Barriers to Point-of-Care Ultrasound Utilization Among Emergency Medicine Residents in Riyadh, Saudi Arabia.

BACKGROUND: Point-of-care ultrasound (POCUS) is increasingly recognized as a valuable diagnostic tool in emergency medicine (EM). This study aimed to identify barriers to POCUS utilization among EM residents in the Riyadh region. MATERIALS AND METHODS: An observational cross-sectional study was conducted among 116 EM residents from various training centers in Riyadh. Data were collected through self-administered questionnaires assessing demographics, ultrasound (US) training, perceived barriers, and facilitators to POCUS usage. Statistical analysis included descriptive statistics, multiple response dichotomy analysis, and multivariable linear regression. RESULTS: The majority of residents had completed US training and recognized the importance of POCUS in emergency settings. However, significant barriers were identified, including time constraints and logistical challenges. Multivariable regression analysis revealed associations between residents' training status, beliefs in incentives, anticipated POCUS use, and perceived barriers. CONCLUSION: This study highlights the importance of addressing barriers to POCUS integration into residency programs. Efforts should focus on optimizing training, addressing workflow challenges, and enhancing residents' confidence in POCUS utilization. Targeted interventions tailored to specific clinical contexts may facilitate greater acceptance and integration of POCUS into routine practice.

Migrated toothpick causing a hepatic abscess with portal vein thrombosis: A case report and review of literature.

Key Clinical Message: Accidental foreign body ingestion is the most common hidden cause of abdominal pain. A high index of suspicion should be implemented in patients with unresolved abdominal pain. Here we reported a 54-year-old patient with vague abdominal pain who had a successful laparoscopic removal of a toothpick. Abstract: Toothpicks and fish bones are considered one of the most common accidentally ingested foreign bodies. Fortunately, most patients are asymptomatic. About 80%-90% of ingested foreign bodies pass through the gut spontaneously within a week. We present a case of a 54-year-old female with chronic epigastric pain and fever found to have a foreign body (toothpick) that penetrated the stomach and migrated to the liver causing liver abscess with portal vein thrombosis. The patient was managed with laparoscopic removal of the foreign body with an uneventful postoperative course.

A CYP11A1 homozygous exonic variant inducing an alternative splicing, frameshift and truncation in a family with congenital adrenal hyperplasia.

Background: Congenital adrenal hyperplasia (CAH) is a heterogeneous group of adrenal steroidogenesis disorders with variable degrees of glucocorticoid, mineralocorticoid and sex steroid deficiencies. CYP11A1 gene encodes the mitochondrial cholesterol side-chain cleavage enzyme (P450scc), which initiates the first reaction in steroidogenesis by converting cholesterol to pregnenolone. Variants in this gene are extremely rare but associated with severe forms of CAH due to its early and critical function in various steroid biosynthesis pathways. Here, we report a CYP11A1 exonic homozygous variant that, although exonic in location, affects splicing by creating an additional aberrant splicing site with frameshift and truncation of the gene. Patients and methods: The proband is a 23-year old 46,XY patient raised as a girl. She was a product of normal pregnancy for first-degree relative parents. Soon after birth, she had vomiting, dehydration, hypotension, hyponatremia and hyperkalemia. She was started on glucocorticoids and mineralocorticoids with prompt recovery. Apart from a chronic need for these medications, her neonatal and childhood history was unremarkable. She sought medical advice at age 19 years for delayed puberty with primary amenorrhea and lack of breast development. On evaluation, she had normal external female genitalia, no breast development, undescended testes and absent uterus and ovaries. Her hormonal evaluation revealed very low estrogen, testosterone, cortisol, aldosterone, 17-hydroxyprogesterone, and androstenedione levels. ACTH, LH, FSH and renin were very high consistent with primary gonadal and adrenal failure. Her parents are healthy first-degree cousins. She has three sisters, all with 46,XX karyotype. One of them is clinically and biochemically normal while the other two sisters have normal female phenotype, normal uterus and ovaries, similar hormonal profile to the proband but different karyotype (46,XX) and absence of undescended testes. gDNA was used for whole exome sequencing (WES). Sanger sequencing was performed to confirm the detected variant and its segregation with the disease. Results: WES identified a homozygous missense variant in CYP11A1 changing the second nucleotide (GCG > GTG) at position 189 in exon 3 and resulting in a change of Alanine to Valine (p.Ala189Val). This variant was confirmed by PCR and Sanger sequencing. It was found in a homozygous form in the proband and her two affected sisters and in a heterozygous form in the unaffected sister. In-silico analysis predicted this variant to create a new splicing site with frameshift and truncation of the gene transcript. This was confirmed by isolation of RNA, cDNA synthesis, gel electrophoresis and sequencing. Conclusion: We describe a family with a very rare form of CAH due to a CYP11A1 variant leading to creation of a new splice site, frameshift and premature truncation of the protein.

