Prevalence of QT prolongation and its risk factors in patients with type 2 diabetes.

BACKGROUND: QT prolongation increases cardiovascular mortality in diabetes. The risk factors for QT prolongation vary across different studies. There is no data on the QT prolongation in patients with diabetes from the Arab region, where diabetes is highly prevalent. Here we aimed to assess the prevalence of QT prolongation and its associated risk factors in patients with type 2 diabetes from Saudi Arabia. METHOD: This was a retrospective, cross-sectional, hospital-based file review study. Data were collected from the medical records of patients with type 2 diabetes aged above 14 years and underwent ECG examination, and laboratory investigations were done within one month of ECG. RESULTS: The study included 782 patients with a prevalence of QTc prolongation of 13%. Patients with prolonged QTc interval were characterized by older age, higher BMI, longer diabetes duration, lower total cholesterol and LDL-C, and more diabetic nephropathy, hypertension, and CVD cases. They were also more in insulin treatment, antihypertensive medications, loop diuretics, and potassium-sparring diuretics. Logistic regression analysis revealed the odds of prolonged QTc interval increased significantly with CVD (OR = 1.761, 95% CI:1.021-3.036, p = 0.042), and usage of loop diuretics (OR = 2.245, 95% CI:1.023-4.923, p = 0.044) after adjusting for age, gender, and duration of diabetes. CONCLUSION: The risk factors associated with QTc prolongation in patients with type 2 diabetes are CVD, and loop diuretics. Age, BMI, and diabetes duration were more in people with QTc prolongation, whereas total cholesterol and LDL-C levels were lower. More patients had diabetic nephropathy, hypertension, and CVD with prolonged QTc.

Students' Feedback about Feedback; Have our PBL tutors started the shift towards a dialogic ask-tell-ask approach?

OBJECTIVE: A paradigm shift towards a PBL bidirectional dialogic feedback can enhance learners' performance. This study aimed to investigate undergraduate medical students' perceptions of their PBL feedback. METHODS: We sent e-mail invitations to a web-based survey to year one and two students at College of Medicine, King Saud University. Items included the process, content, and benefits of PBL feedback. RESULTS: Of 209 respondents, 110 (53%) were first and 99 (47%) were second-year students. About 50% agreed that the feedback was regularly provided at scheduled timing and 72% perceived feedback environment as non-threatening. Agreement rates that the tutors asked students first to assess their performance, tell them what went well, what the areas for improvement are and develop with them an improvement plan were 59%, 61%, 61% and 52%, respectively. 61% agreed that tutors judged performance not personality. More year one students significantly agreed that the PBL feedback helped them to improve their knowledge acquisition and non-technical skills. CONCLUSION: Many of our PBL tutors have started the shift to a dialogic bi-directional feedback. We recommend continuing the faculty development efforts, peer-reviewing, and seeking student's feedback within the academic quality satisfaction surveys.

Alterations in circulating lipidomic profile in patients with type 2 diabetes with or without non-alcoholic fatty liver disease.

Objective: Non-alcoholic fatty liver disease (NAFLD) and Type 2 diabetes mellitus (T2DM) often coexist and drive detrimental effects in a synergistic manner. This study was designed to understand the changes in circulating lipid and lipoprotein metabolism in patients with T2DM with or without NAFLD. Methods: Four hundred thirty-four T2DM patients aged 18-60 years were included in this study. Fatty liver was assessed by FibroScan. The comprehensive metabolic lipid profiling of serum samples was assessed by using high-throughput proton NMR metabolomics. Results: Our data revealed a significant association between steatosis and serum total lipids in VLDL and LDL lipoprotein subclasses, while total lipids in HDL subclasses were negatively associated. A significant positive association was found between steatosis and concentration of lipids, phospholipids, cholesterol, and triglycerides in VLDL and LDL subclasses, while HDL subclasses were negatively associated. Furthermore, a significant, association was observed between fibrosis and concentrations of lipids, phospholipids, cholesterol, and triglycerides in very small VLDL, large, and very large HDL subclasses. Subgroup analysis revealed a decrease in the concentrations of lipids, phospholipids, cholesterol, and other lipid biomolecules in patients using antilipemic medications. Conclusion: The metabolomics results provide evidence that patients with T2DM with higher steatosis grades have altered lipid metabolomics compared to patients without steatosis. Increased lipid, phospholipids, cholesterol, and triglycerides concentration of VLDL and LDL subclasses are associated with steatosis in patients with T2DM.

