Physicians' Job Satisfaction and its Correlates in a Tertiary Medical Care Center, Riyadh, Saudi Arabia.

OBJECTIVES: To measure the degree of job satisfaction among physicians working in a Tertiary Care Hospital and to identify background and work environment characteristics that affect overall and differential job satisfaction. SUBJECTS AND METHODS: This is a cross-sectional study of 340 physicians selected from a Tertiary Care Center using a stratified random sample with proportional allocation using a self-administered questionnaire with the 5-point Likert scale. From the 340 physicians requested to participate in the study, 217 (63.8%) completed the questionnaire. Descriptive statistics were used appropriately, including mean ± standard deviation for the quantitative variables, while frequency and percentages were used for the qualitative variables. ANOVA, t-test, and Chi-square were used as necessary to determine if there are any significant relationships between satisfaction scores and the predictor variables. SUBJECTS AND METHODS: This is a cross-sectional study of 340 physicians selected from a Tertiary Care Center using a stratified random sample with proportional allocation using a self-administered questionnaire with the 5-point Likert scale. From the 340 physicians requested to participate in the study, 217 (63.8%) completed the questionnaire. Descriptive statistics were used appropriately, including mean ± standard deviation for the quantitative variables, while frequency and percentages were used for the qualitative variables. ANOVA, t-test, and Chi-square were used as necessary to determine if there are any significant relationships between satisfaction scores and the predictor variables. RESULTS: A total of 217 physicians (males 75.6% females 24.4%) completed the questionnaire. Of this total, 52.5% were non-Saudis. The overall perceived satisfaction as measured by one question was 3.42 points out of 5 (68.4%) significantly lower than the overall satisfaction which took in consideration all variables 3.67 points (73.4%). Mean satisfaction scores were significantly negatively related to the number of children (P < 0.001) the physicians had, but positively correlated to stipend, duration of vacation leave, sick leave policy, health coverage for the employee and family, overall benefits package, involvement in academic work, and involvement in research work (P < 0.001). CONCLUSION: The working environment and policies of an organization play important roles in the satisfaction of its physicians. Boosting physician satisfaction is important for both the success of a Tertiary Care Center and for the high quality services offered to patients.

Autologous bone marrow transplanation for extramedullary plasmacytoma presenting as adrenal incidentaloma.

Extramedullary adrenal plasmacytoma (EMP) involving the adrenal glands is rarely encountered clinically. We report a A 47-year-old male who presented with bilateral adrenal incidentalomas. After confirming EMP, the patient received two consecutive autologous hematopoietic stem cell transplants (HSCT) using high-dose melphalan. Following HSCT, a serial follow-up helical CT revealed a substantial decrease in the size of both adrenal masses. Serial periodic serum protein and urine electrophoresis and immunofixation showed abrogation of a previously noted monoclonal band. At 50 months follow-up the patient was alive and well. Our patient is the first with EMP to have received an autologous HSCT, which may prove to have a role in therapy due to the immunological effect of the infused donor marrow T-lymphocytes against the clonal proliferation of abnormal plasma cells in extrammedullary sites.This case indicates that an EMP should be added to the differential diagnosis of adrenal incidentalomas.

Intrahepatic splenosis mimicking hepatocellular carcinoma in a cirrhotic liver.

We report a patient who has a cirrhotic liver secondary to hepatitis C virus infection with a liver lesion incidentally found on routine liver ultrasound. The patient had a history of splenectomy 30 years earlier. The magnetic resonance imaging (MRI) characteristics suggested the diagnosis of intrahepatic splenosis, which is confirmed by core needle biopsy. Knowledge of these imaging findings makes this entity important to be considered in the differential diagnosis of a hepatic tumor in the presence of a history of splenic trauma or surgery.

Late-onset rosiglitazone-associated acute liver failure in a patient with Hodgkin's lymphoma.

OBJECTIVE: To report a case of rosiglitazone-associated hepatotoxicity in a patient with Hodgkin's lymphoma. CASE SUMMARY: A 52-year-old man presented with low-grade fever and fatigue that had been present for 4 months. He had been receiving insulin for 5 years and rosiglitazone 4 mg/day for 11 months for control of type 2 diabetes; he was receiving no other drug therapy. During hospitalization, hepatotoxicity was shown, with abnormal liver function test results including alanine aminotransferase 488 U/L, aspartate aminotransferase 344 U/L, alkaline phosphatase 832 U/L, total bilirubin 4.61 mg/dL, and direct bilirubin 3.63 mg/dL. Rosiglitazone was discontinued after further elevation of bilirubin (total 14.67 mg/dL, direct 12.10 mg/dL) occurred. Other causes for hepatotoxicity were ruled out. Hodgkin's lymphoma was diagnosed during the workup; however, liver imaging and biopsy also excluded this as the direct cause of acute liver failure. Despite discontinuation of rosiglitazone, the bilirubin level continued to increase to 49.29 mg/dL (direct > 20 mg/dL). The patient died 3 months after admission. DISCUSSION: Rosiglitazone maleate is a thiazolidinedione approved for treatment of type 2 diabetes mellitus. The first member of this drug class, troglitazone, was withdrawn from the market due to reports of acute liver failure. Rosiglitazone has been shown to be much safer than troglitazone, despite some reported cases of early-onset nonfatal hepatotoxicity. Use of the Naranjo probability scale indicated that rosiglitazone was the probable cause of acute liver failure in our patient. CONCLUSIONS: We conclude that rosiglitazone may be associated with late-onset acute liver failure. Clinicians should be aware of such a complication and monitor liver function in patients receiving the drug.