False-negative 99mTc-sestamibi scans: factors and outcomes in primary hyperparathyroidism.

Primary hyperparathyroidism has emerged as a prevalent endocrine disorder in clinical settings, necessitating in most cases, surgical intervention for the removal of the diseased gland. This condition is characterised by overactivity of the parathyroid glands, resulting in excessive parathyroid hormone production and subsequent disturbances in calcium homeostasis. The primary mode of management is surgical treatment, relying on the accurate localisation of the pathological parathyroid gland. Precise identification is paramount to ensuring that the surgical intervention effectively targets and removes the diseased gland, alleviating the hyperfunctioning state. However, localising the gland becomes challenging, as discrepancies between the clinical manifestation of active parathyroid and radiological identification are common. Based on our current knowledge, to date, no comprehensive review has been conducted that considers all factors collectively. This comprehensive review delves into the factors contributing to false-negative 99mTc-sestamibi scans. Our research involved an exhaustive search in the PubMed database for hyperparathyroidism, with the identified literature meticulously filtered and reviewed by the authors. The results highlighted various factors, including multiple parathyroid diseases, nodular goitre, mild disease, or the presence of an ectopic gland that causes discordance. Hence, a thorough consideration of these factors is crucial during the diagnostic workup of hyperparathyroidism. Employing intraoperative PTH assays can significantly contribute to a successful cure of the disease, thereby providing a more comprehensive approach to managing this prevalent endocrine disorder.

Physical activity policies in Saudi Arabia and Oman: a qualitative study using stakeholder interviews.

BACKGROUND: Countries in the Middle East have some of the lowest rates of physical activity and some of the highest rates of obesity in the world. Policies can influence population levels of physical activity. However, there is a dearth of research on physical activity policies in the Gulf region. This qualitative study analyses cross-sectoral barriers and facilitators for the development, implementation and evaluation of physical activity policies in Saudi Arabia and Oman, two of the largest countries in the region. METHODS: Semi-structured interviews were conducted with 19 senior policymakers from the Ministries of Health, Education, and Sport in Saudi Arabia and Oman, and were examined using thematic analysis. RESULTS: We identified seven themes related to physical activity policies in Saudi Arabia and Oman: leadership; existing policies; physical activity programs related to policies; private sector policies; challenges; data/monitoring; and future opportunities. Both countries have a central document that guides policy-makers in promoting physical activity, and the available policies in both countries are implemented via multiple programs and initiatives to increase physical activity. Compared with Oman, in Saudi Arabia, programs from the non-profit sector, represented by community groups, play a more significant role in promoting physical activity outside the government framework. The private sector has contributed to promoting physical activity in both countries, but interviewees stated that more financial support is required. Policy limitations differ between Saudi Arabia and Oman: intersectoral collaboration in Oman is limited and mainly based on individuals' own initiative, while the health transformation in Saudi Arabia tends to slow down policy implementation in relevant areas. Physical education in Saudi Arabia and Oman is similar; however, increased support and collaboration between government agencies and the private sector for out-of-school sports academies are needed. CONCLUSIONS: This study addresses key gaps in analysing physical activity policies in Gulf Cooperation Council countries. Our study highlights the importance of increasing financial support, improving collaboration between governmental agencies and between them and the private sector and consolidating efforts to back physical activity policies and dismantle cross-sectoral barriers in Saudi Arabia and Oman. Educational institutions in Saudi Arabia and Oman play a crucial role in promoting physical activity from early childhood to young adults. Our insights assist policy-makers, public health officials and stakeholders in shaping effective physical activity-promoting policies, programs and interventions to prevent non-communicable diseases. Challenges identified in Saudi Arabia and Oman's policies will inform their future development.