Gender Differences in the Attitudes and Management of People with Obesity in Saudi Arabia: Data from the ACTION-IO Study.

Purpose: Several studies have investigated gender differences in various obesity-related outcomes. Females were found to have more accurate weight perception and reported more frequency of attempted weight loss. The objective of this study was to assess gender differences in the attitudes and management of people with obesity (PwO) in Saudi Arabia using data from the ACTION-IO study. Patients and Methods: A survey was conducted in Saudi Arabia in June and July 2018 on adults with obesity (based on self-reported body mass index of ≥30 kg/m2). Results: A total of 1000 people with obesity completed the survey; 565 (56.5%) were male (mean age of 36.9 years and mean BMI of 33.5 kg/m2) and 435 (43.5%) were female (mean age of 36.3 years and mean BMI of 34.5 kg/m2). The two most reported motivations for wanting to lose weight for both groups were to improve appearance (38%) and to have more energy (35%). Females were more likely to trust their health-care provider (HCP) advice about weight management when compared to males (87% females, 82% males, p = 0.059) and were more likely to have concerns regarding long-term safety associated with prescription weight loss medications (65% female versus 59% males, p = 0.043). On the other hand, males were more likely to seek their physician to prescribe weight loss medication if they hear of a new medication (55% males versus 46% females, p = 0.014), and more to believe that there are good options available for weight loss medications (74% males versus 67% females, p = 0.040). Also, more males prefer to take weight loss medications than to have a weight loss surgery (65% males, 59% females, p = 0.054). Conclusion: Overall, this study increases our understanding on the attitudes of both females and males towards the management of weight loss and opens the discussion for gender-specific weight loss interventions.

Outcome measures of the 6 minute walk test: relationships with physiologic and computed tomography findings in patients with sarcoidosis.

BACKGROUND: We assessed the relationship between physiologic parameters, computed tomography patterns, 6 minute walk distance (6MWD) and the distance-saturation product [DSP; defined as the product of the 6MWD and the lowest oxygen saturation during the 6 minute walk test (6MWT)]. In addition, we investigated factors affecting 6MWD in patients with pulmonary sarcoidosis. METHODS: We performed a retrospective study of patient demographics, treatment, pulmonary function, 6MWT, echocardiography and computed tomography results. RESULTS: Fifty nine patients were included in this study. Their mean+standard deviation age was 47.5 years + 12.5 years, and 42 (71.2%) were female. Mean pulmonary function parameters for forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1) and total lung capacity (TLC) results, as percentages of predicted values, were 77.6 +/- 22.2, 77.1 +/- 22.8 and 78.7 +/- 16.1, respectively. Comparison of the DSP with distance walked revealed a significant correlation with factors underlying reduced 6MWD, including gender, pulmonary function indices, partial pressure of oxygen (PaO2), and Borg dyspnea score. Other factors were significantly associated with DSP but not distance; these included lung fibrosis (p = 0.02), pulmonary hypertension (p = 0.01) and systemic therapy (p = 0.04). Backward elimination stepwise multiple regression analysis revealed that gender, and FEV1 were independent predictors of 6MWD, but FEV1 was more strongly related when DSP applied [DSP, R2 = 0.53, p = 0.02; distance, R2 = 0.45, p < 0.0001]. CONCLUSION: Our findings reveal that, compared to 6MWD alone, the DSP is correlated with a greater number of factors associated with reduced 6MWT performance. Therefore, the DSP may be a useful indicator of functional status in patients with sarcoidosis. Additional large-scale studies are warranted to validate our findings.

Diabetes complications in 1952 type 2 diabetes mellitus patients managed in a single institution in Saudi Arabia.

