Role of Multidisciplinary Team Meetings in the Diagnosis and Management of Diffuse Parenchymal Lung Diseases in a Tertiary Care Hospital.

Background Decisions on the management of interstitial lung diseases (ILD) and prognostication require an accurate diagnosis. It has been proposed that multidisciplinary team (MDT) meetings for ILD (ILD-MDT) improve these decisions in challenging cases of ILD. However, most studies in this field have been based on the decisions of individual clinicians and there are few reports on the outcomes of the ILD-MDT approach. We therefore describe the experience of the ILD-MDT meetings at our institution. Methods A single-center retrospective review of the electronic health care records of patients discussed in the ILD-MDT meetings at our institution from February 2016 to January 2021 was performed. At out institution, at each ILD-MDT meeting, the referring pulmonologist presents the clinical history and the results of all relevant investigations including serology, blood gas analyses, lung function tests, bronchoscopy, and bronchoalveolar lavage. A radiologist then describes the imaging including serial computed tomography (CT) scans. When available, the findings on lung biopsy are presented by a pathologist. Subsequent discussions lead to a consensus on the diagnosis and further management. Results The study included 121 patients, comprising 71 (57%) males and 76 nonsmokers (62.8%), with a mean age of 65 years (range: 25-93 years). The average number of comorbidities was 2.4 (range: 0-7). Imaging-based diagnoses were usual interstitial pneumonia (UIP)/chronic hypersensitivity pneumonitis (CHP) in 32 (26%) patients, UIP in 20 (17%) patients, probable UIP in 27 (22%) patients, nonspecific interstitial pneumonia in 11 (9%) patients, and indeterminate interstitial lung abnormalities (ILA) in 10 (8%) patients. The most common consensus clinical diagnosis after an ILD-MDT discussion was chronic hypersensitivity pneumonitis/idiopathic pulmonary fibrosis in 17 patients (14%), followed by idiopathic pulmonary fibrosis and connective tissue disease associated interstitial lung disease in 16 patients (13%), CHP in 11 patients (9.1%), and ILA in 10 patients (8.4%). Only a 42 patients (35%) required surgical lung biopsy for confirmation of the diagnosis. Conclusion This study describes the characteristics of the patients discussed in the ILD-MDT meetings with emphasis on their clinical, radiological, and laboratory data to reach a diagnosis and management plan. The decisions on commencement of antifibrotics or immunosuppressive therapy for patients with various ILDs are also made during these ILD-MDT meetings. This descriptive study could help other health care professionals regarding the structure of their ILD-MDT meetings and with discussions about diagnostic and care decisions for diffused parenchymal lung disease patients.

MicroRNA profiles in critically ill patients.

The use of biomarkers to expedite diagnosis, prognostication, and treatment could significantly improve patient outcomes. The early diagnosis and treatment of critical illnesses can greatly reduce mortality and morbidity. Therefore, there is great interest in the discovery of biomarkers for critical illnesses. Micro-ribonucleic acids (miRNAs) are a highly conserved group of non-coding RNA molecules. They regulate the expression of genes involved in several developmental, physiological, and pathological processes. The characteristics of miRNAs suggest that they could be versatile biomarkers. Assay panels to measure the expression of several miRNAs could facilitate clinical decision-making for a range of diseases. We have, in this paper, reviewed the current understanding of the role of miRNAs as biomarkers in critically ill patients.

A survival analysis of idiopathic pulmonary fibrosis in the context of antifibrotic therapy in Saudi Arabia.