Patient satisfaction with Saudi community pharmacy services (Wasfaty System).

Introduction: The healthcare system in KSA has been substantially transformed as part of Vision 2030, including implementation of an electronic prescribing system, called Wasfaty, to enable patients to receive their prescriptions from community pharmacies (CPs). This study assessed patient satisfaction with CPs and the Wasfaty system. Methods: This cross-sectional observational study used existing data from the Saudi Ministry of Health's patient experience program. Data were collected from patients (≥15 years of age) visiting governmental primary care clinics in 2022. Summary statistics were determined and multivariable logistic regression analyses were conducted. Results: The sample included 66,541 patients. More than 70% of patients were satisfied with the services of the CPs and the Wasfaty system. Being older and being female consistently showed a positive association with satisfaction across several services. Whereas patients in preventive clinics had higher odds of satisfaction with medication availability (OR: 1.19, 95% CI: 1.03-1.37) and waiting time (OR: 1.23; 95% CI: 1.03-1.47), patients in chronic disease clinics had lower satisfaction with medication availability (OR: 0.92, 95% CI: 0.85-0.99). Saudi patients had lower odds of being satisfied with multiple services. Conclusions: The overall high satisfaction among patients suggested the success of the Wasfaty system in meeting patient needs and expectations. However, areas for improvement exist to increase patient satisfaction, such as addressing medication shortages and ensuring clear patient-pharmacist communication. The results highlight the importance of continued monitoring and evaluation to support the patient experience with pharmacy services, and to improve patients' journeys, medication adherence, and overall healthcare outcomes.

Hereditary vitamin D resistant rickets (HVDRR) case series: phenotype, genotype, conventional treatment, and adjunctive cinacalcet therapy.

INTRODUCTION: Hereditary vitamin D resistant rickets (HVDRR) is a rare autosomal recessive disorder marked by end-organ resistance of 1,25-dihydroxyvitamin D secondary to various mutations in the vitamin D receptor gene. The currently accepted treatment modality involves bypassing the affected receptors in the gut with high-dose intravenous calcium. In a few limited case reports, cinacalcet, a calcimimetic, has been used as an adjunctive therapy. MATERIAL AND METHODS: Retrospective chart reviews were conducted to collect the clinical and biochemical data of 8 patients with HVDRR from 5 Saudi families. Four patients received only high-dose calcium, while the remaining 4 received adjuvant cinacalcet. Serum chemistry and PTH levels were measured before and during cinacalcet treatment. Gene sequencing was performed to identify the disease-causing mutation. RESULTS: All 8 patients exhibited alopecia and secondary hyperparathyroidism. Other clinical and biochemical features of rickets were present to varying degrees. Genetic analysis revealed 3 distinct mutations: a ligand-binding domain mutation in 3 unrelated patients, a ligand-binding domain mutation in 2 sisters, and a missense DNA-binding domain mutation in 3 brothers. While the overall response to therapy was variable, none of the 4 patients who received adjunctive cinacalcet developed hypocalcaemia, and there was some initial promise in improving serum PTH levels. CONCLUSIONS: This series provides new insight into the clinical and biochemical characteristics as well as treatment responses in Saudi children with HVDRR. The findings suggest that cinacalcet is a safe and potentially valuable adjuvant in this understudied population; however, further research is required to verify these results.

Assessment of Knowledge, Attitudes, and Practices Regarding Non-Inherited Risk Factors for Congenital Heart Disease Among Mothers in Al-Baha City, Saudi Arabia: A Cross-Sectional Study.