BACKGROUND AND OBJECTIVES: Because there is no recent update on the state of diabetes and its concomitant complications in Saudi Arabia, we undertook a study of the prevalence of health complications in patients with type 2 diabetes mellitus admitted to our institution. METHODS: We conducted a retrospective review of medical records of adult Saudi patients with type 2 diabetes who were seen in clinics or admitted to the Security Forces Hospital, Riyadh, Saudi Arabia, between January 1989 and January 2004. RESULTS: Of 1952 patients, 943 (48.3%) were males. For the whole study population the mean age at enrollment was 58.4+/-14.2 years, the mean age at onset of diabetes was 48.1+/-12.8 years, the mean duration of diabetes was 10.4+/-7.5 years, and the mean duration of follow-up was 7.9+/-4.6 years. Nephropathy was the most prevalent complication, occurring in 626 patients (32.1%). Acute coronary syndrome occurred in 451 (23.1%), cataracts in 447 (22.9%), retinopathy in 326 (16.7%), and myocardial infarction in 279 (14.3%), Doubling of serum creatinine was seen in 250 (12.8%) and 79 (4.0%) went into dialysis. Hypertension was present in 1524 (78.1%) and dyslipidemia in 764 (39.1%). Overall mortality was 8.2%. Multiple complications were frequent. Males had higher prevalence of complications than females (P<.05). Mortality was significantly higher in males 92 (9.8%) than females 69 (6.8%) (P=.024). The prevalence of complications significantly increased with duration of diabetes and age (P<.05). CONCLUSION: Among Saudis, the prevalence of concomitant diabetic complications is high, with cardiovascular and renal complications the most frequent. Many patients had multiple complications. Early and frequent screenings in the patients with type 2 diabetes are desirable to identify patients at high risk for concomitant complications and to prevent disabilities.

Histological and laboratory features of patients undergoing liver biopsy at a university hospital in Central Saudi Arabia.

OBJECTIVE: To identify the most common liver pathologies seen in our center, to find the prevalence of advanced fibrosis and cirrhosis in patients with chronic hepatitis B and C, and to correlate the histological and laboratory features of the most common diseases and compare between them. METHODS: Liver biopsy procedures performed in our Gastroenterology Unit at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia were traced from records between the years 1997-2003. Clinical, histopathological, and laboratory features were recorded. RESULTS: We identified 574 liver biopsies during the study period. Of the 502 included patients, males were 58.6%. The mean age of the patients was 43.5 years. Approximately half of the biopsies (49%) were performed for patients with hepatitis C, followed by hepatitis B, for which 17% of the biopsies were performed. Patients with hepatitis B were approximately 10 years younger than patients with hepatitis C (p = 0.01). They were 10% more likely to be males. In terms of fibrosis, only approximately 17% of patients with hepatitis B and 27% of patients with hepatitis C had advanced fibrosis. CONCLUSION: Most liver biopsies performed in our center are performed for patients with hepatitis C. Rates of advanced fibrosis in our series are significantly lower than what was previously reported in other studies.

Epidemiology and outcome of Crohn's disease in a teaching hospital in Riyadh.

AIM: To know the epidemiology and outcome of Crohn's disease at King Khalid University Hospital, Riyadh, Saudi Arabia and to compare the results from other world institutions. METHODS: A retrospective analysis of patients seen for 20 years (between 1983 and 2002). Individual case records were reviewed with regard to history, clinical, findings from colonoscopy, biopsies, small bowel enema, computerized tomography scan, treatment and outcome. RESULTS: Seventy-seven patients with Crohn's disease were revisited, 13% presented the disease in the first 10 years and 87% over the last 10 years. Thirty-three patients (42.9%) were males and 44 (57.1%) were females. Age ranged from 11-70 years (mean of 25.3+/-11.3 years). Ninety-two (92%) were Saudi. The mean duration of symptoms was 26+/-34.7 mo. The mean annual incidence of the disease over the first 10 years was 0.32:100,000 and 1.66:100,000 over the last 10 years with a total mean annual incidence of 0.94:100,000 over the last 20 years. The chief clinical features included abdominal pain, diarrhea, weight loss, anorexia, rectal bleeding and palpable mass. Colonoscopic findings were abnormal in 58 patients (76%) showing mostly ulcerations and inflammation of the colon. Eighty nine percent of patients showed nonspecific inflammation with chronic inflammatory cells and half of these patients revealed the presence of granulomas and granulations on bowel biopsies. Similarly, 69 (89%) of small bowel enema results revealed ulcerations (49%), narrowing of the bowel lumen (42%), mucosal thickening (35%) and cobblestone appearance (35%). CT scan showed abnormality in 68 (88%) of patients with features of thickened loops (66%) and lymphadenopathy (37%). Seventy-eight percent of patients had small and large bowel disease, 16% had small bowel involvement and only 6% had colitis alone. Of the total 55 (71%) patients treated with steroids at some point in their disease history, a satisfactory response to therapy was seen in 28 patients (51%) while 27 (49%) showed recurrences of the condition with mild to moderate symptoms of abdominal pain and diarrhea most of which were due to poor compliance to medication. Seven patients (33%) remained with active Crohn's disease. Nine (12%) patients underwent surgery with resections of some parts of bowel, 2 (2.5%) had steroid side effects, 6 (8%) with perianal Crohn's disease and five (6.5%) with fistulae. CONCLUSION: The epidemiological characteristics of Crohn's disease among Saudi patients are comparable to those reported from other parts of the world. However the incidence of Crohn's disease in our hospital increased over the last 10 years. The anatomic distribution of the disease is different from other world institutions with less isolated colonic affection.

