Impaired Awareness of Hypoglycemia and its Risk Factors among Diabetic Patients in Jazan, Saudi Arabia: A Cross-Sectional Study.

BACKGROUND: Impaired awareness of hypoglycemia (IAH) is related to a three- to sixfold increase in the risk of severe hypoglycemia in adults with type 1 diabetes mellitus (T1D). This study aimed to assess the prevalence of IAH and its risk factors and determine the frequency of hypoglycemic symptoms. OBJECTIVE: This study aimed to assess the prevalence of IAH and its risk factors and determine the frequency of hypoglycemic symptoms. METHODOLOGY: A cross-sectional study was conducted among T1D patients attending Jazan Endocrine and Diabetes Center in Jazan province, Saudi Arabia. A total of 151 patients participated, using the interview-based Clarke questionnaire, a validated eight-item questionnaire to evaluate IAH. Scoring four or more answers as reduced awareness categorizes the participant as having IAH. RESULTS: The prevalence of IAH was 25.2% among the T1D patients. IAH was significantly associated with body mass index (BMI; p = 0.034), occupation (p = 0.014), and blood glucose monitoring methods (p = 0.027). Shaking and sweating were the most commonly reported symptoms of hypoglycemia. A BMI of <25 kg/m2 was higher linked to hunger and speech difficulty compared to a BMI of ≥25 kg/m2 (p < 0.05). Changing the insulin injection site was associated with confusion, odd behavior, and speech difficulty (p < 0.05). Monitoring blood glucose four times daily was associated with sweating, odd behavior, and incoordination (p = 0.024) compared to monitoring less than four times daily (p < 0.05). A hemoglobin A1c (HbA1c) reading of ≥7 was linked to odd behavior compared to an HbA1c reading of <7 (p = 0.032). Patients committed to insulin injections were more likely to experience palpitations than non-committed patients (p = 0.038). Each one-unit increase in age, monitoring blood glucose, and income was associated with a decrease in the odds of IAH (OR of Age = 0.89, 95% CI: 0.83-0.95) (OR of income = 0.10, 95% CI: 0.01-0.55). Moreover, individuals with a Body Mass Index (BMI) greater than or equal to 25 (OR = 2.99, 95% CI: 1.13-8.25), employed individuals (OR = 18.2, 95% CI: 3.75-105), and diabetes duration of more than ten years (OR = 3.96, 95% CI: 1.31- 13.2) exhibited an increase in the higher risk of IAH. CONCLUSION: IAH was prevalent among T1D patients attending Jazan Endocrine and Diabetes Center. The main associated factors included BMI, blood glucose monitoring method, and occupation. Future research should investigate the underlying causes of the observed associations and explore strategies to enhance the awareness of hypoglycemia.

A Case Report of a Challenging Disease: Immunoglobulin G4-Related Disease With Acute Kideny Injury.

Immunoglobulin G4-related disease (IgG4-RD), which was initially identified as a type of autoimmune pancreatitis around the year 2000, is now widely acknowledged to be a systemic sickness. Based on both general and organ-specific criteria, alongside laboratory measurements of IgG4-subtype, the diagnosis is made. The diagnosis requires, however, a heightened index of suspicion, especially given the nonspecific clinical presentation. In addition to this, the symptoms may be "disseminated" in time and the multitude of organ-system involvement may seem initially unrelated. Furthermore, IgG4 levels may be falsely normal especially during the first presentation of IgG4-RD. We report a case of a 33-year-old male who was referred by his general practitioner (GP) to the fast access nephrology clinic due to elevated creatinine and fatigue, which was found after the patient had undergone some investigations at the GP office. He had history of atopic dermatitis and a prior admission for acute pancreatitis of unknown cause and recent bilateral anterior uveitis treated with steroid eyedrops. His urinalysis showed one to two granular casts per high-power field (HPF), and his creatinine was 262 µmol/L (previously normal). Three main differential diagnoses were considered given the patient's history: sarcoidosis, tubulointerstitial nephritis with uveitis (TINU) and IgG4-related disorder. Investigations were undertaken in that regard showing elevated serum IgG4 levels (2.7 times upper-limit of normal). Renal biopsy demonstrated tubulointerstitial nephritis (TIN) with 30 IgG4-positive plasma cells per HPF. Given the patient's presentation over time, a diagnosis of IgG4-TIN was considered. The patient was treated with high-dose steroids and has shown signs of improvement of both his renal and ocular problems. The uniqueness of the case is reflected through the fact that IgG4-renal disease is usually diagnosed in patients with an already established manifestation of another organ, whilst in our patient the renal involvement led to establishing IgG4-RD. It is also important to note that, in spite of initially negative serum IgG4 levels, the diagnosis still needs to be considered especially if multisystem involvement is present (as in this case).

