Point-of-care diagnostic lung ultrasound is highly applicable to the practice of medicine in Saudi Arabia but the current skills gap limits its use.

CONTEXT: Coronavirus disease 2019 (COVID-19) has put a spotlight on point-of-care diagnostic lung ultrasound (POCDLUS). However, the spectra of respiratory disease and resources available for investigation vary internationally. The applicability of POCDLUS to internal medicine (IM) practice in Saudi Arabia and the current use by Saudi physicians are unknown. AIMS: The aim of the present study was to determine the applicability of POCDLUS to IM practice in Saudi Arabia and quantify the residents' current skills, accreditation, and use of POCDLUS. METHODS: A questionnaire was distributed to the IM residents at our institution to assess their knowledge, use of POCDLUS, and their perceptions of its applicability in IM. STATISTICAL ANALYSIS: Standard descriptive statistical techniques were used. Categorical data, presented as frequency, were compared using the Chi-squared test. The Likert scale responses, presented as mean ± standard deviation, were compared with a Student's t-test. RESULTS: In total, 100 residents participated (response rate 92.6%) and reported that POCDLUS was applicable to their practice. Identifying pleural effusions was most applicable. A small proportion (n = 7) had received training, nine used POCDLUS regularly, none were accredited and the overall self-reported level of knowledge was poor. CONCLUSIONS: Whilst POCDLUS is applicable to IM practice in Saudi Arabia, the significant skills gap preclude the provision of a POCDLUS service. As COVID-19 can cause an interstitial syndrome, our pandemic preparation response should include POCDLUS training. The current study is supported by a similar Canadian study and the international standardisation of POCDLUS training may be feasible. The findings of the current study may facilitate the development of POCDLUS training programs for internists throughout Saudi Arabia.

Feasibility of using a handheld ultrasound device to detect and characterize shunt and deep vein thrombosis in patients with COVID-19: an observational study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) causes an atypical acute respiratory distress syndrome associated with thromboembolism and high shunt fraction. Shunt may be intrapulmonary, or extrapulmonary. Handheld devices are increasingly being used for point-of-care ultrasound, but their use to characterize shunt has not been reported. OBJECTIVES: Determine the feasibility of using handheld ultrasound to detect and characterize anatomical substrates of hypoxia and deep vein thrombosis (DVT) in patients with COVID-19 suspected to have severe shunt. METHODS: A handheld ultrasound device (iQ, Butterfly, USA) was used to perform lung ultrasound, vascular assessment for DVT, and limited transthoracic echocardiography (TTE) with color Doppler and saline microbubble contrast in patients with COVID-19 suspected to have severe shunt. Images were reassessed by an independent reviewer. RESULTS: After screening 40 patients, six patients who fulfilled the inclusion criteria were identified. Two were excluded because palliation had been initiated. So, four patients were studied. Interpretable images were obtained in all cases. Interobserver agreement was good. All patients had abnormal lung ultrasound (lung ultrasound score range 17-22). Identified lung pathology included interstitial syndrome with light beams and small peripheral consolidation (4), lobar consolidation (1), and pleural effusion (1). Abnormal echocardiographic findings included interatrial shunt (2), intrapulmonary shunt (1), and dilated right ventricle with tricuspid valve regurgitation (1). Significant DVT was not detected. CONCLUSION: Use of handheld ultrasound to perform combined lung ultrasound, DVT ultrasound, and limited TTE with color Doppler and saline microbubble contrast is feasible, and may be able to characterize shunt in critically hypoxic patients. Serial studies could be used to monitor changes in shunt. Further studies are required to determine whether this can guide treatment to improve the outcomes of patients with refractory hypoxia.

Systemic thromboemboli in patients with Covid-19 may result from paradoxical embolization.