Background Despite advancements in healthcare, congenital heart disease (CHD) remains a global concern. It is crucial to understand non-inherited risk factors for CHD to develop effective prevention strategies. This study evaluates the awareness and impact of socio-economic factors on the knowledge and practices regarding CHD among mothers in Al-Baha City, Saudi Arabia. Methods A cross-sectional study was conducted using a structured questionnaire distributed among 300 mothers. This questionnaire collected demographic data and assessed the knowledge of non-inherited CHD risk factors, along with associated health practices. Chi-square tests were employed for categorical variables, and logistic regression was used to analyze the influence of socioeconomic factors on awareness levels. Results The study revealed a significant association between higher educational levels and increased awareness of CHD risk factors. About 75% of mothers with postgraduate education accurately identified major risk factors, compared to 30% of those with only a high school education. Additionally, income levels influenced health practices, with higher-income groups showing better adherence to recommended health behaviors. Conclusion Our findings highlight the need for targeted educational interventions tailored to diverse socio-economic backgrounds to enhance awareness of CHD risk factors and promote preventive health practices. The study emphasizes the importance of incorporating socioeconomic considerations into public health strategies to reduce the incidence of CHD.

Impact of Preoperative Serum Albumin Level on the Outcome of Colorectal Cancer Surgery.

Background Gastrointestinal malignancy surgeries are known to have a risk of postoperative complications. Preoperative nutritional status has been suggested as a potential predictor of postoperative outcomes, with low serum albumin levels utilized as a marker of malnutrition and increased risk of postoperative complications. This paper investigated the association between preoperative serum albumin levels and postoperative outcomes in patients undergoing colorectal cancer surgery. Methods This retrospective data-maintained study was based on all patients aged 18 years and above who underwent colorectal cancer surgery at King Abdulaziz Medical City, Riyadh, Saudi Arabia between 2015 and 2022. Results A total of 400 patients were included in the study. With an average age of 64.43 years. Males represented 254 (63%) of the patients, while females accounted for 146 (37%). Thirty percent of patients had hypoalbuminemia (i.e., albumin level below 35 g/L) before surgery. Among the sample, 112 (28%) experienced complications after surgery. The mean albumin level for patients who experienced postoperative complications was 30.46 g/L while patients without complications had a normal albumin level. As for the length of hospital stay, it was eight days for patients with a normal albumin level and 23 days for hypoalbuminemia patients. Conclusion In conclusion, preoperative hypoalbuminemia is associated with poor patient outcomes and can be utilized as a prognostic marker for patients in need of colorectal cancer surgery.

Germline Variants in Sporadic Pituitary Adenomas.

Context: Data on germline genetics of pituitary adenomas (PAs) using whole-exome sequencing (WES) are limited. Objective: This study investigated the germline genetic variants in patients with PAs using WES. Methods: We studied 134 consecutive functioning (80.6%) and nonfunctioning (19.4%) PAs in 61 female (45.5%) and 73 male patients (54.5%). Their median age was 34 years (range, 11-85 years) and 31 patients had microadenomas (23.0%) and 103 macroadenomas (77%). None of these patients had family history of PA or a known PA-associated syndrome. Peripheral blood DNA was isolated and whole-exome sequenced. We used American College of Medical Genetics and Genomics (ACMG) criteria and a number of in silico analysis tools to characterize genetic variant pathogenicity levels and focused on previously reported PA-associated genes. Results: We identified 35 variants of unknown significance (VUS) in 17 PA-associated genes occurring in 40 patients (29.8%). Although designated VUS by the strict ACGM criteria, they are predicted to be pathogenic by in silico analyses and their extremely low frequencies in 1000 genome, gnomAD, and the Saudi Genome Project databases. Further analysis of these variants by the Alpha Missense analysis tool yielded 8 likely pathogenic variants in 9 patients in the following genes: AIP:c.767C>T (p.S256F), CDH23:c.906G>C (p.E302D), CDH23:c.1096G>A (p.A366T), DICER1:c.620C>T (p.A207V), MLH1:c.955G>A (p.E319K), MSH2:c.148G>A (p.A50T), SDHA:c.869T>C (p.L290P) and USP48 (2 patients): c.2233G>A (p.V745M). Conclusion: This study suggests that about 6.7% of patients with apparently sporadic PAs carry likely pathogenic variants in PA-associated genes. These findings need further studies to confirm them.