Bacterial Contamination of Mobile Phones Used by Healthcare Workers in Critical Care Units: A Cross-Sectional Study from Saudi Arabia.

BACKGROUND: Healthcare-associated infections (HAIs) present a formidable challenge for healthcare institutions, resulting in heightened mortality, morbidity, and economic burden. Within healthcare settings, various equipment and materials, including mobile phones, can potentially act as sources of infection. This study sought to examine the occurrence of bacterial contamination on mobile phones utilized by healthcare workers (HCWs) in intensive care units (ICUs), pediatric intensive care units (PICUs), neonatal intensive care units (NICUs), and cardiac care units (CCUs) within a central hospital (CH) and two peripheral hospitals (PHs) situated in the southwestern province of Saudi Arabia. MATERIALS AND METHODS: We collected a total of 157 samples from mobile phones utilized by HCWs across all ICUs in the CH and PHs. These samples underwent bacteriological analysis to evaluate the degree of bacterial contamination. RESULTS: We found that 45 out of 55 samples from physicians (81.81%) and 58 out of 77 samples from nurses (75.32%) showed bacterial contamination. Contamination rates on HCWs' mobile phones in the ICU, PICU, and NICU departments of the CH were observed at 69.56%, 80.95%, and 70.27%, respectively. Furthermore, the overall contamination rates in the ICUs, NICUs, and CCUs of the PHs were 78.26%, 88.88%, and 66.66%, respectively. The overall contamination rates of mobile phones in the CH and PHs were 72.11% and 81.13%, respectively. CONCLUSION: These findings underscore the necessity of routinely disinfecting the mobile phones of HCWs to mitigate the risk of cross-contamination. Implementing robust disinfection protocols can significantly contribute to curtailing the propagation of bacterial pathogens and reducing the incidence of HAIs in healthcare settings.

Natural and synthetic drugs and formulations for intravaginal HPV clearance.

BACKGROUND: Except for a few preventative Human Papillomavirus (HPV) vaccines, there is currently no cure for HPV infection. There are a number of cutting-edge strategies and potent medications or herbal formulations that can be applied topically for early clearance of HPV infection before HPV DNA gets integrated into host cell genome. This is facilitated due to cervical cancer having distinct and well-recognized long precancerous stages. OBJECTIVES: This review aims to outline every possible medication and formulation, both natural and synthetic, that can be applied topically as intravaginal application to help remove HPV infection at an early precancerous stage. RESULTS: Several anti-HPV/HPV clearance compounds and formulations for high-grade lesions are undergoing clinical trials. However, the majority of compounds are still in the early stages of development and require additional research to become viable HPV clearance candidates. Synthetic drugs may be more promising because they may have a more targeted effect; however, they may also have significant adverse effects. On the other hand, natural medications are safer to use. They are less specific, but have minimal to no adverse effects. CONCLUSIONS: This article may serve as a valuable resource of information for managing and preventing precancerous carcinogenic HPV infections. Research could be directed toward developing candidate drugs to make evidence-based decisions about advancing them to clinical trials and, eventually, to the market for potential use in the prevention and control of cervical cancer, which is almost always preventable or even curable if detected early.

The Appropriateness of Empirical Antimicrobial Treatment of Uncomplicated Urinary Tract Infection in Adult Female Patients in Jazan Region, Saudi Arabia.