There is increasing evidence that Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection causes an unusual pneumonia and a pro-coagulant state that significantly increases the risk of arterial and venous thromboembolism. We hypothesize that, in select patients, some complications of COVID-19 may be due to right-to-left (RTL) shunt. Shunt may be intra-pulmonary, or extra-pulmonary, and can cause paradoxical embolization, hypoxia and platypnoea orthodeoxia. Saline microbubble contrast echocardiography is a minimally invasive, inexpensive, bedside test that can detect, quantify, and define the anatomical substrate of intra-pulmonary and intra-cardiac shunts. The prevalence of patent foramen ovale (PFO) in the general population is high (20-30%) but is even higher in patients who have a stroke (50%). Thus, the striking absence of data on patients with PFO who develop COVID-19 suggests that this is being under-diagnosed. This may be because physicians and sonographers currently feel that screening for shunt is unnecessary. This could be an unintended consequence of guidance from several specialist societies to defer procedures to close PFO until after the pandemic. This may be counterproductive. Patients with shunt may be at particularly high risk of complications from COVID-19 and interventions to minimise RTL shunt could prevent paradoxical embolization and improve hypoxia in select high risk patients with COVID-19.

The use of ivabradine in a patient with inappropriate sinus tachycardia and cardiomyopathy due to limb girdle muscular dystrophy type 2I.

Muscular dystrophies are a heterogeneous group of disorders that commonly involve cardiac and skeletal muscle. Comprehensive guidelines for the management of cardiac failure and arrhythmias are available. However, the studies from which their recommendations are derived did not include any patients with muscular dystrophy. Some medications (eg, betablockers) may have significant side effects in this cohort. In some situations the use of agents with unique mechanisms of action such as ivabradine (a 'funny' channel inhibitor) may be more appropriate. Use of ivabradine has not previously been reported in limb girdle muscular dystrophy (LGMD). We describe the course of a patient with LGMD type 2I, cardiomyopathy and inappropriate sinus tachycardia treated with ivabradine. As advances in respiratory support have improved the outcomes of patients with muscular dystrophy; the prognostic significance of cardiac disease has increased. Ivabradine is tolerated and may reduce symptoms, morbidity and mortality in this cohort.

Focused Cardiac Ultrasound is Applicable to Internal Medicine and Critical Care but Skill Gaps Currently Limit Use.

CONTEXT: Coronavirus Disease 2019 (COVID-19) put a spotlight on focused cardiac ultrasound (FoCUS). However, the spectra of cardiac disease, and the resources available for investigation vary internationally. The applicability of FoCUS to internal medicine (IM) and critical care medicine (CCM) practice in Saudi Arabia and their current use of FoCUS are unknown. AIMS: To determine the applicability of FoCUS to IM and CCM practice in Saudi Arabia and quantify the residents' current proficiency, accreditation and use of FoCUS. METHODS: A questionnaire was distributed to the residents in IM and CCM at our institution to determine their proficiency, use of FoCUS, and perceptions of its applicability. RESULTS: In total, 110 residents (IM 100/108; CCM 10/10) participated (Response rate 93.2%) and reported that FoCUS was very applicable to their practice, most specifically for pericardial effusion, right heart strain, and left ventricular function. Two IM residents had received postgraduate training, ten used FoCUS regularly, none were accredited and overall self-reported proficiency was poor. In contrast all CCM residents had received postgraduate training and reported regular use of FoCUS. Two were accredited. CONCLUSIONS: Whilst FoCUS is applicable to IM practice in Saudi Arabia, significant skills gaps exist. The skills gap in CCM is lower but unaccredited practice is common. Our residents' responses were similar to those from Canada. Thus, international standardization of FoCUS training could be considered.

Knowledge, attitude and practice on medication error reporting among health practitioners in a tertiary care setting in Saudi Arabia.