Patient Satisfaction with Private Community Pharmacies versus Pharmacies in Primary Health Care Centers in Saudi Arabia.

Introduction: Saudi Arabia has begun reforming its government-run health care system to increase efficiency and reduce costs. One effort is the adoption of an electronic prescribing system (Wasfaty) and outsourcing pharmaceutical services from government-run clinics to community pharmacies (CP). This study aims to compare satisfaction with pharmaceutical services offered in the two systems. Materials and methods: This cross-sectional observational study used existing survey data collected from patients (≥15 years of age) visiting government primary health care centers from January 2022 to June 2022. Satisfaction with three pharmaceutical services (availability of medications, pharmacist's explanation of the prescription, and waiting time to get medications) were the main outcomes. Results: The study comprised 91,317 participants, 74.06 % of them were CP/Wasfaty users. CP/Wasfaty patients had lower odds of satisfaction with the three pharmaceutical services: availability of medications (OR = 0.49, 95 % CI = 0.47-0.51), pharmacists' explanation of prescription (OR = 0.55, 95 % CI = 0.53-0.58), and waiting time to get medications (OR = 0.81, 95 % CI = 0.75-0.88). Additional findings showed variations in satisfaction levels based on demographic factors and clinic types. Conclusions: The significant differences observed in satisfaction levels based on demographic characteristics and type of clinics visited emphasize the importance of tailoring pharmaceutical services to meet the specific needs and expectations of different patient populations.

EPAS1-related pheochromocytoma/paraganglioma.

In 2012, somatic EPAS1 pathogenic variants were found to cause a triad of pheochromocytoma/paragangliomas (PPGLs), polycythemia, and somatostatinoma. Since then, a limited number of studies on this subject have been reported, and data on the long-term outcome of metastatic disease are not available on this rare syndrome. We comprehensively reviewed EPAS1-related PPGL and describe an unusual patient who has been living with an EPAS1-related metastatic PPGL for 47 years. The results of this work show that EPAS1 pathogenic variants are rare, more in females and patients without pathogenic variants in other PPGL susceptibility genes. PPGLs are the most common manifestation followed by polycythemia and somatostatinoma. The EPAS1 pathogenic variants are often postzygotic, and the timing of their acquirement during embryonic development seems to correlate with the number and timing of development of the disease manifestations. Although recurrent and multifocal disease is common in EPAS1-related PPGL, distant metastases are uncommon and usually indolent. This is illustrated by a case of a man who was diagnosed at the age of 9 years and is currently 56 years old, alive, and well for 47 years with these metastases. He was found to have a somatic EPAS1 pathogenic variant (c.1592C>A, p.Pro531His) in bilateral pheochomocytoma and a pancreatic NET (somatostatinoma) but not in genomic DNA isolated from peripheral leukocytes. This and previous reports suggest that distant metastases are uncommon and less aggressive in EPAS1-related PPGLs compared to those found in other hereditary PPGLs.

Parameter free AEWMA control chart for dispersion in semiconductor manufacturing.

The study presents a new parameter free adaptive exponentially weighted moving average (AEWMA) control chart tailored for monitoring process dispersion, utilizing an adaptive approach for determining the smoothing constant. This chart is crafted to adeptly detect shifts within anticipated ranges in process dispersion by dynamically computing the smoothing constant. To assess its effectiveness, the chart's performance is measured through concise run-length profiles generated from Monte Carlo simulations. A notable aspect is the incorporation of an unbiased estimator in computing the smoothing constant through the suggested function, thereby improving the chart's capability to identify different levels of increasing and decreasing shifts in process dispersion. The comparison with an established adaptive EWMA-S2 dispersion chart highlights the considerable efficiency of the proposed chart in addressing diverse magnitudes of process dispersion shifts. Additionally, the study includes an application to a real-life dataset, showcasing the practicality and user-friendly nature of the proposed chart in real-world situations.

