. HbA1c was expressed in percentage. RESULTS: The hypoglycemic scores before, during, and after Ramadan were 14.21±8.50, 6.36±6.17, and 5.44±5.55 in the intervention group, respectively (P<0.001) and 14.01±5.10, 13.46±5.30, and 9.27±4.65 in the control group, respectively (P<0.001). HbA1c levels were 9.79±1.89, 8.26±1.54, and 8.52±1.61 before, during, and after Ramadan in the intervention group, respectively (P<0.001), and 10.04±1.47, 9.54±1.38, and 9.59±1.79 in the control group, respectively (P<0.001). Post-Ramadan reductions of HbA1c and hypoglycemic scores were significantly higher in the intervention group (-13.0% vs -4.5%, P=0.004 for HbA1c and -61.7% vs -33.8%, P<0.001 for hypoglycemic score). Low-density lipoprotein cholesterol improved in the intervention group from 2.41±0.91 mmol/L before Ramadan to 2.28±0.68 mmol/L after Ramadan (P<0.001). No statistically significant effects were observed on blood pressure or body weight in the intervention group. Also, no change was observed in the control group. CONCLUSION: Ramadan educational program had a positive impact with reduction of hypoglycemic risk, HbA1c, and low-density lipoprotein cholesterol. Therefore, it could be recommended for patients with increased risk of hypoglycemia during Ramadan fasting.

Adherence to the American Diabetes Association standards of care among patients with type 2 diabetes in primary care in Saudi Arabia.

OBJECTIVES: To assess adherence to 11 American Diabetes Association (ADA) standards of diabetic care. METHODS: We conducted this one-year historical prospective study between October 2010 and September 2011 on 450 adult type 2 diabetes patients in a primary care center in Saudi Arabia. We used the definitions of the 2010 ADA standards of diabetic care processes and targets. RESULTS: Four-hundred and fifty medical files were valid. The adherence to ADA process standards of measurement of glycated hemoglobin (HbA1c) was 68.7%, 92.9% for blood pressure, and 80.2% for serum lipids. Screening was lowest for nephropathy (35.6%), and highest for diabetic foot (72%). Adherence to medications ranged between 82.2% for antiplatelets, and 92.4% for dyslipidemia. For outcome standards, 24.2% of the patients had an HbA1c <7%, and 32.2% had controlled blood pressure (<130/80 mm Hg); and 58.5% achieved targeted low-density lipoproteins (LDL). Only 7.2% had glycemic control in addition to controlled blood pressure and targeted LDL level. An increasing trend of patients achieving glycemic control (<7%) was shown throughout follow-up (p=0.003). CONCLUSIONS: We found suboptimal adherence with many ADA standards of diabetic care among patients with type 2 diabetes treated at a primary care center in Saudi Arabia. The achievement of outcome standards, either singly or combined, is lower than the adherence rates. However, the figures show improvement in adherence during the follow-up period.

The prevalence of smoking and its associated factors among military personnel in Kingdom of Saudi Arabia: A national study.

AIM: The aim was to measure the prevalence of smoking and identify its potential predictors among military personnel in Kingdom of Saudi Arabia (KSA). MATERIALS AND METHODS: This cross-sectional study was carried out among military personnel in the five military regions of KSA between January 2009 and January 2011. The sample of 10,500 military personnel in the Saudi Armed Forces was equally divided among the five regions with a ratio 3:7 for officers and soldiers. A multistage stratified random sampling was used to recruit participants in the four services of the armed forces in the five regions. Information on sociodemographic characteristics with a detailed history of smoking was collected by means of a self-administered questionnaire. Bivariate analysis was used to identify the factors associated with smoking, and multiple logistic regression analysis to discover its potential predictors. RESULTS: About 35% of the sample was current smokers, with higher rates among soldiers. The eastern region had the highest rate (43.0%), and the southern region the lowest (27.5%). Navy personnel had a higher risk of being current smokers (40.6%), and the air defense the lowest risk (31.0%). Multivariate analysis identified working in the navy, and low income as positive predictors of current smoking, while residing in the southern region, older age, years of education, being married, and having an officer rank were negative (protective) factors. CONCLUSION: Smoking is prevalent among military personnel in KSA, with higher rates in the Navy and Air Force, among privates, younger age group, lower education and income, and divorced/widowed status. Measures should be taken to initiate programs on smoking cessation that involve changes in the environment that is likely to promote this habit.

Assessment of framingham cardiovascular disease risk among militaries in the Kingdom of Saudi Arabia.