BACKGROUND: The prognosis of idiopathic pulmonary fibrosis (IPF) can be predicted by the gender, age, and physiology (GAP) index. However, antifibrotic therapy (i.e., nintedanib and pirfenidone) may improve survival. AIMS: This study aimed to compare the outcomes of antifibrotic-treated IPF with the survival predicted by the GAP index. METHODS: A retrospective cohort study was conducted from March 2014 to January 2020. The electronic health-care records of all IPF patients treated with nintedanib or pirfenidone were reviewed. Besides standard demographic and mortality data, the variables required to calculate the GAP index were also extracted. RESULTS: Eighty-one patients (male 55, 68%; age 71.4 ± 10.2 years) with IPF received antifibrotic therapy (nintedanib 44.4%; pirfenidone 55.6%; mean follow-up 35 ± 16.5 months). Cumulative mortality (whole cohort 3 years 12%; 4 years 26%; 5 years 33%) was significantly less than predicted by the GAP index. CONCLUSIONS: The survival of antifibrotic-treated IPF is better than predicted by the GAP index. Novel systems for prognostication are required. The survival benefit from pirfenidone and nintedanib seem similar overall.

The efficacy of medicinal plant preparations in the alleviation of radiodermatitis in patients with breast cancer: A systematic review of clinical trials.

Radiodermatitis in breast cancer patients varies from mild irritation to life-threatening lesions. Several studies suggest a role for topical corticosteroid ointments in the treatment of radiodermatitis. Yet, to avoid the adverse effects of corticosteroids, many authors recommend the use of topical herbal products instead. The therapeutic role of herbal treatments has yet to be fully understood. This systematic review evaluates the role of topical or oral herbal medicines in radiodermatitis prevention and treatment. A systematic search of four databases (Embase, PubMed, Web of Science, and Scopus) was performed without language and time restrictions from their inception until April 2023. The bibliographies of potential articles were also searched manually. Studies evaluated and compared the effects of herbal preparations with the control group, on dermatitis induced by radiotherapy for breast cancer. The Cochrane risk of bias tool was used to assess the included studies. Thirty-five studies were included in the systematic review. Studies which used herbal drugs including topical and oral formulations were evaluated. Herbal monotherapy and combination therapy were reported, and their effects on radiodermatitis were explained in the systematic review. In conclusion, henna ointments, silymarin gel, and Juango cream were reported to reduce the severity of radiodermatitis. These agents should be considered for radiodermatitis prophylaxis and treatment. The data on aloe gel and calendula ointment were conflicting. Further randomized controlled trials of herbal medications and new herbal formulations are required to determine their effects on breast cancer radiodermatitis.

Nintedanib and pirfenidone for idiopathic pulmonary fibrosis in King Abdulaziz Medical City, Riyadh: Real-life data.

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a chronic progressive age-related lung disease causing relentless fibrosis of the lung parenchyma. Currently, pirfenidone and nintedanib are the two antifibrotic drugs, approved for the treatment of IPF. Both are shown to slow progression by preserving lung functions from rapid decline compared to a placebo. We are reporting a real-life patient experience using these two antifibrotic medications (AFMs) in our tertiary care hospital. METHODS: A retrospective cohort study was conducted for all IPF cases diagnosed in multidisciplinary meetings between 2015 and 2020 at KAMC, Riyadh (Saudi Arabia). We are reporting patients' demographics, lung function, survival, tolerance, side effects, or death in patients taking AFMs. RESULTS: A total of 81 cases were identified. The majority of patients aged 67 years (68%) were men with a median age of 68 years. Late presentation, severe disease, and definite usual interstitial pneumonia patterns were reported in 60% of our patients. The average number of hospital admissions before starting treatment was 1 (range: 0-3) in the nintedanib group and 1.4 (range: 1.2-5) in the pirfenidone group. There was an increase in the number of hospital admissions in the group started on pirfenidone 1.7 (range: 1.9-8) compared to nintedanib 0.5 (range: 0-3), P = 0.001. The observed mortality outcome in this cohort was 4 (11%) and 12 (27%) for nintedanib and pirfenidone, respectively. The predominant side effects were gastrointestinal symptoms for both the groups 18 (22%). CONCLUSIONS: Pirfenidone and nintedanib are the available approved antifibrotic agents used for many years to treat IPF patients. Real-life data showed better tolerability than reported in the West, good compliance, and a manageable side effect profile in this group of elderly and severe IPF patients.

Measurement of the awareness of venous thromboembolism in the Saudi population.