INTRODUCTION: Uncomplicated urinary tract infection (uUTI) is one of the most prevalent bacterial infections in clinical practice. Empirical treatment is used commonly; thus, knowledge of the local antimicrobial susceptibility pattern is crucial to avoid the growing antibiotic resistance. PURPOSE: The aim of this study is to evaluate the effectiveness of the empirical treatment of uUTI and determine the susceptibility pattern for common uUTI causative microorganisms at outpatient clinics in hospitals in the Jazan region. METHOD: This is a prospective observational study of 120 patients with uncomplicated urinary tract infections attending internal medicine outpatient clinics in Al-Hayat Jazan hospital, Saudi Arabia, from September 2021 to January 2023. RESULTS: In total, 120 patients were included in the study. The mean age of the participants was 48.53 ± 9.29. Risk factors for UTI were found in 57.5%, and type 2 diabetes mellitus (DM) was the major risk factor (27.5%). The most common causative microorganism was Escherichia coli (E. coli) (87.5%), followed by Klebsiella pneumoniae (5%), Staphylococcus aureus, Enterobacter spp., and Enterococcus spp. (2.5%). Nitrofurantoin was the most effective antimicrobial agent (sensitivity rate of 91.7%) against all microorganisms, followed by Ciprofloxacin (75%). CONCLUSIONS: This study concluded that nitrofurantoin and Ciprofloxacin are suitable empirical treatments for uncomplicated urinary tract infection in the Jazan region, and increased resistance against trimethoprim/sulphamethoxazole (TMPSMX) and cefaclor was observed; thus, empirical therapy with these agents should be reconsidered in local guidelines. Wide surveillance research is necessary to monitor effective empirical therapies and to evaluate the regional antimicrobial susceptibility pattern.

Urinary Bladder Schistosomiasis Mimicking Neoplasm: A Case Report.

Schistosomiasis is a neglected disease that is prevalent in tropical and subtropical areas. A 20-year-old woman presented to the emergency room with a history of right flank pain and lower abdominal discomfort for one day, which coincided with the onset of menses. The patient did not provide any history of premenstrual hematuria. The physical examination revealed right costovertebral angle tenderness and was otherwise unremarkable. The urinalysis demonstrated a mild increase in red and white blood cells and no ova or parasite. The blood test was normal, except for eosinophilia. A right pedunculated intraluminal urinary bladder mass was detected by the computerized axial tomographic scan and ultrasonography, and after the transurethral resection of the mass, the patient was diagnosed with urinary schistosomiasis. The patient received two doses of oral praziquantel of 1200 mg every 12 h for one day. The cure was confirmed with a one-month post-treatment follow-up that revealed a normal urine microscope and eosinophil count. The S. haematobium infection should be evaluated as a possible cause of urinary bladder lesion in those who have travelled or lived in endemic areas.

Prospective Evaluation of Side-Effects Following the First Dose of Oxford/AstraZeneca COVID-19 Vaccine among Healthcare Workers in Saudi Arabia.

