Primary hyperparathyroidism in Saudi Arabia revisited: a multi-centre observational study.

PURPOSE: Primary hyperparathyroidism (PHPT) is a common cause of hypercalcemia and remains understudied within the Arabian population. The present study, the largest of its kind within the Gulf Cooperation Council (GCC) countries, aims to determine the demographics and clinical presentation of PHPT in Saudi Arabia. METHODS: In this multi-center retrospective study involving three tertiary hospitals in different geographic locations of Saudi Arabia namely, Riyadh, Al Ahsa and Jeddah, a total of 205 out of 243 confirmed PHPT cases aged 16 to 93 years old were included (N = 96 from Riyadh; N = 59 from Al Ahsa and N = 50 from Jeddah). Demographics, clinical manifestations and surgical outcomes were recorded as well as laboratory and radiologic investigations including serum parathyroid hormone (PTH), 25(OH)D, adjusted calcium, estimated glomerular filtration rate (eGFR) and nuclear scan outcome. RESULTS: PHPT cases appeared to increase over time when compared to other local studies published so far, with 12.8 cases per 100,000 hospital population. Females outnumber males (3:1) with 86% seen as out-patients. The average age was 59.8 ± 15.5 years. Abnormal PTH scan was seen in 171 patients (83.4%). Kidney stones was the most common renal manifestation (32 cases, 15.6%) and osteoporosis was the most common skeletal manifestation (67 cases, 32.7%). Al Ahsa had the highest prevalence of multiple comorbidities at 54% and the highest prevalence of obesity as a single comorbidity (17%) compared to other regions (p < 0.05). Jeddah recorded the highest prevalence of osteoporosis with bone and joint pains (30%) (p < 0.05). CONCLUSION: Comparison of present data with previous local studies suggest an increasing trend in PHPT cases in Saudi Arabia. Regional variations in the clinical presentation of PHPT were observed and warrant further investigation.

Electronic early notification of sepsis in hospitalized ward patients: a study protocol for a stepped-wedge cluster randomized controlled trial.

BACKGROUND: To evaluate the effect of screening for sepsis using an electronic sepsis alert vs. no alert in hospitalized ward patients on 90-day in-hospital mortality. METHODS: The SCREEN trial is designed as a stepped-wedge cluster randomized controlled trial. Hospital wards (total of 45 wards, constituting clusters in this design) are randomized to have active alert vs. masked alert, 5 wards at a time, with each 5 wards constituting a sequence. The study consists of ten 2-month periods with a phased introduction of the intervention. In the first period, all wards have a masked alert for 2 months. Afterwards the intervention (alert system) is implemented in a new sequence every 2-month period until the intervention is implemented in all sequences. The intervention includes the implementation of an electronic alert system developed in the hospital electronic medical records based on the quick sequential organ failure assessment (qSOFA). The alert system sends notifications of "possible sepsis alert" to the bedside nurse, charge nurse, and primary medical team and requires an acknowledgment in the health information system from the bedside nurse and physician. The calculated sample size is 65,250. The primary endpoint is in-hospital mortality by 90 days. DISCUSSION: The trial started on October 1, 2019, and is expected to complete patient follow-up by the end of October 2021. TRIAL REGISTRATION: ClinicalTrials.gov NCT04078594 . Registered on September 6, 2019.

Level of dietary awareness among Saudi dialysis patients and the influence of various factors.

Our objective was to investigate the degree of dietary awareness of Saudi patients on chronic hemodialysis and influencing factors on this awareness. This is an interviewadministered survey-based cross-sectional study carried out on adult dialysis patients at the King Abdulaziz Medical City, Riyadh. The first part of the survey consisted of the collection of demographic data and the second part consisted of questions in the areas of awareness on the dietary influence of sodium, potassium, fluid intake and calcium/phosphorous and lipids. The questions are simply answered as "yes" or "no." The overall awareness score was 79%. The awareness scores were highest in the area of lipids (86.5%) and lowest in the fluid intake area (71.3%). The scores for sodium, phosphorous/calcium and potassium were 80%, 79.6% and 73%, respectively. The degree of awareness was influenced by the number of visits by the dietitian (P = 0.008) and the educational level of the patients (P = 0.02), but not by age, duration on dialysis or gender. In conclusion, our findings suggest that there is a need for better of awareness among our dialysis patients. The highest score for awareness was seen in the cholesterol-related questions and the lowest score was seen in the fluid intake questions area. This is influenced by the number of visits by the dietitian and the educational level of the patients, but not by age, duration on dialysis or gender.