BACKGROUND: Venous thromboembolism (VTE) causes significant morbidity and mortality. International studies have suggested poor public awareness of VTE, with a few data from Saudi Arabia. The aim of this study was to investigate the knowledge and awareness of VTE in the Saudi population. Awareness of other important diseases was also investigated to allow contextualization. METHODS: A cross-sectional survey study was conducted throughout Saudi Arabia from April to June 2021. A nonprobability, purposive, social media-driven, snowballing sampling technique was used to distribute a validated online questionnaire to Saudi adults (aged over 18 years) from the general population. RESULTS: Of 1226 respondents, 214 were excluded as they were health-care professionals. The majority of the participants were unaware and unconcerned about VTE. They were more aware of other medical conditions such as hypertension. Immobility and old age were frequently recognized as risk factors for VTE. While less than half of the participants were aware that thrombosis is the cause of VTE, most participants correctly identified leg pain and tenderness as symptoms of deep venous thrombosis. The majority of the participants identified chest pain and breathlessness as symptoms of pulmonary embolism. However, leg paralysis and slow, shallow breathing were frequently identified as symptoms of VTE. The majority of subjects disagreed with the statement, "having a blood clot is not considered a medical emergency." Awareness of VTE varied significantly with age. CONCLUSION: In Saudi Arabia, the public awareness of VTE is poor. To improve outcomes, public health initiatives must increase awareness, introduce preventive measures, encourage early diagnosis, and ensure compliance with treatment.

A Single-Center Study of the Utility of Bronchoalveolar Lavage in Critically Ill Patients With Haematological Malignancy or Stem Cell Transplants.

INTRODUCTION: The aim of this study was to evaluate the yield of bronchoscopy-guided bronchoalveolar lavage (BAL) and decisions on management of antimicrobials in critically ill patients with hematological malignancy and/or hematological stem cell transplant (HSCT). The safety and tolerance of bronchoscopy were also reported. METHODS: A retrospective cohort study was conducted by reviewing health charts of all adult patients with a hematological malignancy and/or an HSCT who were admitted to the intensive care unit and underwent bronchoscopy and BAL over four years from April 2016 to April 2020 at King Abdulaziz Medical City, Riyadh.  Results: The cohort included 75 critically ill patients. Of these 75 patients, 53 (70.7%) had HSCT (allogenic 66%, autologous 32.1%, haplogenic 3.8%). Computed tomography of the chest was abnormal in all patients. Predominant findings included airspace abnormalities, ground glass opacities, and others. The positive yield was found to be 20% for bacterial, 22% for viral, 21% for fungal, and other organisms were identified in 2%. Although cytology was not performed in 18 patients, malignant cells were identified on BAL in two patients. While the overall mortality of the cohort was high (46.7%), the vast majority (94.7%) tolerated bronchoscopy and BAL without any complications. However, three patients (4%) developed a pneumothorax and one patient bled and developed the acute respiratory distress syndrome post bronchoscopy. CONCLUSIONS: BAL can identify and detect microorganisms directly influencing the clinical care of patients who have received non-invasive diagnostic tests that yielded negative culture results. Bronchoscopy and BAL are generally safe and well tolerated by critically ill patients with hematological malignancy or HSCT.

A Machine Learning Model for Predicting the Risk of Readmission in Community-Acquired Pneumonia.