Hurthle cell neoplasm of the thyroid gland.

BACKGROUND: A clinicopathological analysis and long-term follow up of 32 patients with Hurthle cell neoplasm (HCN) was undertaken to contrast the clinical and histological features between benign versus malignant HCN of thyroid and to examine the effect of treatment on the outcome. METHODS: This is a retrospective study of 32 patients with HCN who were identified out of an archival clinical/pathological/imaging database of 3752 thyroid cancer patients seen between 1976 and June 2006. All patients underwent thyroid surgery. Data for the non-surgical treatment along with follow up were also analysed. RESULTS: Seventeen patients were classified as malignant HCN (MHCN) and 15 as benign HCN (BHCN). Among the MHCN, there were 11 women and 6 men, whereas among BHCN there were 14 women and 1 man. Three patients designated MHCN presented with metastases, one with pulmonary metastases and two others with skeletal metastases who developed lung metastases 9-19 months later. The mean tumour size was 4.43 +/- 0.66 cm for MHCN, and 2.57 +/- 0.32 cm for BHCN (P = 0.03). Multicentric tumour foci were evident in five cases (29%) of MHCN but none among the BHCN (P = 0.03). At neck exploration cervical lymph node dissection was carried out in nine MHCN patients with findings of tumour metastases in 33%. Postoperatively, three MHCN patients had no thyroid remnant on ultrasound and computed tomography of neck and undetectable serum thyroglobulin; these were considered to be in remission. Fourteen other MHCN patients with postoperative thyroid remnant and/or distant metastases received 131I treatment. Eight of these patients had negative whole-body scans after 131I treatment and undetectable thyroglobulin. Accordingly, 11 MHCN patients (64.7%) showed evidence of remission and 6 patients did not respond to 131I treatment. After a mean follow up of 35 months, all BHCN patients are alive with no evidence of disease. Of the MHCN, 11 (64.7%) were in remission and 35% had evidence of persistence/recurrence. One patient who had recurrence is dead. A lack of effectiveness of 131I therapy in two patients with distant metastases is an important finding. CONCLUSION: Features of MHCN consisted of a large tumour size, unequivocal capsular and vascular invasion, multicentric tumour foci, metastatic lymph node deposits in one-third of patients and presence of distant metastasis in a few. Findings of dominant Hurthle cell cytology in a fine-needle aspiration biopsy from a thyroid nodule should prompt surgical resection of the lesion to assess malignancy.

Long-term outcome (up to 15 years) of balloon angioplasty of discrete native coarctation of the aorta in adolescents and adults.

OBJECTIVES: This study evaluated the long-term follow-up results of balloon angioplasty (BA) in adolescent and adult patients with discrete coarctation of the aorta. BACKGROUND: Although the immediate and intermediate term results of BA for patients with aortic coarctation (AC) have been encouraging, there is a paucity of data on long-term follow-up results. METHODS: This basis of this study was follow-up of 49 patients (mean age, 22 +/- 7 years) undergoing BA for discrete AC at median interval of 10.2 years, including cardiac catheterization, magnetic resonance imaging, and Doppler echocardiography. RESULTS: No early or late deaths occurred. Balloon angioplasty produced a reduction in peak AC gradient from 66 +/- 23 mm Hg (95% confidence interval [CI]: 59.5 to 72.7) to 10.8 +/- 7 mm Hg (95% CI: 8.8 to 12.5) (p < 0.0001). Follow-up catheterization 12 months later revealed a residual gradient of 6.2 +/- 6 mm Hg (95% CI: 4.4 to 7.9) (p < 0.001). Four patients (7.5%) with suboptimal initial outcome with peak gradient >20 mm Hg had successful repeat angioplasty. Aneurysm developed at the site of dilation in four patients (7.5%). Magnetic resonance imaging follow-up results revealed no new aneurysm or appreciable changes in the size of pre-existing aneurysms, and no recoarctation was observed. Also, no appreciable changes in the Doppler gradient across the AC site were noted. The blood pressure had normalized without medication in 31 (63%) of the 49 patients. CONCLUSIONS: Long-term results of BA for discrete AC are excellent and should be considered as first option for treatment of this disease.