Biochemical and radiological predictors of malignant biliary strictures.

AIM: Differentiation of benign biliary strictures (BBS) from malignant biliary strictures (MBS) remains difficult despite improvement in imaging and endoscopic techniques. The aim of this study was to identify the clinical, biochemical and or radiological predictors of malignant biliary strictures. METHODS: We retrospectively reviewed all charts of patients who had biliary strictures (BS) on endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous cholangiography (PTC) in case of unsuccessful ERCP from March 1998 to August 2002. Patient characteristics, clinical features, biochemical, radiological and biopsy results were all recorded. Stricture etiology was determined based on cytology, biopsy or clinical follow-up. A receiver operator characteristic (ROC) curve was constructed to determine the optimal laboratory diagnostic criterion threshold in predicting MBS. RESULTS: One hundred twenty six patients with biliary strictures were enrolled, of which 72 were malignant. The mean age for BBS was 53 years compared to 62.4 years for MBS (P=0.0006). Distal bile duct stricture was mainly due to a malignant process 48.6% vs 9% (P=0.001). Alkaline phosphates and AST levels were more significantly elevated in MBS (P=0.0002). ROC curve showed that a bilirubin level of 84 micromol/L or more was the most predictive of MBS with a sensitivity of 98.6%, specificity of 59.3% and a positive likelihood ratio of 2.42 (95% CI=0.649-0.810). Proximal biliary dilatation was more frequently encountered in MBS compared to BBS, 73.8% vs 39.5% (P=0.0001). Majority of BBS (87%) and MBS (78%) were managed endoscopically. CONCLUSION: A serum bilirubin level of 84 micromol/L or greater is the best predictor of MBS. Older age, proximal biliary dilatation, higher levels of bilirubin, alkaline phosphatase, ALT and AST are all associated with MBS. ERCP is necessary to diagnose and treat benign and malignant biliary strictures.

Malignant biliary strictures. Diagnosis and management.

OBJECTIVE: To identify the cause, methods of diagnosis and management of malignant biliary strictures in our institution and compare with studies from other communities. METHODS: From March 1998 through to August 2002, we reviewed 1000 files of patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) at the Gastroenterology unit, King Khalid University Hospital in Riyadh, Kingdom of Saudi Arabia for malignant biliary strictures (MBS). Clinical, laboratory data, method of diagnosis and management were recorded. RESULTS: Seventy-two patients (72/1000) with MBS were encountered. Forty one (57%) were males and 31 (43%) were females and the majority were Saudi nationals (82%). Jaundice and right upper quadrant pain were the most frequent symptoms in 84.7% and 52.8% of patients. Cholangiocarcinoma was present in 31 (43%) and pancreatic adenocarcinoma in 23 (31.9%) patients. Other malignancies found included gallbladder carcinoma in 5 patients (6.9%), ampullary carcinoma in 5 (6.9%), metastatic liver carcinoma in 4 patients (5.6%), hepatocellular carcinoma in 2 (2.8%) and lymphoma in 2 (2.8%). The diagnosis was entertained mainly by ERCP (93%). Endoscopic palliation was carried out in 77.8% of patients, percutaneous transhepatic drainage in 13.9% and surgery in 6 (8.3%). The mean survival was higher for the endoscopic compared to the percutaneous transhepatic and surgery groups (6.9 +/- 4.13, 4.27 +/- 4.29 and 3.67 +/- 2.65 months). CONCLUSION: In non-resectable tumors, ERCP is the optimal method of diagnosis and palliation of MBS.