A case of first degree AV block in carbon monoxide poisoning patient.

Carbon monoxide (CO) intoxication is one of the most common types of poisoning. Cardiac manifestations of CO poisoning are limited to case reports of Electrocardiogram (ECG) changes, myocardial dysfunction and myocardial ischemia. A 22 year old Saudi male was admitted to the emergency department with decreased level of consciousness after being involved in a fire at home. ECG showed first degree AV block. To the best of our knowledge, this case report is the first CO poisoning case in the literature presented with first degree AV block.

Acute brucellosis presenting as gastroenteritis: case report.

Brucellosis is a systemic infection with multiple presentations. In spite of its oral mode of transmission and gastrointestinal pathogenesis, systemic symptoms are usually more prominent than gastrointestinal ones. Acute brucellosis presenting as gastroenteritis is rare in adults and could be the only manifestation of the disease. We report a case of gastroenteritis caused by Brucella species.

Prevalence and associated factors of polypharmacy among adult Saudi medical outpatients at a tertiary care center.

OBJECTIVE: The objective of this study was to assess the prevalence of polypharmacy (PP) and the associated factors in medical outpatients. MATERIALS AND METHODS: A cross-sectional, observational, descriptive study was carried out in adult medical outpatients attending internal medicine clinics at King Abdulaziz Medical City, Riyadh, Saudi Arabia from 1 March 2009 to 31 December 2009. PP was defined as the concomitant use of ≥5 medications daily. The number of medications being currently taken by patient was recorded. Effect of patients' age, gender, educational level, number of prescribers, disease load and disease type on PP was assessed by multivariate analysis using Statistical Package for Social Sciences Incorporated (SPSS Inc) Version 18. RESULTS: Out of 766 patients included in the study, 683 (89%) had PP. The mean number of prescribed medications, oral pills and doses was 8.8, 9.6 and 12.1, respectively. Factors significantly associated with PP included age (≥61 years), disease load and the number of prescribers. Gender had no impact on PP while education beyond primary education significantly decreased PP. Hypertension, diabetes mellitus and dyslipidemia alone and as a cluster increased PP. CONCLUSION: We found an extremely high level of PP in medical outpatients at our tertiary care center. The impact of PP on medication compliance and control of underlying diseases in Saudi Arabia is unknown and needs to be studied at different levels of care.

Increased risk of hypertension, proteinuria and preeclampsia in pregnant Saudi females with IgA nephropathy.

BACKGROUND: IgA nephropathy is fairly prevalent in Saudi Arabia. In this paper we examine the natural history of pregnancies and their impact on renal function in Saudi females affected by this condition. METHODS: We followed a series of 12 patients, documented to have IgA nephritis by kidney biopsy, during their gestation. We monitored their blood pressure, serum creatinine, creatinine clearance, 24-hour protein before conception and at the third trimester of pregnancy. We also documented any maternal or fetal complications. RESULTS: All patients had well-controlled blood pressure, normal renal function, and proteinuria of less than one gram per day prior to conception. During pregnancy, all patients (100%) developed hypertension-requiring treatment and three of them (25%) developed preeclampsia. One patient (8.3%) had hemolysis, elevated liver enzymes, and, low platelets syndrome. All patients had worsening of their proteinuria during pregnancy from 535.2 (101.4) to 2179.2 (636.6) mg/24 h (p < 0.01) with a decrease in creatinine clearance from 88.6 (7.6) mls/min to 77.4 (5.9) mls/min (p < 0.05). No fetal complications were observed. CONCLUSION: We conclude that pregnancies in patients, even with mild IgA nephritis, require close observation as there is an increased incidence of worsening hypertension and preeclampsia.

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.

Primary CNS lymphoma presenting as fever of unknown origin.

We report a case of fever of unknown origin in an immunocompetent patient as the first manifestation of primary central nervous lymphoma. To our knowledge this is the first reported case in the literature of this association. We recommend brain imaging to be considered in patients presenting with fever of unknown origin and no apparent diagnosis after extensive investigation.

Acute renal infarction secondary to atrial fibrillation - mimicking renal stone picture.

Acute renal infarction presents in a similar clinical picture to that of a renal stone. We report a 55-year-old Saudi female, known to have atrial fibrillation secondary to mitral stenosis due to rheumatic heart disease. She presented with a two day history of right flank pain that was treated initially as a renal stone. Further investigations confirmed her as a case of renal infarction. Renal infarction is under-diagnosed because the similarity of its presentation to renal stone. Renal infarction should be considered in the differential diagnosis of loin pain, particularly in a patient with atrial fibrillation.