OBJECTIVES: To measure the risk factors for cardiovascular disease (CVD) among militaries in the Kingdom of Saudi Arabia and to assess their Framingham CVD risk. METHODS: A nationwide survey included 10,500 active military personnel selected by multistage stratified random sampling representing various ranks in the army forces of 5 regions. The study used the World Health Organization STEPwise approach to chronic disease risk factor surveillance (STEPS) in the design of data collection tool. Data included demographic and health behavior information; physical assessment; and anthropometric, random blood glucose, serum cholesterol, and triglycerides measurements. RESULTS: The response rate was 97.4%. The results showed that 9.1% of the sample population had 10% or higher Framingham 10-year office-based CVD risk score, with a mean of 4.5. The risk varied by region, armed force, crowding index, waist-hip ratio, total cholesterol, and triglycerides. Multivariate analysis identified crowding index, physical inactivity, and military rank as independent predictors, apart from Framingham predictors. CONCLUSION: The prevalence of CVD risk factors is high among militaries in the Kingdom of Saudi Arabia, with an associated high 10-year CVD Framingham risk. The military health services must implement intervention programs to reduce these risks, with follow-up of the participants with identified CVD risk.

Prevalence of obesity among military personnel in Saudi Arabia and associated risk factors.

OBJECTIVE: To measure the prevalence of obesity among military personnel in the Kingdom of Saudi Arabia (KSA), and to identify its risk factors. METHODS: This nationwide cross-sectional study covered all 5 military regions of KSA. It included a multistage stratified random sample of 10,500 active military personnel. The World Health Organization STEP wise approach to chronic disease risk factor surveillance (STEPS) was used in the design of the data collection tool. The project lasted from January 2009 to February 2011. RESULTS: The response rate was 97.4%; 40.9% of the participants were overweight, 29% obese, and 42.4% had central obesity. Multivariate analysis revealed age, education years, and family history of diabetes or hypertension as statistically significant positive predictors of body mass index, while higher military rank, smoking, eating fruits more than twice per week, and heavy physical activities were negative predictors. CONCLUSION: Obesity is a major health problem among military personnel in this survey especially among soldiers, and is associated with unhealthy dietary and physical activity habits. Prompt action must be taken by the military medical services department in terms of intervention programs primarily directed to soldiers and overweight personnel to control obesity and mitigate its consequences. Review of the anthropometric standards for recruitment, continuation, and promotion in military service is recommended.

Gender differences in health education needs and preferences of Saudis attending Riyadh Military Hospital in the Kingdom of Saudi Arabia.

BACKGROUND AND AIM: Health reforms that tend to increase the participation of clients in decision-making requires them to be health-literate; hence, the importance of health education. However, not much research has been done to investigate the differences in health education needs according to demographic characteristics of the clients. The aim of this study was to find out any possible gender differences there may be in health education needs and preferences. SUBJECTS AND METHODS: This cross-sectional study was conducted at Riyadh Military Hospital, Saudi Arabia, on a convenience sample of adult Saudis attending its clinics. Data was collected from April 2009 to May 2010 using a self-administered questionnaire covering demographic data, history and needs of health education, methods, and preferred educator. RESULTS: Of the 1300 forms distributed, 977 were returned completed (75.2% response). Most men (74.0%) and women (77.9%) had had health education, but more women reported that it had been helpful (P = 0.014). More men mentioned health education needs relating to primary prevention (P = 0.027), and unhealthy practices (P = 0.003), and considered the different language a barrier (P = 0.002) even after adjustment for age and education. The one-to-one method was the most preferred health education method for men (72.7%) and women (67.9%). More women preferred group health education (P = 0.02) after adjustment for age and education. Significantly more men preferred pharmacists and dietitians as health educators. CONCLUSION: The results point to a few significant differences between men and women regarding their health education needs, barriers, and preferences. These must be taken into consideration when planning health education programs.

Home caregivers' satisfaction with the services provided by Riyadh Military Hospital's home support program.

BACKGROUND AND OBJECTIVES: The satisfaction of the family is essential to the success of home care support services. This study aimed to assess home caregivers' satisfaction with support services and to identify potential factors affecting their satisfaction. DESIGN AND SETTINGS: The study was conducted in the Family and Community Medicine Department at Riyadh Military Hospital using cross-sectional design over a period of six months. PATIENTS AND METHODS: Two hundred forty participants were recruited by systematic random sampling from the division registry. Data were collected through telephone calls using a designed structured interview form. All research ethics principles were followed. RESULTS: The response rate was 76.25%. Most caregivers were patients' sons or daughters. The duration of patients' disabling illnesses varied from less than 1 year to up to 40 years. The majority of caregivers agreed that a home care services team provided the proper healthcare-related support to the patients and improved caregivers' self-confidence in caring for their patients. Overall, on a scale of 100%, the median level of satisfaction was 90%, and 73.2% of caregivers had a satisfaction score of 75% or higher. Increased age, female gender, and more frequent home visits were positive independent factors associated with caregivers' satisfaction scores. CONCLUSION: Although most caregivers are satisfied with the services provided by a home care support program, there are still areas of deficiency, particularly in physiotherapy, vocational therapy, and social services. The implications are that caregivers need to be educated and trained in caring for their patients and need to gain self-confidence in their skills. The program's administration should improve physiotherapy, vocational therapy, social services, and procedures for hospital referral.