Experience and attitude of interns to pelvic and sensitive area examinations during their undergraduate medical course.

OBJECTIVE: To explore the experience of interns in sensitive area examination during their undergraduate medical course and identify factors interfering with such examinations. METHODS: A cross sectional study was carried out from May to June 2010. Interns (n=315) at King Saud University College of Medicine were invited via email to complete a web-based questionnaire developed using surveymonkey.com. RESULTS: Out of 315 interns, 211 completed the questionnaire; 60% males and 40% females. The mean percentage of interns who never performed any of these examinations was 28.9% for digital rectal examination, 17.5% for breast, 43.1% for female pelvic examination, 13.3% for inguinal (hernia), and 34.6% for male external genitalia. Compared to females, male students conducted more rectal examinations (87 versus 63, p<0.005), and male external genitalia examinations (112 versus 26, p<0.001). On the other hand, compared to male students, females conducted more pelvic examination (68 versus 52, p=0.03) and breast examinations (92 versus 82, p=0.27). The most common reasons for not performing sensitive area examinations included patient's refusal (33.1%), and examining patients of opposite gender (27.6%). Confidence in performance of these examinations was correlated to increased frequency of the examination. CONCLUSION: This study highlights that most common factors interfering with the students' conducting sensitive area examinations are patient's refusal and examining patients of the opposite sex. There is a strong correlation between increased frequency of conducting an examination and student's confidence in performance.

Dyslipidemia in dialysis patients.

In order to evaluate the lipid profiles of dialysis patients, we retrospectively reviewed all the chronic kidney disease (CKD) patients on chronic hemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD), followed up between June 2004 and May 2005, in two tertiary hospitals in Riyadh, Saudi Arabia. There were 380 patients including 206 (54.2%) females and the mean age of the patients was 45.9 ± 15.8 years. The mean dialysis duration was 65.0 ± 58.3 months. Diabetes was present in 97 (25.5%) of the patients and hypertension in 84 (22.1%). Younger patients had more disturbed lipid profile than elderly patients, and females had higher lipid values than males. The CAPD patients had worse lipid profile than those on HD, irrespective of age, sex and duration of dialysis. The presence of diabetes, hypertension, smoking and cardiovascular disease (CVD) all contributed to the worsening of lipid profiles of our patients. Dialysis patients showed improvement in lipid profile initially followed by gradual deterioration. We conclude that dyslipidemia, which increases the risk of CVD by increasing atherogenesis, progresses over time in dialysis patients and becomes worse in CAPD patients.

Factors affecting the progression of diabetic nephropathy and its complications: a single-center experience in Saudi Arabia.

BACKGROUND AND OBJECTIVES: One out of five Saudi diabetics develops end-stage renal disease (ESRD). Factors associated with progressive loss of renal function have not been extensively studied and reported in our community. We sought to evaluate the pattern and progression in glomerular filtration rate (GFR) and investigate the potential risk factors associated with progression to diabetic nephropathy (DN) among Saudi patients. DESIGN AND SETTING: Hospital-based retrospective analysis of type 2 diabetic patients seen between January 1989 and January 2004 at Security Forces Hospital and King Saud University in Riyadh, Saudi Arabia. PATIENTS AND METHODS: DN was defined as persistent proteinuria assessed by urine dipstick [at least twice for at least two consecutive years and/or serum creatinine >130 µmol/L; and/or GFR <60 mL/min/1.73m(2) ]. RESULTS: Of 1952 files reviewed, 621 (31.8%) met the criteria for DN, and 294 (47%) were males. The mean (SD) age of the patients at baseline was 66.9 (11.4) years, and mean duration of diabetes was 15.4 (7.5) years. GFR deteriorated from a baseline value of 78.3 (30.3) mL/min/1.73m(2) to 45.1 (24.1) mL/min/1.73m(2) at the last visit, with a mean rate of decline in GFR of 3.3 mL/min/year. Progression of nephropathy was observed in 455 (73.3%) patients, with 250 (40.3%) patients doubling their first-hospital-visit serum creatinine level in a mean of 10.0 (6.0) years. At the end of the study, 16.5% of the cohort developed ESRD and were dialyzed. GFR >90 mL/min/1.73m(2) at the first hospital visit; duration of diabetes >10 years; persistent proteinuria; systolic blood pressure >130 mm Hg; and presence of retinopathy were significant markers associated with progression of nephropathy. CONCLUSION: Diabetic nephropathy tends to be progressive among Saudis, with GFR deteriorating at a rate of 3.3 mL/year and with a doubling of serum creatinine level in 40.3% of patients in 9.9 years.