LncRNA GAS8-AS1 dinucleotide genetic variantn.713A>G, n.714T>C is associated with early-stage disease, lymph node, and distant metastasis in differentiated thyroid cancer.

PURPOSE: Long noncoding RNAs (lncRNAs) play an essential role in the epigenetic regulation of various key genes involved in vital cellular functions. A somatic dinucleotide mutation in the lncRNA GAS8-AS1 was reported in Chinese papillary thyroid cancer. However, GAS8-AS1 dinucleotide alteration and its impact have never been explored in differentiated thyroid cancers and other populations. METHODS: We extracted genomic DNA from 265 DTCs and 97 normal healthy subjects, PCR amplified and Sanger sequenced to examine the GAS8-AS1 dinucleotide alteration. Calculated genotype/allele frequency to test Hardy-Weinberg Equilibrium (HWE) and performed a genetic model of inheritance to determine its association with DTC risk. Correlated the GAS8-AS1 dinucleotide variant distribution with clinical characteristics to find the association. Predicted GAS8-AS1 RNA secondary structure for wild type and variant using RemuRNA and RNAfold to assess the conformational changes. RESULTS: GAS8-AS1 dinucleotide alteration (n.713A > G, rs55742939; n.714T > C, rs61118444) identified in DTCs is a germline variant not somatic. The GAS8-AS1 genotype and allele frequency significantly deviated for HWE in DTCs (χ2 = 37.954; p = 0.0001) though not associated with its risk. Dinucleotide variant distribution was remarkably associated with early-stage disease (p = 0.002), lymph node (p = 0.01), and distant metastasis (p = 0.01) in DTCs. The GAS8-AS1 bearing dinucleotide variant markedly showed conformational change compared to that of its wild type. CONCLUSIONS: These findings indicate that GAS8-AS1 is genetically deregulated and implicated in several stages of DTC tumorigenesis suggesting it could be a promising prognostic biomarker in DTCs.

Makkah healthcare cluster response, challenges, and interventions during COVID-19 pandemic: A qualitative study.

BACKGROUND: The global COVID-19 crisis has underscored the critical role of effective decision-making in healthcare systems. Saudi Arabia has shown resilience by implementing comprehensive testing, tracing, and vaccination measures. Given the unique cultural and religious characteristics of Makkah, specific challenges have prompted efforts to uncover local pandemic responses. This qualitative assessment aims to delineate the challenges faced by decision-makers during COVID-19 in Makkah and identify key interventions implemented by the Makkah healthcare cluster to manage and coordinate care. METHOD: Utilizing a purposive sampling approach, executive leaders within the Makkah Healthcare Cluster were invited for semi-structured interviews during the COVID-19 period. Thematic analysis was carried out in five steps, ensuring rigor and trustworthiness through multiple checks, and employing a critical and collaborative approach. RESULT: Throughout the COVID-19 outbreak in Makkah, participants revealed Several factors that have hindered healthcare organizations' ability to effectively manage the pandemic, including testing difficulties, resource shortages, vaccination misconceptions, continuity of care issues, infections among healthcare workers, and the need for consistent protocols. The participant leaders in Makkah's healthcare cluster specified implemented strategies that helped in overcoming the encountered challenges, such as adopting new technologies, enhancing communication, managing supply and demand, and improving workforce adaptability and development. Their experience in managing Hajj and Umrah provided valuable insights for handling the pandemic effectively. CONCLUSION: The study emphasizes the significance of technology adoption, effective communication, supply management, workforce development, and lessons from managing religious events. Its findings have implications for healthcare systems globally, emphasizing the importance of preparedness, response, and resilience in diverse cultural contexts.

Risk adjusted EWMA control chart based on support vector machine with application to cardiac surgery data.

