Assessment of Using the Syndromic Approach in Managing Patients With Sexually Transmitted Diseases Among the National Guard Primary Health Care Physicians, Jeddah City, Saudi Arabia.

Background Sexually transmitted infections (STIs) include a group of clinical syndromes that can be transmitted mainly through sexual activity. Using STIs' syndromic approach for diagnosis and management is widely recommended to control and reduce the burden of these transmissible diseases. Objective The objective of this article is to assess the knowledge and practice of physicians concerning syndromic management of STIs in National Guard Primary Health Care (PHC) centers in Jeddah city, Saudi Arabia. Materials and methods This observational study was conducted at the National Guard PHC centers in Jeddah City, Saudi Arabia. An interview-administered questionnaire was designed. Fifty physicians have met the inclusion criteria, and all of them were included in the present study. Results Of the study population, 47 PHC physicians (response rate was 94%) were interviewed and the questionnaire was completed. Overall, the physicians' knowledge was different from one syndrome to another; it was highest for urethral discharge (72%) and lowest for vaginal discharge in pregnant women (21%). During the last 10 days, the physicians in the present study reported that two-thirds of their cases of STI were urethral discharge cases. However, during the previous 10 days, the practice assessment revealed that most physicians (76%) were correctly prescribed the medications as indicated by specific patients' syndromes. Conclusion Syndromic management is essential guidance to control and reduce the burden of STIs. Overall knowledge and practice of physicians were different from one syndrome to another. There is a need to design continuing medical education programs targeting PHC physicians to be clinically and culturally competent against socially sensitive diseases like STIs.

Infant Oral Healthcare and Anticipatory Guidance Practices among Dentists in a Pediatric Care Shortage Area.

OBJECTIVES: To assess dentists' practices and barriers towards infant oral healthcare (IOH) and anticipatory guidance (AG) in eastern Saudi Arabia. METHODS: A regional, cross-sectional survey was distributed to 340 (323 general dentists (GPs) and 17 pediatric dentists (PDs)) working in a governmental setting in eastern Saudi Arabia. A 23 close-ended, pilot-tested questionnaire was developed. The questionnaire asked about dentists' IOH and AG practices. A five-point Likert scale question assessed barriers interfering with AG practices. Descriptive and multivariate logistic regressions were used. RESULTS: Participation rate was 98.5% (335/340). Only 18% of GPs indicated performing IOH exams, while 100% of PDs do. About 90% of GPs would see children on a first visit when they are ≥3 years old, whereas 60% of PDs reported seeing one-year-old children. Older practitioners and those performing AG were more likely to perform IOH (OR = 1.8, CI = 1.06-3.1, and OR = 3.84, CI = 1.93-7.65, resp.). The majority of respondents (94%) felt their training did not prepare them to practice AG. "Parents bringing their children for the first time for emergency or existing conditions" was cited by 99% of respondents as a barrier to performing AG. CONCLUSION: Increasing the awareness of GPs and parents about the importance of IOH and AG is crucial in improving children's oral health. Collaboration with pediatricians for early referral of children is equally important in increasing the awareness on prevention principles.

Acute myocardial infarction with multiple coronary thromboses in a young addict of amphetamines and benzodiazepines.

A 35-year-old man of average build and a smoker, with a background of a psychiatric disorder, was brought by his neighbor to the emergency department after an hour of severe chest pain. Upon arrival at the hospital he had cardiac arrest, was resuscitated, and moved to the catheterization laboratory with inferior, posterior, and lateral myocardial infarction. Coronary angiography showed an unusual thrombosis in multiple coronary branches. Toxicology report showed high levels of amphetamines and benzodiazepines in the patient's original blood sample. The patient was kept under ventilation for 18 days, with difficult recovery due to severe withdrawal manifestations, ventilation acquired pneumonia, and rhabdomyolysis inducing acute renal failure. The patient regained near normal left ventricular function after baseline severe regional and global dysfunction. We postulate a relationship between the use of amphetamines, potentiated by benzodiazepines, and occurrence of acute thrombosis of multiple major coronary arteries.