Physicians' awareness of bisphosphonates-related osteonecrosis of the jaw.

OBJECTIVE: To assess the awareness and knowledge of physicians and dentists regarding bisphosphonates related osteonecrosis of the jaw (BRONJ). METHODS: A cross-sectional descriptive study was carried out in the Department of Dentistry, Riyadh Military Hospital, Kingdom of Saudi Arabia from June to September 2010. Data were collected through a self-administered questionnaire distributed among a sample of physicians and dentists at the hospital. RESULTS: A total of 222 valid completed responses were obtained (response rate: 82.2%). Less than one-third of the participants (31.5%) were aware of osteonecrosis of the jaw, while slightly more than half of them were treating patients with bisphosphonates (BP). None of the physicians had a correct response in all 4 knowledge questions. There were statistically significant associations between knowledge and qualification (p=0.019), years of experience (p=0.002), and specialty (p=0.034). CONCLUSION: We found that physicians and dentists have low awareness and deficient knowledge regarding BRONJ, although most of them do prescribe BP to their patients. Therefore, intervention to raise awareness and knowledge among healthcare providers is needed.

Meningitis and seasonal influenza vaccination coverage among military personnel in central Saudi Arabia.

OBJECTIVE: To determine the meningitis and influenza vaccination coverage rates among Saudi military personnel in Riyadh (Central Military Region [CMR]), Kingdom of Saudi Arabia, (KSA) and the socio-demographic factors that influence vaccination. METHODS: This cross-sectional descriptive study was carried out on a sample of 2286 military personnel from different army forces and different military ranks in CMR in KSA selected by a 2-stage stratified random sampling technique. A self-administered questionnaire designed for the National Military Health Survey was used with a section added for assessment of vaccination status. Data collection was carried out from May to August 2009. RESULTS: The response rate was 97.6%. The vaccination coverage was higher for meningitis (51.7%) compared with influenza (17.8%). A high percentage lacked awareness of their vaccination status. Vaccination rates were higher in the Land Forces, and increased with more years of education, and lower crowding index. CONCLUSION: The proportion of vaccination coverage among military personnel in CMR of KSA is low, especially for influenza, along with their awareness of their vaccination status. A vaccination program that includes awareness promotion of vaccine-preventable diseases is recommended, with changes in the policies to mandate vaccination against meningitis and influenza.

Introducing computer-assisted training sessions in the clinical skills lab at the Faculty of Medicine, Suez Canal University.

BACKGROUND: The Faculty of Medicine, Suez Canal University clinical skills lab was established in 1981 as the first skills lab in Egypt to cope with innovation in medical education adopted since school inauguration in 1978. Students are trained using their peers or models. Training is done weekly, guided by checklists tested for validity and reliability and updated regularly. Students receive immediate feedback on their performance. Recently, the number of students has increased, leading to challenges in providing adequate supervision and training experiences. A project to design and implement a computer-assisted training (CAT) system seemed to be a plausible solution. AIMS: To assess the quality of a newly developed CAT product, faculty and students' satisfaction with it, and its impact on the learning process. METHODS: The project involved preparation of multimedia video-films with a web interface for links of different scientific materials. The project was implemented on second year students. A quality check was done to assess the product's scientific content, and technical quality using questionnaires filled by 84 faculty members (139 filled forms) and 175 students (924 filled forms). For assessment of impact, results of examinations after project implementation were compared with results of 2nd year students of previous 3 years. RESULTS: More faculty (96.3%) were satisfied with the product and considered its quality good to excellent, compared to 93.9% of students, p < 0.001. Most faculty (76.2%) have agreed on its suitability for self-learning, while most students considered the product would be suitable after modification. The percentage of students' failures was lower after project implementation, compared to previous 3 years, p < 0.05. CONCLUSION: CAT materials developed for training of second year students in skills lab proved to be of good scientific content and quality, and suitable for self-learning. Their use was associated with lower failure rates among students. A randomized trial is recommended to ascertain the effectiveness of its application.