BACKGROUND: Several different types of vaccines have been developed for the prevention of coronavirus disease (COVID-19). Despite several local and systemic side-effects to COVID-19 vaccination reported, the vaccines are still considered the best intervention to tackle the spread of the virus and reduce the severity of COVID-19 infection. However, the reported side-effects continue to have a crucial role in public confidence in the vaccine and its acceptance. This study aimed to investigate the short-term side-effects reported by the healthcare workers (HCWs) in Saudi Arabia after receiving the first dose of the Oxford/AstraZeneca (ChAdOx1 nCoV-19) COVID-19 vaccine. METHODS: A prospective cohort study was conducted among HCWs in the Jazan region of southwestern Saudi Arabia. Healthcare workers who had received the first dose of the COVID-19 vaccine and agreed to participate in the study were followed up for 3 weeks post vaccination through a weekly online survey. Information was collected on local and/or systemic side-effects reported following vaccine administration. Participants' general and demographic information was also collected. RESULTS: A total of 57.2% (250/437) of the HCWs who participated in this study reported at least one side-effect. Injection site pain and redness (80.0%), fever (73.2%), whole-body pain/fatigue (56.4%), and headache (48.8%) were the most commonly reported side-effects. Moreover, 12.4% of the participants who reported side-effects needed to see a physician, and only one female participant was admitted to the hospital. Multivariate regression analyses revealed that nationality (Saudi, adjusted odds ratio (aOR) = 3.65; 95% CI = 2.40, 5.55) and residency (Jazan governorate, aOR = 0.38; 95% CI = 0.15, 0.95) were the significant factors associated with reporting COVID-19 post-vaccination side-effects, while the number of reported side-effects was found to be significantly influenced by occupation (medical, aOR = 0.42; 95% CI = 0.26, 0.66; p < 0.001) and gender (female, aOR = 0.61; 95% CI = 0.38, 0.97; p = 0.038). CONCLUSIONS: Findings of the present study support the safety of the Oxford/AstraZeneca COVID-19 vaccine among HCWs in Saudi Arabia. All the reported side-effects were mild-to-moderate side-effects. The findings may help convince vaccine-hesitant individuals and skeptics to accept the COVID-19 vaccine.

Community-Based Seroprevalence of SARS-CoV-2 Antibodies following the First Wave of the COVID-19 Pandemic in Jazan Province, Saudi Arabia.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to spread globally, causing unprecedented effects on global health and economies. Community-based serological data are essential for understanding the true prevalence of infections, specifically the subclinical infections, as COVID-19 asymptomatic infections are common. Such data would also be important for decision making around choosing appropriate epidemiological control measures, as well as for the true estimation of mortality rates in the population. Further, determining the seroprevalence of anti-SARS-CoV-2 antibodies in the population would provide important information on herd immunity. In this study, we conducted a population-based age-stratified serological study to understand the prevalence of SARS-CoV-2 in Jazan Province, Saudi Arabia. Out of 594 participants who were recruited from 29 August to 30 December 2020, just before the vaccination rollout program in Saudi Arabia, about 157 were seropositive for SARS-CoV-2, indicating an estimated seropositivity rate of 26%. Although no significant difference in seropositivity was seen between male and female participants, we found that lower seroprevalence was associated with the younger (below 18 years old) and older populations (older than 56 years) compared with other age groups (19-55 years). These data indicate a high prevalence of SARS-CoV-2 antibodies following the peak of COVID-19 spread in Jazan province; however, most of the population (three-quarters) remains susceptible to SARS-CoV-2 infection.

Tuberculosis among people living with HIV/AIDS in Jazan Region, Southwestern Saudi Arabia.

BACKGROUND: Tuberculosis (TB) and human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) infections are leading causes of morbidity and mortality worldwide. People living with HIV/AIDS (PLWHA) are highly susceptible to TB infection and progression to active TB disease. This study aims to determine the proportion and risk factors of TB among PLWHA in Jazan Region, southwestern Saudi Arabia. METHODS: A cross-sectional study was conducted among HIV-infected individuals attending the main referral hospital in Jazan Region during the period 2017-2019. The participants' TB status, CD4+ lymphocyte count, and viral load were assessed. In addition, their demographic and clinical information was collected using a structured questionnaire. RESULTS: A total of 316 HIV-positive individuals aged between 13 and 81 years (75% male and 25% female) were enrolled in this study. Of them, 30 (9.5%; 95% confidence interval [CI]: 5.2, 10.6%) were diagnosed with TB: 46.7% (14/30) had pulmonary TB and 53.3% (16/30) had extrapulmonary TB. The highest proportion of TB-positive PLWHA was found among participants aged 18-30 years (11.6%) and among non-Saudis (14.0%) when compared to other age groups and Saudi participants (7.4%). Multivariate analysis showed that male gender (adjusted odds ratio [AOR] = 4.79; 95% CI = 1.22, 18.74), past medical history (PMH) of TB (AOR = 29.67; 95% CI = 5.31, 164.32), PMH of other RTIs (AOR = 5.86; 95 % CI = 2.14, 16.06), CD4+ lymphocyte count of <200 cells/mm³ (AOR = 4.33; 95% CI = 1.65, 11.36), and viral load of ≥1 × 103 copies/mL (AOR = 5.46; 95% CI = 2.02, 14.77) were the significant risk factors of TB among the studied PLWHA. CONCLUSION: The prevalence of TB/HIV co-infection among the studied population was 9.5%. Therefore, all PLWHA should be screened for TB at every visit to a health facility. The findings highlight that integration of health services for both TB and HIV/AIDS in Saudi Arabia is recommended.