Inherited IL-12p40 deficiency: genetic, immunologic, and clinical features of 49 patients from 30 kindreds.

Autosomal recessive interleukin (IL)-12 p40 (IL-12p40) deficiency is a rare genetic etiology of mendelian susceptibility to mycobacterial disease (MSMD). We report the genetic, immunologic, and clinical features of 49 patients from 30 kindreds originating from 5 countries (India, Iran, Pakistan, Saudi Arabia, and Tunisia). There are only 9 different mutant alleles of the IL12B gene: 2 small insertions, 3 small deletions, 2 splice site mutations, and 1 large deletion, each causing a frameshift and leading to a premature stop codon, and 1 nonsense mutation. Four of these 9 variants are recurrent, affecting 25 of the 30 reported kindreds, due to founder effects in specific countries. All patients are homozygous and display complete IL-12p40 deficiency. As a result, the patients lack detectable IL-12p70 and IL-12p40 and have low levels of interferon gamma (IFN-γ). The clinical features are characterized by childhood onset of bacille Calmette-Guérin (attenuated Mycobacterium bovis strain) (BCG) and Salmonella infections, with recurrences of salmonellosis (36.4%) more common than recurrences of mycobacterial disease (25%). BCG vaccination led to BCG disease in 40 of the 41 patients vaccinated (97.5%). Multiple mycobacterial infections were rare, observed in only 3 patients, whereas the association of salmonellosis and mycobacteriosis was observed in 9 patients. A few other infections were diagnosed, including chronic mucocutaneous candidiasis (n = 3), nocardiosis (n = 2), and klebsiellosis (n = 1). IL-12p40 deficiency has a high but incomplete clinical penetrance, with 33.3% of genetically affected relatives of index cases showing no symptoms. However, the prognosis is poor, with mortality rates of up to 28.6%. Overall, the clinical phenotype of IL-12p40 deficiency closely resembles that of interleukin 12 receptor ß1 (IL-12Rß1) deficiency. In conclusion, IL-12p40 deficiency is more common than initially thought and should be considered worldwide in patients with MSMD and other intramacrophagic infectious diseases, salmonellosis in particular.

Drowning in children: Aseer Central Hospital experience, Southwestern Saudi Arabia.

AIM: To study the reasons, magnitude and outcome of drowning following submersion in water of children admitted to the Pediatric Intensive Care Unit in Aseer Province, Saudi Arabia. MATERIALS AND METHODS: A retrospective cohort study of all pediatric patients (0-13) years old who drowned and were admitted to the Pediatric Intensive Care Unit, Aseer Central Hospital, Southwestern Saudi Arabia, between January 1st 1999 and December 31st 2009. RESULTS: A total of 19 cases were admitted following submersion in water. The mean age was 5.2 years ±3.8. Majority of victims (94.1%) were from the highland areas. Events most frequently occurred in the summer (46.7%), followed by spring and winter, 33.3% and 20%, respectively. Home events constituted 44.4% of submersion cases. Of these, 55.6% drowned in a washing container, While 53.4% submersed in swimming pools. Twenty-two percent of these accidents occurred in the sea and in wells while 11.1% occurred in a lake. The mean duration of submersion was 4.04 minutes ± 5.35. Cardiac arrest was reported upon arrival at hospital in 42.1% of the victims. There were seven deaths (36.8 %) and in one patient (5.2 %) there was severe brain injury. In all deceased cases, no adults were watching the children when the accidents occurred. CONCLUSION: Drowning is a significant risk factor facing our children and can claim lives. The media as well as the authority should play a major role in increasing the public awareness to minimize or prevent such a problem.

Construction of intrauterine growth curves in a high altitude area of Saudi Arabia.