OBJECTIVES: To assess knowledge, attitudes and practices towards the reporting of medication errors among health practitioners at King Abdulaziz Medical city in Riyadh, Kingdom of Saudi Arabia. Methods: A cross-sectional study using a self-administered questionnaire was conducted in a convenient sample of 62 physicians and 303 nurses, between June and September 2017 at King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia. Results: The sample consisted of 365 subjects, with a response rate of 73%. Approximately 97% had sufficient  knowledge and a favorable attitude (90%) towards medication error reporting. With regard to reporting practices, some participants (21.6%) preferred to educate those who made a medication error, rather than reporting it. Approximately 44.8% had not reported medication errors during their work experience. Conclusion: Study participants demonstrated a sufficient knowledge base with regard to medication error reporting. Despite sufficient knowledge and favorable attitudes towards medication error reporting, there is still an under-reporting of medication errors when it comes to practice. We recommend the establishment of frequent medication safety courses as a prerequisite for all health care providers. We also advocate the application of error detecting alarms such as digital programs to minimize medication errors.

Meeting the American Diabetic Association standards of diabetic care.

Although there are numerous studies on diabetes mellitus in Saudi Arabia, data on the extent to which American Diabetic Association (ADA) standards of diabetic care are met, is scarce. We studied the computerized records of adult diabetic patients followed-up in outpatient internal medicine clinics at our tertiary care center in Riyadh, Saudi Arabia to find out how many of them met the ADA standards of diabetic care regarding fasting blood glucose, HbA1c, LDL-C, hypertension, proteinuria screening and use of anti-platelet, lipid lowering or recommended anti-hypertensive medications. Out of 1,188 type-2 diabetic patients studied, blood pressure readings were available in 1180 (99%) while results of fasting blood glucose, HbA1c, LDL-C and albuminuria screening were available for 1123 (95%), 968 (81%), 1037 (87%) and 307 patients, (26%) respectively. Patients achieving the ADA targets for overall, systolic and diastolic blood pressure, fasting blood glucose, HbA1c, LDL-C and albuminuria screening were 39.0%, 40.6%, 74.6%, 25.0%, 21.8%, 55.5% and 34.9%, respectively. For prevention of cardiovascular events, 61.0%, were using angiotensin converting enzyme inhibitors (ACE-I) or angiotensin-2 receptor blockers (ARBs) or both, while 71.5% and 72.3% of our patients were on anti-platelet and statin medications, respectively. In conclusion, as reported in most other studies, we also found that ADA standards of diabetic care are not met in most of our diabetic patients, indicating that these standards are easy to preach than to practice. There is need for further research to investigate the reasons for this failure and to adopt better multi-disciplinary approach and realistic targets in the future.

Global hospital bed utilization crisis. A different approach.

OBJECTIVE: To test the effect of improved physician availability on hospital bed utilization. METHODS: A prospective cohort study was conducted from 1st January 2009 to 31st March 2009 in the Division of Internal Medicine (DIM), King Abdul-Aziz Medical City (KAMC), Riyadh, Kingdom of Saudi Arabia. Two clinical teaching units (CTU) were compared head-to-head. Each CTU has 3 consultants. The CTU-control provides standard care, while the CTU-intervention was designed to provide better physician-consultant availability. Three outcomes were evaluated: patient outsourcing to another hospital, patient discharge during weekends, and overall admissions. Statistical analysis was carried out by electronic statistics calculator from the Center for Evidence-Based Medicine. RESULTS: Three hundred and thirty-four patients were evaluated for admission at the Emergency Room by both CTU's. One hundred and eighty-three patients were seen by the CTU-control, 6 patients were outsourced, and 177 were admitted. One hundred fifty-one patients were seen by the CTU-intervention: 39 of them were outsourced, and 112 were admitted. Forty-eight weekend patient discharges occurred during this period of time: 21 by CTU-control, and 27 by CTU-intervention. Analysis for odds ratio in both the rate of outsourcing, and weekend discharges, showed statistical significance in favor of the intervention group. CONCLUSION: The continuous availability of a physician-consultant for patient admission evaluation, outsourcing, or discharge during regular weekdays and weekends at DIM, KAMC proved to have a positive impact on bed utilization.