In the current study, we demonstrate the use of a quality framework to review the process for improving the quality and safety of the patient in the health care department. The researchers paid attention to assessing the performance of the health care service, where the data is usually heterogeneous to patient's health conditions. In our study, the support vector machine (SVM) regression model is used to handle the challenge of adjusting the risk factors attached to the patients. Further, the design of exponentially weighted moving average (EWMA) control charts is proposed based on the residuals obtained through SVM regression model. Analyzing real cardiac surgery patient data, we employed the SVM method to gauge patient condition. The resulting SVM-EWMA chart, fashioned via SVM modeling, revealed superior shift detection capabilities and demonstrated enhanced efficacy compared to the risk-adjusted EWMA control chart.

The assessment of readiness to change among head managers of primary healthcare centers in Makkah, KSA.

Background: KSA is currently undergoing significant changes in its healthcare system, with a particular emphasis on enhancing the role of primary healthcare centers (PHCs) to elevate patient experience and overall healthcare quality. At the forefront of this transformation are head managers in PHCs, who play a crucial role in implementing these changes effectively. The readiness of these managers is paramount to the successful execution of the envisioned transformation and the subsequent improvement of patient experience. Objective: This study aims to assess the readiness to change among head managers of primary healthcare centers in Makkah, KSA. Methodology: Cross-sectional study utilized the ADKAR model questionnaire, consisting of 22 Likert scale questions, to assess PHCs head managers' awareness, desire, knowledge, ability, reinforcement, and overall change readiness. Results: The study found a significant association between higher educational levels and increased awareness (ß = 0.214, p = 0.030), along with greater desire (ß = 0.207, p = 0.029) among primary healthcare (PHC) managers. Additionally, a positive association was found between age (≥41 years) and knowledge among PHC managers (ß = 0.138, p = 0.030). However, managers with 11 or more years of experience showed a negative association with change readiness (ß = -0.112, p = 0.001). Conclusion: The ADKAR model outlines five dimensions that are useful for identifying the readiness and willingness of head managers in PHCs in Makkah cluster to undergo change. Assessing change readiness is crucial for organizational transformation, with head managers playing a significant role. Factors such as age, education, and experience influence managers' readiness for change in primary healthcare centers (PHCs) in Makkah.

Awareness of Medication-Related Osteonecrosis of the Jaws Amongst Patients on Antiresorptive and Antiangiogenic Medications.

Background Medication-related osteonecrosis of the jaws (MRONJ) is a rare but severe condition that has garnered increasing attention in recent years. It primarily affects individuals undergoing treatment with antiresorptive and antiangiogenic medications, such as bisphosphonates and denosumab, commonly prescribed for osteoporosis and cancer-related bone metastases. Therefore, the present study aimed to assess awareness and understanding of MRONJ among patients receiving antiresorptive and antiangiogenic medications. Methods A cross-sectional survey was conducted among 110 patients receiving antiresorptive and antiangiogenic medications in a clinical setting. Participants were given a structured questionnaire to assess their awareness of MRONJ. The questionnaire covered aspects such as MRONJ, bisphosphonate usage, and awareness of the condition's potential complications. Demographic information was also collected. Chi-square and Fisher's tests were performed using SPSS statistical software. Results In terms of gender distribution, 63.6% of the participants were female. Concerning age distribution, the majority (43.6%) fell within the 21 to 40 age group, whereas only 5.5% were aged over 60. Regarding educational attainment, a substantial majority (58.2%) of the participants held a bachelor's degree. The study findings reveal that a considerable proportion (35.5%) of participants possess awareness regarding jaw osteonecrosis, and this association is statistically significant (p=0.002). A substantial number of participants administered the medication orally (30.9%), while others utilized various administration routes, including injection (IV and others) (40%), and this difference was also statistically significant (p=0.001). Most participants took bisphosphonates for osteoporosis (41.8%) or cancer (13.6%), both statistically significant (p<0.01). Gender had no significant impact (p>0.01), but age showed potential associations (p=0.07 for awareness, p=0.003 for medication use). Educational backgrounds had no significant link, except for bisphosphonate usage (p<0.01) and side effects reporting (p<0.01). Conclusion Notably, a small percentage of participants demonstrated awareness of this condition, indicating a need for continued education and awareness campaigns. Further research and interventions may be warranted to address the specific needs of different age groups and educational backgrounds in promoting safe and effective medication management.