Evaluation of Side Effects Associated with COVID-19 Vaccines in Saudi Arabia.

BACKGROUND: Pfizer-BioNTech and Oxford-AstraZeneca are recently introduced vaccines to combat COVID-19 pandemic. During clinical trials, mild to moderate side effects have been associated with these vaccines. Thus, we aimed to evaluate short-term post-vaccination side effects. METHODS: Cross-sectional, retrospective study using an online questionnaire was conducted among COVID-19 vaccines recipients in Saudi Arabia. General and demographic data were collected, and vaccine-associated side effects after receiving at least one dose of each vaccine were evaluated. RESULTS: Our final sample consisted of 515 participants with a median age of 26 years. Most of the study participants were female (57%). Nearly 13% of the study subjects have reported previous infections with SARS-CoV-2. Oxford-AstraZeneca and Pfizer-BioNTech vaccines have been received by 75% and 25% of the study participants, respectively. Side effects associated with COVID-19 vaccines have been reported by 60% of the study subjects, and most of them reported fatigue (90%), pain at the site of the injections (85%). CONCLUSION: Side effects that are reported post Oxford-AstraZeneca and Pfizer-BioNTech vaccines among our study participants are not different from those that were reported in the clinical trials, indicating safe profiles for both vaccines. Further studies are needed to evaluate the effectiveness of the current vaccines in protection against SARS-CoV-2 reinfections.

Residual malaria in Jazan region, southwestern Saudi Arabia: the situation, challenges and climatic drivers of autochthonous malaria.

BACKGROUND: Saudi Arabia and Yemen are the only two countries in the Arabian Peninsula that are yet to achieve malaria elimination. Over the past two decades, the malaria control programme in Saudi Arabia has successfully reduced the annual number of malaria cases, with the lowest incidence rate across the country reported in 2014. This study aims to investigate the distribution of residual malaria in Jazan region and to identify potential climatic drivers of autochthonous malaria cases in the region. METHODS: A cross-sectional study was carried out from 1 April 2018 to 31 January 2019 in Jazan region, southwestern Saudi Arabia, which targeted febrile individuals attending hospitals and primary healthcare centres. Participants' demographic data were collected, including age, gender, nationality, and residence. Moreover, association of climatic variables with the monthly autochthonous malaria cases reported during the period of 2010-2017 was retrospectively analysed. RESULTS: A total of 1124 febrile subjects were found to be positive for malaria during the study period. Among them, 94.3 and 5.7% were infected with Plasmodium falciparum and Plasmodium vivax, respectively. In general, subjects aged 18-30 years and those aged over 50 years had the highest (42.7%) and lowest (5.9%) percentages of malaria cases. Similarly, the percentage of malaria-positive cases was higher among males than females (86.2 vs 13.8%), among non-Saudi compared to Saudi subjects (70.6 vs 29.4%), and among patients residing in rural rather than in urban areas (89.8 vs 10.2%). A total of 407 autochthonous malaria cases were reported in Jazan region between 2010 and 2017. Results of zero-inflated negative binomial regression analysis showed that monthly average temperature and relative humidity were the significant climatic determinants of autochthonous malaria in the region. CONCLUSION: Malaria remains a public health problem in most governorates of Jazan region. The identification and monitoring of malaria transmission hotspots and predictors would enable control efforts to be intensified and focused on specific areas and therefore expedite the elimination of residual malaria from the whole region.

A 42-year-old man with nodular skin lesions.