Background Pneumonia is a common respiratory infection that affects all ages, with a higher rate anticipated as age increases. It is a disease that impacts patient health and the economy of the healthcare institution. Therefore, machine learning methods have been used to guide clinical judgment in disease conditions and can recognize patterns based on patient data. This study aims to develop a prediction model for the readmission risk within 30 days of patient discharge after the management of community-acquired pneumonia (CAP). Methodology Univariate and multivariate logistic regression were used to identify the statistically significant factors that are associated with the readmission of patients with CAP. Multiple machine learning models were used to predict the readmission of CAP patients within 30 days by conducting a retrospective observational study on patient data. The dataset was obtained from the Hospital Information System of a tertiary healthcare organization across Saudi Arabia. The study included all patients diagnosed with CAP from 2016 until the end of 2018. Results The collected data included 8,690 admission records related to CAP for 5,776 patients (2,965 males, 2,811 females). The results of the analysis showed that patient age, heart rate, respiratory rate, medication count, and the number of comorbidities were significantly associated with the odds of being readmitted. All other variables showed no significant effect. We ran four algorithms to create the model on our data. The decision tree gave high accuracy of 83%, while support vector machine (SVM), random forest (RF), and logistic regression provided better accuracy of 90%. However, because the dataset was unbalanced, the precision and recall for readmission were zero for all models except the decision tree with 16% and 18%, respectively. By applying the Synthetic Minority Oversampling TEchnique technique to balance the training dataset, the results did not change significantly; the highest precision achieved was 16% in the SVM model. RF achieved the highest recall with 45%, but without any advantage to this model because the accuracy was reduced to 65%. Conclusions Pneumonia is an infectious disease with major health and economic complications. We identified that less than 10% of patients were readmitted for CAP after discharge; in addition, we identified significant predictors. However, our study did not have enough data to develop a proper machine learning prediction model for the risk of readmission.

Clinical profile, course and outcomes of adults with inflammatory bowel disease over a decade: a single center experience.

BACKGROUND: Inflammatory bowel disease (IBD) is an important cause of morbidity in Saudi Arabia. OBJECTIVES: Determine the incidence, clinical profile, course and outcomes of IBD in Riyadh, Saudi Arabia. DESIGN: Medical record review SETTING: Tertiary care center PATIENTS AND METHODS: Data were extracted from the medical records of all patients with IBD admitted to King Abdulaziz Medical City, Riyadh, from 1 January 2009 to 31 December 2019. The complications of IBD were classified as gastrointestinal or extraintestinal. Comorbidities were classified as either systemic diseases or gastrointestinal diseases. MAIN OUTCOME MEASURES: Epidemiology, clinical manifestations and complications of IBD. SAMPLE SIZE AND CHARACTERISTICS: 435 patients with IBD, median (IQR) age at presentation 24.0 (14.0) years, 242 males (55.6%) RESULTS: The study population consisted of 249 patients with Crohn's disease (CD) (57.2%) and 186 with ulcerative colitis (UC) (42.8%). Nearly half were either overweight or obese. Abdominal pain, diarrhea and vomiting were the most common presenting symptoms. The most common extraintestinal manifestations were musculoskeletal (e.g., arthritis and arthralgia). Colorectal cancer was diagnosed in 3.2%. Patients with other gastrointestinal (GI) comorbidities were at higher risk of developing GI complications of IBD (P≤.05). Biological agents were used to treat 212 patients (87%) with CD and 102 patients (57%) with UC. CONCLUSIONS: The number of patients diagnosed with IBD and their body mass index increased each year over the period of interest. However, the rate of surgical intervention and number of serious complications fell. This improvement in outcomes was associated with a higher percentage of patients receiving biological therapy. LIMITATIONS: Incomplete data. Some patients diagnosed and/or followed up at other hospitals. CONFLICT OF INTEREST: None.

Benefit of natriuresis and cardiac resynchronisation therapy in acute decompensated heart failure with cardiorenal syndrome and hypernatraemia.

A man in his eighties with acute heart failure and cardiorenal syndrome developed severe hypernatraemia with diuresis. In this situation, palliation is often considered when renal replacement therapy is inappropriate. The literature to guide treatment of dysnatraemia in this setting is limited. Diuretics often worsen hypernatraemia and fluid replacement exacerbates heart failure. We describe a successful approach to this clinical Catch-22: sequential nephron blockade with intravenous 5% dextrose. Seemingly counterintuitive, the natriuretic effect of this combination had not previously been compared with diuretic monotherapy for heart failure. Yet this immediately effective strategy generated a high natriuresis-to-diuresis ratio and functioned as a bridge to cardiac resynchronisation therapy (CRT). In conjunction with a low salt diet, CRT facilitated the maintenance of sodium homeostasis and fluid balance. Thus, by improving the underlying pathophysiology (ie, inadequate cardiac output), CRT may enhance the outcomes of patients with cardiorenal syndrome and hypernatraemia.