OBJECTIVE: The aim of the present study was to construct intrauterine percentile growth curves for body weight, length and head circumference for local use in a high altitude area of Saudi Arabia. METHODS: This is a cross-sectional study of all Saudi births from Abha General Hospital over a 6-year period from 1999 to 2004. We included a total of 6,035 Saudi births in the present study after eliminating babies that were stillbirths, twins or those with major congenital anomalies. The gestational age of the infants ranged from 26-42 weeks. The anthropometric measurements included birth weight, crown-heel length and head circumference. We calculated the 10th, 25th, 50th, 75th, and 90th percentiles for weight, length and head circumference against the periods of gestation. We also calculated the mean weight and mean +/- 2SD. We determined the curves of best fit for weight, length and head circumference measurements at different weeks of gestation by polynomial regression of the following general form to construct the clinical curves: Y=a + bX + cX2. RESULTS: We derived intrauterine growth curves for weight, length and head circumference from measurements made on infants born at each week of gestation in the latter half of pregnancy. By calculating mean values and deviations around these (expressed either as centiles or standard deviations), we constructed distance (size attained) growth curves. The mean values for weight and length of births of the present study are lower than those of published charts in all gestational periods. However, for head circumference, evident appeared only before 32 weeks of gestation. The mean values of head circumference were nearly comparable. CONCLUSION: Constructed smoothed gestational curves are a useful tool for assessing the intrauterine growth of births in high altitude areas of Saudi Arabia.

Late presentation of a right Bochdalek hernia with a right intrathoracic stomach and organo-axial torsion.

A postero-lateral hernia through the foramen of Bochdalek is a rare type of congenital diaphragmatic hernia CDH. The incidence of Bochdalek hernia on the right side is 10-20% compared to the left side, and herniation of the stomach into the right pleural cavity is extremely rare. We report a case of right-sided Bochdalek hernia with a right intrathoracic stomach and organo-axial torsion misdiagnosed initially, and treated as a case of hyperactive airway disease. The child had a right thoracotomy, excision of the hernia sac that contained the stomach, greater omentum and part of the liver, reduction of the viscera into the abdominal cavity and simple closure of the diaphragmatic defect. Recovery was uneventful. This case highlights the consequences of late diagnosis and the effectiveness of surgical relief. A new clinico-anatomical classification of Bochdalek hernia is presented.

Evaluation of 2 real-time PCR assays for the investigation of mecA gene in clinical isolates of MRSA in Western Saudi Arabia.

OBJECTIVE: In diagnostic microbiology laboratories, Methicillin resistant Staphylococcus aureus (MRSA) is identified by positive coagulase test and positive deoxyribonuclease (DNase) activity followed by demonstration of oxacillin resistance on susceptibility testing on agar plate. This usually takes an approximately 48-72 hours. The purpose of this study is to evaluate 2 real-time polymerase chain reaction (PCR) assays for the presence of mecA gene in a population of MRSA strains circulating in Jeddah, Western Saudi Arabia, in order to determine their usefulness in the speedy diagnosis of MRSA in our clinical setting and their contribution to optimal patient management. METHODS: Ninety MRSA isolates obtained from clinical samples were identified by using conventional methods. They were collected between February 2004 and August 2004, from 2 major hospitals in Jeddah; King Abdul-Aziz University Hospital, Jeddah (50 strains) and King Khalid National Guard Hospital, Jeddah (40 strains). All isolates were confirmed as MRSA using Gram stain, catalase and coagulase activity, confirmatory DNAse activity and Kirby Bauer disc diffusion method with resistance to oxacillin by the agar disc method. The DNA extract was tested by 2 assays. The first was the commercial IVD Roche kit, which detects the mecA gene using the Light Cycler system. The other method employs multiplex PCR which detects As442 fragment and mecA optimized for the Smart Cycler system (Cephied). The length of time taken to perform the assays was recorded. RESULTS: All isolates were positive for Sa442 fragment and the coa gene specific for Staphylococcus aureus (S. aureus). However, 88/90 isolates (97.7%) tested were positive for mecA gene with both systems. The amplification, detection and melting curve analysis took 59.2 minutes for 32 samples on the Light Cycler and 46.7 minutes for 16 samples on the Smart Cycler. CONCLUSION: The 2 methods studied were equally specific and sensitive for the detection of mecA gene in confirmed S. aureus isolates and capable of identifying MRSA much earlier than conventional methods. The detection of 2 targets in the multiplex PCR assay reduces the 2-hour time required for DNase testing and may be used as a primary screening test for the detection of MRSA in clinical samples, such as blood cultures and sterile body fluids.