Practices and perceptions of physicians to prescribing elastic compression stockings in a single center in Saudi Arabia.

OBJECTIVE: To assess Saudi physicians' attitudes, practices, and perceptions towards use of elastic compression stockings (ECS) and knowledge of effective treatment in patients with deep vein thrombosis (DVT). METHODS: In January 2009, we surveyed 38 physicians from King Saud University, Riyadh, Kingdom of Saudi Arabia who are involved in the management and treatment of patients with DVT. RESULTS: Thirty (78.9%) of 38 respondents have prescribed ECS in their practices wherein only 6 (20%) prescribed ECS to patients only if venous signs and symptoms are present. Not all respondents perceived benefit from use ECS. Common perceived benefits included control of edema (70%), prevention of DVT recurrence (56.7%) and control of symptoms (46.7%). The main reasons for patient non-compliance were discomfort (66.7%), hard to put on (16.7%), appearance (13.3%), no help (10%), and makes leg worse (3.3%). CONCLUSION: The prescription of ECS in our institution needs to be systematically examined. Physicians involved in the management of DVT need to be further acquainted with the benefit of ECS. Although some of our respondents do prescribe ECS, they need to be further instructed on the timing of initiation of ECS, duration of therapy, and even compression strength.

Concomitant macro and microvascular complications in diabetic nephropathy.

To determine the prevalence of concomitant microvascular and macrovascular complications of diabetic nephropathy we retrospectively reviewed the medical records of all 1,952 type 2 diabetic patients followed-up at Security Forces Hospital, Riyadh, Saudi Arabia from January 1989 to December 2004. There were 626 (32.1%) patients (294 (47%) were males) who developed diabetic nephropathy. Their mean age was 66.9 +/- 11.4 years, mean duration of diabetes was 15.4 +/- 7.5 years, mean age at the onset of nephropathy was 61.5 +/- 12.4 years, and mean duration of nephropathy was 3.9 +/- 3.8 years. Concomitant diabetic complications included cataract (38.2%), acute coronary syndrome (36.1%), peripheral neuropathy (24.9%), myocardial infarction (24.1%), background retinopathy (22.4%), stroke (17.6%), proliferative retinopathy (11.7%), foot infection (7.3%), limb amputation (3.7%) and blindness (3%). Hypertension was documented in 577 (92.2%) patients, dyslipidemia in 266 (42.5%) and mortality from all causes in 86 (13.7%). There were 148 (23.6%) patients with one complication, 81 (12.9%) with two, 83 (13.3%) with three, and 61 (9.7%) with four or more. Deterioration of glomerular filtration rate was observed in 464 (74%) patients and doubling of serum creatinine in 250 (39.9%), while 95 (15.2%) developed end-stage renal disease (ESRD) at the end of study and 79 (12.6%) required dialysis. Complications were significantly more prevalent among males with greater number reaching ESRD level than females (P< 0.05). Relative risks of developing complications were significant after the onset of nephropathy; ACS (1.41), MI (1.49), stroke (1.48), diabetic foot (1.6), amputation (1.58) and death (1.93). We conclude that complications of diabetes are aggressive and progressive including high prevalence of diabetic nephropathy. Careful monitoring and proper institution of management protocols should be implemented to identify diabetic patients at high risk for complications and mitigate progression into ESRD.