Nodular skin lesions are infrequently reported among patients with syphilis. We describe a 42-year-old man with secondary syphilis who presented with a nodular cutaneous eruption involving his neck, upper chest, back, arms, and legs. Because there was uncertainty regarding the diagnosis at presentation, the patient underwent a punch biopsy of one of the lesions. Spirochetes were not seen with a Steiner silver stain, but they were visualized on subsequent immunohistochemical staining. The diagnosis was confirmed with serology, and the patient responded well to treatment with benzathine penicillin G. Given the current increase in syphilis cases across North America, it is critical that clinicians become familiar with some of the less common dermatologic manifestations of this infection so that the diagnosis is entertained and appropriate serologic testing is ordered in a timely fashion.

Les lésions nodulaires ne sont pas fréquentes chez les patients atteints de syphilis. Les auteurs décrivent le cas d'un homme de 42 ans atteint de syphilis secondaire qui a consulté à cause d'une éruption nodulaire lui touchant le cou, le haut du thorax, le dos, les bras et les jambes. Puisque le diagnostic était incertain, le patient a subi une biopsie à l'emporte-pièce de l'une des lésions. Aucunes spirochètes n'ont été observées au moyen d'une coloration à l'argent Steiner, mais elles ont été visualisées à la coloration immunohistochimique subséquente. La sérologie a confirmé le diagnostic, et le patient a bien répondu au traitement à la pénicille G benzathine. Étant donné l'augmentation des cas de syphilis en Amérique du Nord, il est essentiel que les cliniciens se familiarisent avec quelques manifestations dermatologiques plus rares de cette infection, afin que ce diagnostic soit envisagé et que le bon test sérologique soit effectué rapidement.

Genotyping and antiretroviral drug resistance of human immunodeficiency Virus-1 in Jazan, Saudi Arabia.

Determination of human immunodeficiency virus-1 (HIV-1) genotypes and identification of antiretroviral drug-resistant mutations. Among treatment naïve HIV patients in Jazan, Saudi Arabia. HIV is a major public health problem. HIV genotyping and antiretroviral resistance testing is an important guide for better management of treatment-naive. Antiretroviral resistance testing before starting of treatment regimen leads to a better virological response. A total of 57 samples of treatment-naive patients were collected from King Fahd Central Hospital in Jazan, Saudi Arabia. Samples were tested for HIV-1 antibodies, western blot, viral load, HIV-1 genotypes through direct sequencing, and antiretroviral resistance testing. The HIV-1 Genotypes were as follow; C: 66.6%, D: 10.5%, G: 8.8%, B: 7.0%, CRF01_AE: 3.5%, A and CRF02_AG: 1.8% each. 77.2% of cases showed susceptibility to the 3 major classes of antiretroviral drugs; Protease inhibitor (PI), Nucleoside reverse transcriptase inhibitor (NRTI), and non-nucleoside reverse transcriptase inhibitors (NNRTI); while 8.8% had mutations conferring resistance to NRTI. Mutations conferring resistance to PI were detected in 7.0% of cases, and 1.8% of cases had mutations conferring resistance to both NRTI and PI. Mutations conferring resistance to NNRTI were detected in 5.3% of cases. Mutations associated with antiretroviral drugs include (V82A+I84IV), (L10F+Q58E), (L10F+V82Y), L10FV, L33LF, L89LMV, M184V, E138A, V106I, and V179VD. The prevalence of HIV-1 antiretroviral resistance mutations is 22.8% in the studied population, which may warrant antiretroviral drug resistance testing as a pretreatment to help and guide physicians for the proper HIV treatment.

Interleukin-22 Polymorphisms in Plasmodium falciparum-Infected Malaria Patients.