The body surface area of Saudi newborns.

Cancer chemotherapy drugs, fluids and electrolytes are best dosed per square meter of body surface area (BSA). Since newborns have an exceptionally large surface to mass ratio, their BSA needs to be accurately estimated, if it is to serve as a safe denominator for drugs and fluids. In this study, BSA was measured directly in 15 full-term Saudi newborns, using a coating technique. The data was used to construct a BSA weight-length prediction formula. Mean body mass index (BMI +/-SD) of our subjects was 12.56 +/- 1.29 kg/m2 and surface to mass ratio, .068 +/- .005 m2/kg. The closest fit to measured values was given by the regression equation: BSA (m2) = 0.03614H(0.294)W(0.529) +/- 0.0027 (SEE) A simplified formula based on weight alone: BSA = 7.4 + 4.2W +/- 0.0022(SEE) was derived for bedside use, in urgent situations. Our formulae may be applicable to non-Saudi newborns, if as expected, body size and shape variations in different populations develop after birth.

Bronchiolitis in Abha, Southwest Saudi Arabia: viral etiology and predictors for hospital admission.

BACKGROUND: Bronchiolitis is the most common lower respiratory tract infection in children less than 24 months of age and the most frequent cause of hospitalization in infants under 6 months of age. OBJECTIVES: To determine the viral etiology and predictors for hospital admission of children with bronchiolitis in Abha city, southwest Saudi Arabia. METHODS AND MATERIALS: Children five years old or younger diagnosed with bronchiolitis were enrolled in the study as a study-group of admitted cases (n=51) and a control-group of non-admitted cases (n=115). Clinical features and risk factors of bronchiolitis were recorded at the time of presentation and the clinical course was monitored during the hospital stay. Nasopharyngeal aspirates (NPA) for respiratory virus isolation were obtained from each of the admitted cases at the time of hospital admission. RESULTS: Prematurity, chronic lung diseases, atopic dermatitis, pure formula feeding, passive smoking and age = one year were significant predictors of admission. Respiratory syncytial virus (RSV) was isolated in 40% of the admitted cases. Eighty percent of brochiolitis due to RSV were in children less than six months of age. Adenovirus was isolated in 22% of cases. Other viruses isolated were: Influenza virus A (11%), influenza virus B (7%), Parainfluenza viruses (18%), parainfluenza virus type 1 (4%), parainfluenza virus type 2 (2%) and parainfluenza virus type 3 (13 %). CONCLUSIONS: Respiratory syncytial virus was the most frequent cause of admitted-cases of bronchiolitis, followed by adenovirus, parainfluenza virus and influenza virus, respectively. Prematurity, history of atopy, chronic lung disease, passive smoking, age = one year and lack of pure breast-feeding were significant predictors for admission of bronchiolitis cases.

Pattern of childhood poisoning in abha city - southwestern saudi arabia.

OBJECTIVE: To describe the pattern of childhood poisoning in the Emergency Room (ER) of the Pediatrics Department in Aseer Central Hospital (ACH), in order to suggest possible causes and preventive measures. METHODS: This is a retrospective study of cases of childhood poisoning or ingestions attending the pediatric emergency room of Aseer Central Hospital or those admitted to the Pediatric Department of same hospital in Abha, Kingdom of Saudi Arabia, during the period of January 2000 to December 2003. Children aged 12 years and below were included. Review of records was done to collect data on clinical information such as age, sex, type of poison, clinical condition on admission as well as the time, place and date of exposure to the offending agent. RESULTS: In this study, 114 poisoned children aged 12 years and below were studied. It was found that children from 2-4 years were more liable to poisoning (81%, p<0.001). Males were (68%) while females were (32%), with a sex ratio of 2.2:1. Medical drugs offended the most (72%, p<0.001). As regards clinical condition on admission, drowsiness, nausea and vomiting as well as abdominal pain represented (82%) of the cases. Daytime was when 80% of poisoned cases were admitted (p<0.001). The peak months were from June to August (71%, p<0.01). As regard the place of exposure to offending agent, living rooms and bedrooms accounted for 58% of the cases(p<001). CONCLUSION: The peak age for poisonings in children is before the age of four with significantly high diurnal frequency, significant seasonal variation in favor of summer. Medical drugs were the most common agents of poisoning, and living rooms and bedrooms the places where most poisoning occurred. Good and continuous supervision by parents is essential, especially from the age 1-5 years. There should also be legislation for the use of child resistant containers for home medicines and household agents.