Enterobacter cloacae from urinary tract infections: frequency, protein analysis, and antimicrobial resistance.

The genus Enterobacter belongs to the ESKAPE group, which includes Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp. This group is characterized by the development of resistance to various antibiotics. In recent years, Enterobacter cloacae (E. cloacae) has emerged as a clinically important pathogen responsible for a wide range of healthcare-associated illnesses. Identifying Enterobacter species can be challenging due to their similar phenotypic characteristics. The emergence of multidrug-resistant E. cloacae is also a significant problem in healthcare settings. Therefore, our study aimed to identify and differentiate E. cloacae using Matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) as a fast and precise proteomic analytical technique. We also tested hospital-acquired E. cloacae isolates that produce Extended-spectrum beta-lactamases (ESBL) against commonly used antibiotics for treating urinary tract infections (UTIs). We used a total of 189 E. cloacae isolates from 2300 urine samples of patients with UTIs in our investigation. We employed culturing techniques, as well as the BD Phoenix™ automated identification system (Becton, Dickinson) and Analytical Profile Index (API) system for the biochemical identification of E. cloacae isolates. We used the MALDI Biotyper (MBT) device for peptide mass fingerprinting analysis of all isolates. We utilized the single peak intensities and Principal Component Analysis (PCA) created by MBT Compass software to discriminate and cluster the E. cloacae isolates. Additionally, we evaluated the sensitivity and resistance of ESBL-E. cloacae isolates using the Kirby Bauer method. Out of the 189 E. cloacae isolates, the BD Phoenix system correctly identified 180 (95.24%) isolates, while the API system correctly identified 165 (87.30%) isolates. However, the MBT accurately identified 185 (98.95%) isolates with a score of 2.00 or higher. PCA positively discriminated the identified E. cloacae isolates into one group, and prominent peaks were noticed between 4230 mass-to-charge ratio (m/z) and 8500 m/z. The ESBL-E. cloacae isolates exhibited a higher degree of resistance to ampicillin, amoxicillin-clavulanate, cephalothin, cefuroxime, and cefoxitin. Several isolates were susceptible to carbapenems (meropenem, imipenem, and ertapenem); however, potential future resistance against carbapenems should be taken into consideration. In conclusion, MALDI-TOF MS is a powerful and precise technology that can be routinely used to recognize and differentiate various pathogens in clinical samples. Additionally, the growing antimicrobial resistance of this bacterium may pose a significant risk to human health.

Revitalizing oncology medications access in Saudi Arabia: Current challenges and recommendations by the Saudi Oncology Pharmacy Assembly.

BACKGROUND: Cancer care is posing immense challenges to healthcare systems globally. Advances in screening, monitoring, and treating cancer improved patient outcomes and survival rates yet amplified the disease burden. Multiple barriers might impede early access to innovative therapies. We thoroughly examined the current challenges in oncology medication access in Saudi Arabia and provided consensus recommendations to revitalize the process. METHODS: A focus group discussion was conducted. Expert healthcare providers (pharmacists and physicians) were invited to participate based on prespecified criteria. The research team conducted a qualitative analysis of the discussion to identify themes and formulate recommendations. RESULTS: Fourteen experts were equally distributed into two groups, limiting the number in each group to 7. Pharmacists were 12 (∼86%), and physicians were 2 (∼14%). Ten were practicing in governmental hospitals, four representing different sectors; regulatory bodies, including Ministry of Health, National Unified Procurement Company, and Saudi Food and Drug Authority. Five themes were identified: national cancer burden, local data availability, pharmacoeconomic evaluation, patients reported outcomes, administration, and procurement. Consensus recommendations were formulated to optimize the formulary management process, enabling informed decision-making and facilitating early medication access for cancer patients. CONCLUSIONS: The formulary management process can be enhanced by addressing the national cancer burden, promoting local data availability, conducting pharmacoeconomic evaluations, focusing on patient outcomes, and improving administration and procurement procedures. Implementing these recommendations can improve access to oncology medications and improve patient care outcomes in Saudi Arabia.