Training pediatric residents in point-of-care ultrasound: An assessment of the needs and barriers to acquire the skill.

Introduction: The use of point-of-care ultrasound (POCU) is increasing globally. However, owing to the epidemiology of diseases and local management strategies, POCU may not be universally applicable. Before developing a POCU training program, because of limited resources for medical education, it was pivotal to conduct a needs assessment and identify the training barriers. Methods: This study used a validated paper questionnaire. The survey instrument was distributed to 120 pediatric residents (male 60, female 60) training at our institution to assess their self-reported level of skill in POCU, and their perceptions with regard to the applicability of POCU, measured with a 5-point Likert scale. The skills deficit was measured by subtracting the self-reported level of skills in lung, cardiac, and abdominal POCU from the perceived applicability of POCU. Results: Fifty-nine residents participated, resulting in a response rate of 50 and 48% (n = 29) for the male group, and 50% (n = 30) for the female group. The level of knowledge and proficiency was low. Scanning for free abdominal fluid was deemed the most applicable (mean 4.2 ± SD 1.1); however, the use of POCU to detect consolidation was considered least applicable (mean 2.7 ± SD 1.3). The skills deficit was highest for an abdominal POCU (mean 2.4 ± SD 1.6) and lowest for lung ultrasound (mean 1.4 ± SD 1.6). Although the majority (n = 48) agreed that this skill was essential, 3 (5%) had no interest, and 39% (n = 23) indicated a lack of time to acquire the skill. Conclusions: Though pediatric residents in Saudi Arabia agree that POCU is an essential skill, large skill deficits exist, supporting the necessity to provide POCU training. However, there are several barriers to overcome to achieve this.

Headache may be the only symptom of subclavian steal syndrome after thoracic endovascular aortic repair.

Thoracic endovascular aortic repair (TEVAR) is currently the treatment of choice for thoracic aortic disease. In select cases, the TEVAR stent must occlude the left subclavian artery. This is usually well tolerated, but the subclavian steal syndrome (SCSS) may occur. Vertebrobasilar insufficiency can cause headaches, but reports of headache as the only symptom of SCSS are very rare. Thus, this may be under-recognised. To increase the awareness of this complication we describe the course of a patient who developed chronic intermittent headaches after intentional occlusion of the left subclavian artery with a TEVAR stent. Revascularisation may be required to prevent adverse neurological outcomes from SCSS. Some authors recommend prophylactic revascularisation whenever the left subclavian artery is sacrificed during TEVAR. However, transposition or bypass of this artery is not without risk and mild symptoms, such as secondary headache, can be fully controlled with conservative measures that reduce steal pathophysiology.