The knowledge and practices of oral hygiene methods and attendance pattern among school teachers in Riyadh, Saudi Arabia.

OBJECTIVE: The aim of this study was to find out the knowledge and practices of oral hygiene methods among primary and secondary school teachers in Riyadh, Kingdom of Saudi Arabia (KSA). METHODS: The study was carried out using a self-administered questionnaire. Four hundred and seventy teachers, male 236 (50.2%) and female 234 (48.8%) responded with a response rate of 85.5%. The study was conducted during October to December 2001 at primary and secondary schools in Riyadh City, KSA. RESULTS: Almost 86% of male and 90% of female teachers felt that dental caries is due to the wrong method of tooth brushing, while sugar and sugary drinks were considered the main factor by 90% of male and 98% of female teachers. Seventy-five percent of male and 72% of female teachers considered irregular tooth brushing a cause of gums disease with 32% of male and 39% of female teachers not knowing details with regards to microbial relationship of gum disease. Tooth brushing preference was common among 45% male and 49% female teachers due to perceived effect of better cleaning, while almost an equal percentage of male and females (62%) used miswak due to Sunnah. Thirty-three point five percent of female teachers brushed 3 times a day as compared to 19% male teachers. On daily basis brushing 3 times, a day was common among >5000 SR monthly income group. Male teachers preferred horizontal tooth brushing (40%) while female teachers preferred circular tooth brushing (45%). Miswak was more commonly used by male teachers as compared to female teachers. Female school teachers had a higher income as compared to male schoolteachers. Thirty-two percent of females and 28% of male teachers were regular attendees to the dentist. Males were more satisfied by their oral health as compared to female teachers and 56% of male and 63% of female teachers visited the dentist only on having pain (toothache). CONCLUSION: It is concluded that there is much resemblance in knowledge and practice of oral hygiene habits among male and female schoolteachers and there is a need to enhance their knowledge regarding oral health and disease. Both need more awareness regarding oral health promotion to have a positive role in school oral health education for their students in collaboration with oral health care workers.

A formula for the estimation of the body surface area of Saudi male adults.

OBJECTIVE: Human body surface area (BSA) is the preferred denominator for physiological indices of body metabolism and for drug dosages. The Du Bois and Du Bois height/weight nomogram, used for fast and convenient estimation of patients BSA, is not suitable for all populations due to ethnic differences in body shape and build. The purpose of this study was to obtain direct measurements of BSA and use the data to construct a prediction formula for Saudi male adults. METHODS: Body surface area was measured in 21 adult male Saudis at Assir Central Hospital in Abha, Kingdom of Saudi Arabia between 2000 and 2003, using a coating technique. Areas of the coating material were determined with a compensating planimeter. Other anthropometric indices were measured or calculated according to standard procedures. Measured values of BSA were subjected to linear regression analysis using the least squares method to obtain a formula for predicting BSA from heights and weights. RESULTS: Mean body mass index (BMI) was 25.1 +/- 1.6 kg/m2; linearity, 2.46 +/- 0.13 cm/kg; surface to mass ratio, 0.025 +/- 0.0008 m2/kg; relative sitting height (RSH), 0.51 +/- 0.005. The closest fit to measured BSA values was given by the biexponential regression equation: BSA=0.02036 x H(0.516) x W(0.427) +/- 0.01283. This formula predicts BSA of Saudi male adults more accurately than all existing equations tested and yields a convenient BSA table for Saudis. CONCLUSION: The use of our formula, with prediction accuracy superior to those of existing formulae, should facilitate the establishment of normal values of other physiological indices. It should also lead to more reliable and precise drug dosages and expedite rapid decision making in critical care situations.