Background and Objectives. Malaria infection, caused by Plasmodium falciparum, is the most lethal and frequently culminates in severe clinical complications. Interleukin-22 (IL-22) has been implicated in several diseases including malaria. The objective of this study was to investigate the role of IL-22 gene polymorphisms in P. falciparum infection. Material and Methods. Ten single-nucleotide polymorphisms (SNPs), rs976748, rs1179246, rs2046068, rs1182844, rs2227508, rs2227513, rs2227478, rs2227481, rs2227491, and rs2227483, of IL-22 gene were genotyped through PCR-based assays of 250 P. falciparum infection. IL-22 gene promoter activity. RESULTS: We found that the rs2227481 TT genotype (odds ratio 0.254, confidence interval = 0.097-0.663, P. P. falciparum infection. P. P. P. P. CONCLUSION: The study suggests that IL-22 polymorphisms in rs2227481 and rs2227483 could contribute to protection against P. falciparum infection. IL-22 gene promoter activity.

Vitamin D deficiency and glycemic control among patients with type 2 diabetes mellitus in Jazan City, Saudi Arabia.

Background: The prevalence of vitamin D deficiency (VDD) is predicted to be high in patients with type 2 diabetes mellitus (T2DM), but the exact figure is not known in Jazan, Saudi Arabia. Emerging data suggests that VDD plays a role in glycemic control. The aim of this study was to measure the prevalence of VDD among T2DM patients and to investigate its association with patients' characteristics and glycemic control in Jazan. Methods: This is an analytical cross-sectional study which recruited 309 patients with T2DM randomly from primary health care centers in Jazan. Logistic regression analysis was conducted to determine the VDD predictors and to examine the association of VDD and glycemic control. Results: The VDD prevalence was found to be 60.8% in patients with T2DM. Age, gender, diabetic retinopathy (DR), dyslipidemia, glycemic control, and obesity were significantly associated with VDD, and all except obesity were independent predictors of VDD. There was a significant negative correlation between 25-hydroxyvitamin D and HbA1c. VDD was a significant independent predictor of poor glycemic control after adjustment for hypertension, DR, diabetic neuropathy, type of diabetes medication, diabetes duration, and education level. Conclusion: In this Saudi Arabian population, VDD is highly prevalent in people with T2DM and is associated with poor glycemic control. Health education targeting patients with T2DM and national strategies regarding vitamin D fortification are needed to prevent VDD in Saudi Arabia. Earlier VDD diagnosis by health care providers may help to improve the outcome for patients with T2DM. Establishing the causal association between VDD and glycemic control and clarifying the biological role of vitamin D in T2DM are important aims for future studies.

Delayed Presentation of Shoulder Tuberculosis.

Infections caused by Mycobacterium tuberculosis (MTb) have a global distribution, with infections occurring most frequently in persons residing in or who have resided in developing nations. Pulmonary tuberculosis (Tb) is the most common form of infection caused by MTb. Osteoarticular Tb is a far less common condition than pulmonary Tb and is frequently overlooked in the differential diagnosis of persons with joint pathology. Osteoarticular Tb infections are far less common than pulmonary Tb and are usually not considered in the differential diagnosis. We describe a case of a 57-year-old immigrant African male who presented with 5 years of right shoulder pain and a restricted range of movement. Magnetic resonance imaging (MRI) concluded right shoulder septic arthritis, for which he underwent operative drainage and debridement was undertaken. The thick purulent joint fluid subsequently yielded MTb, establishing the diagnosis of osteoarticular Tb. We conclude that Tb should be suspected in cases of long-standing joint pain and stiffness, particularly in persons from endemic areas with Tb as well as patients with a previous history of Tb exposure.

Rapid CD4 decline prior to antiretroviral therapy predicts subsequent failure to reconstitute despite HIV viral suppression.