Adequacy of physician clinical rounds and nursing care elements for non-COVID-19 infected patients admitted during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic created many challenges for healthcare systems. Frontline workers and especially healthcare professionals were the most severely affected through increased working hours, burnout and major psychological distress. OBJECTIVES: To evaluate the changes in standard care elements which occurred during the COVID-19 pandemic, specifically the physician clinical rounds and nursing care provided to non-COVID-19 infected patients. DESIGN: Observational retrospective study. SETTINGS: The study was conducted at King Abdulaziz Medical City, Riyadh Saudi Arabia. KAMC is a 1200 bed tertiary care referral academic medical center. PATIENTS (MATERIALS) AND METHODS: We compared the physician clinical rounds and nursing care elements in all admissions due to non-COVID-19 pneumonia and ST elevation myocardial infarction during the lockdown period with similar admissions in a baseline period in the same weeks in the previous pre-lockdown. MAIN OUTCOME MEASURES: To evaluates the changes occurring during the COVID-19 pandemic in terms of the standard care elements, such as the physician rounds and nursing care. SAMPLE SIZE: Total of 113 patients records were analyzed. RESULTS: During the lock down period, a total of 113 patients were admitted to the medical and cardiology wards, (95 patients with pneumonia and 18 patients with ST segment elevation myocardial infarction (STEMI)) compared to 89 patients in the pre lockdown period (74 patients with pneumonia and 15 patients with STEMI). Both groups were similar in age, gender, disposition, length of stay, goal of care planning and outcome. Chronic respiratory disease and Diabetes were more present in patients admitted on the pre lockdown time. Azithromycin was more frequently used as part of the initial antibiotic regimen for pneumonia during the pre-lockdown while doxycycline was significantly more during the lockdown. For the 95 patients admitted in the medical wards during the lockdown, there were a total of 820 physicians' clinical rounds opportunities for senior and junior physicians each. The residents missed 133 (16.2%) and consultant missed 252 (30.7%) of those clinical rounds opportunities. Missed clinical rounds opportunities during the pre-lock down period was higher for residents and consultants at 19.3% (P = 0.429 ) and 36.3% respectively (P = 0.027 ). Similarly, missed clinical rounds opportunities was less during the lockdown period from 35.2% to 25% (p 0.022) and from 38.8% to 30.6% (p = 1 ) for junior staff and consultant cardiology respectively compared to pre lockdown period. For nursing care elements, there was a decrease in missed opportunities in vital signs measurement (p 0.47 and p 0.226), pain assessment (p 0.088 and p 0,366) and skin care (p 0.249 and p 0.576) for patients admitted during the lockdown period in medical and cardiology wards. CONCLUSIONS: Caring for patients admitted for non COVID 19 infection reasons, physicians' clinical rounds did marginally increase compared to pre lockdown period while nurses monitoring for those patients was significantly higher. No difference in mortality was observed for patients admitted pre and during lockdown. The number of missed opportunities to do clinical rounds by physicians remains high during both periods and measures to improve adherence of physicians to performed clinical rounds are needed.

Acquired long QT syndrome due to antiemetics, COVID-19 and Blastocystis hominis induced exacerbation of congenital chloride losing diarrhoea.

Congenital chloride losing diarrhoea (CCLD) is a rare disease caused by mutations in an intestinal chloride/bicarbonate ion exchange channel. Few reports describe CCLD in adults and none has described the impact of a parasitic infection on CCLD. Severe diarrhoea may result in hypokalaemia with QT interval prolongation. Treatment with antiemetics may further increase the QT interval. To raise awareness of this preventable complication, we describe the course of a woman in her 20s with CCLD who developed COVID-19 and a Blastocystis hominis infestation. Treatment with antiemetics and hypokalaemia resulted in prolongation of the QT interval to 640 ms. While, the QT interval normalised with discontinuation of antiemetics and electrolyte replacement, patients with CCLD must take precautions to prevent gastrointestinal infections. Regardless, whenever patients with CCLD present to hospital, the authors recommend monitoring the QT interval and avoiding medications that predispose to torsade de pointes.

Training medical students in physical examination and point-of-care ultrasound: An assessment of the needs and barriers to acquiring skills in point-of-care ultrasound.

BACKGROUND: With growth of the use of point of care ultrasound (PoCUS) around the world, some medical schools have incorporated this skill into their undergraduate curricula. However, because of epidemiology of disease and regional differences in approaches to patient care, global application of PoCUS might not be possible. Before creating a PoCUS teaching course, it is critical to perform a needs analysis and recognize the training obstacles. MATERIALS AND METHODS: A validated online questionnaire was given to final-year medical students at our institution to evaluate their perceptions of the applicability of specific clinical findings, and their own capability to detect these signs clinically and with PoCUS. The skill insufficiency was assessed by deducting the self-reported clinical and ultrasound skill level from the perceived usefulness of each clinical finding. RESULTS: The levels of expertise and knowledge in the 229 students who participated were not up to the expected standard. The applicability of detection of abdominal aortic aneurysm (AAA) (3.9 ± standard deviation [SD] 1.4) was the highest. However, detection of interstitial syndrome (3.0 ± SD 1.1) was perceived as the least applicable. The deficit was highest in the detection of AAA (mean 0.95 ± SD 2.4) and lowest for hepatomegaly (mean 0.57 ± SD 2.3). Although the majority agreed that training of preclinical and clinical medical students would be beneficial, 52 (22.7%) showed no interest, and 60% (n = 136) reported that they did not have the time to develop the skill. CONCLUSION: Although medical students in Saudi Arabia claim that PoCUS is an important skill, there are significant gaps in their skill, indicating the need for PoCUS training. However, a number of obstacles must be overcome in the process.