HIV-1 infection is characterized by loss of CD4T cells, leading to immunodeficiency. Initiation of antiretroviral therapy (ART) results in suppression of the viral load and increased CD4 counts. Both viral and host factors determine CD4 cell responses to ART with approximately 15-30% of individuals having suboptimal increase of CD4T cell count, most commonly due to lack of compliance to ART. A smaller fraction of patients will have immune reconstitution failure and suboptimal CD4 increase despite suppression of HIV replication, and these individuals are at risk for adverse health outcomes. We sought to characterize the factors associated with decreased immunological response among Manitoba's HIV patient population. This retrospective case-control study included HIV patients with immune reconstitution failure despite suppression of HIV replication by ART. The immune reconstitution failure was defined by CD4 cell count increase from baseline of less than 100 CD4 cells/mm3 or lack of increase to above 200 CD4 cells/mm3 within one year of viral load suppression. Age and nadir CD4 cell counts are known risk factors associated with immune reconstitution failure. We chose controls (Patients with immune reconstitution success) of similar age and CD4 nadir cell with cases (Patients with immune reconstitution failure). We explored the potential effects of gender, HLA type, presence of co-infection, ethnicity, ART type, and rate of pre-treatment CD4 decline among cases and controls. Of more than 550 patients followed by our HIV clinic, 42 individuals met our definition of immune reconstitution failure and they were assigned to the cases group. 31 patients, comprising a range of ages and CD4 nadirs similar to those of the cases, were assigned to the control group. Our primary analysis was a regression model, predicting post-ART change in CD4 over time. After controlling for age and nadir CD4 cell counts, the only potential predictor that appears consistently associated with the rate of post-ART rise in CD4 over time in our cohort, regardless of the other variables that we have controlled for, is the rate of decline in CD4 pre-ART initiation. Several factors have been variably correlated with immune reconstitution failure of CD4 T cell count. Age and low CD4 nadir are factors previously shown to correlate with immune reconstitution failure; and we have controlled for them in our study. Another possible predictor is the rate of decline in CD4 pre-ART, which can serve as an additional marker of reconstitution failure and necessitate prioritizing individuals to ART initiation or identification of a subset of individuals that may be targeted for future adjunct strategies to improve immune recovery.

Evaluation of the Utility of Point-of-Care HIV Testing on a Canadian Internal Medicine Inpatient Unit.

Point-of-care (POC) HIV testing has been shown to be an acceptable method for increasing HIV testing uptake. To date, no studies have examined the use of POC testing for routine HIV screening on the medicine inpatient unit. A prospective cross-sectional study was conducted over a three-month period in July, August, and October 2016 to evaluate the prevalence of undiagnosed HIV and the attitudes towards routine POC HIV testing. Patients admitted directly to medicine inpatient teaching units at a tertiary hospital in Winnipeg, Canada, were approached for participation. The POC HIV test was administered at the bedside. Reactive and indeterminate tests were confirmed with standard serological HIV testing. Participants were given a questionnaire regarding their attitudes towards POC testing on the unit. Although no cases of previously undiagnosed HIV were identified during the study period, only 35% of participants were found to have ever had HIV testing previously. The majority of participants were satisfied with the POC testing experience and would choose to have the POC testing again. Overall, the low rate of outpatient testing highlights the need for routine HIV testing on an inpatient basis.

Immune Reconstitution Syndrome secondary to Rhodococcus equi infection in a patient with HIV and Burkitt's lymphoma.

Immune Reconstitution Syndrome (IRIS) has been associated with a variety of infections in patients with human immunodeficiency virus (HIV). However, we are reporting the first case of IRIS secondary to Rhodococcus equi (R. equi) in a patient with HIV. We report the case of a 48-year-old male found to have HIV infection in the setting of Burkitt's lymphoma. While on anti-retroviral therapy and chemotherapy, he had developed IRIS secondary to R. equi that manifested as a cavitating pneumonia. This report outlines the successful management of the R. equi infection with the use of a combination of antibiotics, radiographic follow up and suppressive antibiotic while on chemotherapy.

A case of tetanus secondary to an odontogenic infection.

Tetanus is a life-threatening clinical syndrome that commonly presents with muscular spasms, rigidity, and autonomic instability. It is considered rare in industrialized countries, and tetanus occurring secondary to dental abscesses, procedures, or infections has been infrequently reported. We describe the case of a patient inadequately immunized for tetanus, who presented to the emergency department with muscular spasms, rigidity, and autonomic instability in the setting of an odontogenic infection. A clinical diagnosis of tetanus was made and subsequently managed successfully.