Characteristics of Hospitalized Adults With Recurrent Urinary Tract Infection Due to Extended Spectrum Beta-Lactamase Producing Escherichia coli in a Tertiary Center in Saudi Arabia.

BACKGROUND: The increase in extended-spectrum ß-lactamase (ESBL) producing microbes in recent years represents a major challenge. AIM: To study the risk factors for urinary tract infections (UTIs) caused by ESBL-producing Escherichia coli in patients requiring hospitalization for treatment. MATERIALS AND METHOD: Electronic health records were used to identify 616 inpatients over the age of 18 who had UTI symptoms and/or signs and an ESBL-producing E. coli strain cultured on urine culture between January 1 and December 31, 2018. The electronic health care records of these patients were searched to identify those patients with previous UTIs due to an ESBL-producing E. coli grown on urine culture. Patients with cancer or those taking prophylactic antibiotics or immunosuppression were excluded. RESULT: Risk factors for the acquisition of ESBL-producing E. coli included male sex (P = 0.0032), age over 66 years (P < 0.0001), renal stones (P = 0.0021), urology intervention within six months of presentation (P = 0.0360), pressure sores (P = 0.0002), feeding tubes (P = 0.0076), and urinary catheter (P = 0.0023). Comorbidities (e.g., diabetes mellitus and duration of antibiotic therapy were not associated with an increased risk of recurrence of ESBL-producing E. coli UTI (P = 0.4680, P = 0.3826, respectively). CONCLUSION: Antimicrobial stewardship programs may have reduced the development of antimicrobial resistance in E. coli. However, the recognition of risk factors for UTI caused by ESBL-producing E. coli may facilitate the early detection of high-risk cases and guide treatment decisions. This can improve patient outcomes while decreasing the length of the hospital stay.

The diagnostic yield and safety of sputum induction in suspected pulmonary tuberculosis: The experience of a single tertiary care center in Saudi Arabia.

Background: Sputum smear microscopy examination and culture for tuberculosis (TB) remain a fundamental tool of diagnosis but may be negative up to 50% case of active pulmonary TB. Bronchoscopy to obtain sputum is invasive and not readily available. Alternative methods of obtaining sputum specimens are crucial in suspected pulmonary TB cases who are unable to expectorate. In this context, it may be beneficial to stimulate sputum production by administering a mist of hypertonic saline produced by ultrasonic nebulization. The aims of the study are to describe the experience of a tertiary center in Saudi Arabia with sputum induction (SI) for the investigation of patients suspected to have sputum scare TB. Methods: A retrospective cohort study was performed. All patients suspected of sputum scare TB and investigated with SI were included. Standard descriptive statistics were used. Categorical data presented as frequency were compared using the Chi square test. Continuous data presented as mean ± standard deviation were compared using Student's t test. Sensitivity, specificity, and predictive values were calculated. Results: Of 252 patients with suspected TB who underwent SI, 78 (31%) were ultimately diagnosed to have TB. Culture of induced sputum confirmed the diagnosis of TB in 44 (56.4%) of these patients. However, the diagnosis of TB would have been missed in 13.5% of the cohort if no further investigations were done. The incidence of complications was low. No patients required hospitalization or specialist intervention. Conclusions: SI is safe well tolerated and inexpensive. It may reduce the need for bronchoscopy in patients with suspected sputum scare TB. However, around 20% of TB can be missed by SI unless further investigations are performed. Hence, patients suspected to have sputum scare TB in whom the risk of bronchoscopy is high, a clinical decision on the appropriateness of empirical therapy is often required.