Use of NOACS in high-risk patients with atrial fibrillation in Saudi Arabia: Perspectives on improving patient care.

BACKGROUND: Despite the widespread and increasing use of NOACs in Saudi Arabia, there is a lack of contemporary guidance specific to the region. In particular, guidance on NOAC use in high-risk patients who are more likely to experience bleeding with oral anticoagulant therapy is needed. There is an unmet need for a review of contemporary evidence coupled with expert insights on safe and effective NOAC use in high-risk patients with AF in Saudi Arabia. RESEARCH DESIGN AND METHODS: This article provides a detailed review of contemporary literature on NOAC use in high-risk patients with AF. Additionally, key gaps in the literature are identified and expert insights are shared to guide effective management of patients and the significance of local data is evaluated with respect to challenges in optimizing the use of NOACs. CONCLUSIONS: This article provides information that complements and expands on existing reviews and guidelines on NOAC use in patients with AF, with a focus on challenges specific to the Saudi Arabian context with the potential to make a positive contribution to the medical community in Saudi Arabia and in other nations.

A 12-case outbreak of pharyngeal plague following the consumption of camel meat, in north-eastern Jordan.

Between late January and early February 1997, an outbreak of plague, associated with cervical lymphadenopathy and fever, occurred in the Jordanian village of Azraq ad-Druze, which lies about 50 km west of the border with Saudi Arabia. The 12 cases who presented at hospital were initially assumed to have tularaemia, and all were successfully treated with gentamicin. When, however, their sera were tested for evidence of Yersinia pestis or Francisella tularensis infection (using haemagglutination, enzyme immuno-assays for specific IgM or the F1 antigen of Y. pestis, and micro-agglutination tests), all 12 were found to have anti-Y. pestis IgM. Three dogs shot near the Saudi Arabian border were also found seropositive for antibodies against Y. pestis. Eleven of the 12 patients reported that, 2-4 days before their symptoms appeared, they had eaten the meat cut from the carcass of the same camel, either raw (10 cases) or cooked (one case). All 12 patients were diagnosed as cases of pharyngeal plague (the first cases of plague reported in Jordan for more than 80 years), caused by Y. pestis that most had acquired when they ate raw meat from a camel that was infected with the pathogen.

Goiter prevalence and urinary iodine excretion in schoolchildren of Jordan.

Iodine deficiency disorders (IDD) are considered a major health problem in the eastern Mediterranean region. In Jordan, an IDD assessment was performed in 1993 following which, a salt iodization and consumption program was implemented and a monitoring survey performed in 2000. In schoolchildren 8 to 10 years of age (2457 in 1993 and 2601 in 2000) goiter was graded according to WHO classification. Urinary iodine was measured in 10% of the children in 1993 and in all of them in 2000. Percent of iodine consumption in households was assessed by rapid kit test in 2000. Prevalence of goiter was 37.7 and 32.1 % and median urinary iodine was 40 and 154 microg/L, in 1993 and 2000, respectively. Before salt iodization, the prevalence of goiter and severity of iodine deficiency was more pronounced in rural regions and in the southern part of Jordan. In 2000, all but one governorate had a median urinary iodine (MUI) of above 100 microg/L. The percentage of urinary iodine levels < 50 microg in two governorates was > 20%. Iodine consumption rate of households was 88.3% throughout the country, but was < 70% in three governorates. It is concluded that moderate and severe IDD existed before 1993 in Jordan. Although the iodized salt program has been successful in optimizing MUI, the program for the control of IDD needs further improvement.

Mass psychogenic illness following tetanus-diphtheria toxoid vaccination in Jordan.

In September 1998, more than 800 young people in Jordan believed they had suffered from the side-effects of tetanus-diphtheria toxoid vaccine administered at school; 122 of them were admitted to hospital. For the vast majority, their symptoms did not result from the vaccine but arose from mass psychogenic illness. The role played by the media, the children's parents, and the medical profession in the escalation of this mass reaction appeared, at first sight, to be unusual and even unique to the circumstances in Jordan at the time. A review of the literature showed, however, that this mass reaction was similar in many ways to previous outbreaks, even though the underlying causes varied. There are about 200 published accounts of mass responses to situations involving suspected poisoning or other events. Because such mass reactions are relatively rare and the triggers so diverse, individuals faced with responding to them are unlikely to have prior experience in how to handle them and are unlikely to take bold steps to prevent their escalation. Indeed they may be unaware that such events have been recorded before. The lessons learned from this incident in Jordan may help other immunization programme managers to handle crisis situations elsewhere.

New sites of Bulinus truncatus and indigenous cases of urinary schistosomiasis in Jordan.

Thirty-two autochthonous cases of Schistosoma haematobium are reported from Ghore As-Safi, Karak Lowlands, Jordan. All infected persons were males (9-46 years-old). New unusual breeding sites for Bulinus truncatus are discovered. The past and current distribution of the snail intermediate host is given.

Urinary schistosomiasis contracted from an irrigation pool in Ramah, the southern Jordan Valley, Jordan.

Autochthonous cases of urinary schistosomiasis are reported for the second time in Jordan. Eight Jordanian juveniles (seven males and one female) ranging in age from 10 to 15 years were diagnosed in 1995 as having the disease. Urine examination using the membrane filtration technique showed varying intensities of infection. The patients were treated with praziquantel and a follow-up showed the passage of dead eggs in the urine of five patients one month after treatment. All had egg-negative urine three months post-treatment. Epidemiologic investigation showed that the patients did not leave Jordan and that the seven males swam frequently in 1994 in an irrigation pool present in a farm at Ramah, in the southern Jordan Valley. The female patient had frequent contact with the pool water since she often went to the farm to obtain water for domestic animals. Bulinus truncatus snails were found in the pool and in pools on other farms in the area. Two hundred snails collected from the site did not shed cercariae after six months of observation. Several foreign workers in the area were found infected with Schistosoma haematobium, suggesting they were the source of infection.

Outbreak of paralytic poliomyelitis in a highly immunized population in Jordan.

Between November 1991 and March 1992, 37 cases of paralytic poliomyelitis occurred in Jordan, where none had been reported since 1988. Of these, 17 (50%) of 34 patients had received at least three doses of oral poliovirus vaccine (OPV3). The first and 2 subsequent case-patients were children of Pakistani migrant workers, and the first 8 and a total of 27 (75%) case-patients resided in or near the Jordan Valley. A seroepidemiologic study of 987 children in all regions of Jordan was performed to assess OPV3 coverage and immune response to OPV. Although OPV3 coverage by 12 months of age was high (96%) in the general population, coverage was lower among Pakistani (21%), Bedouin (63%), and Gypsy (9%) children (P < .001). Seroprevalences for poliovirus type 3 were 71% in the Jordan Valley versus 81% in other regions after 3 doses of OPV (P < .06) and 77% in the Jordan Valley versus 98% in other regions after 5 doses of OPV (P < .001). This outbreak demonstrates the importance of achieving high seroimmunity to infection in all geographic areas to prevent the reintroduction and spread of imported strains of wild poliovirus.

Increased immunogenicity of oral poliovirus vaccine administered in mass vaccination campaigns compared with the routine vaccination program in Jordan.

To compare the immunogenicity of routine versus mass campaign doses of oral poliovirus vaccine (OPV), serum neutralizing antibodies were measured in 254 children before and after two mass vaccination campaigns in Jordan. Precampaign seroprevalences to poliovirus types 1, 2, and 3 in children who had received three, four, or five routine doses of OPV were compared with postcampaign seroprevalences in children who had received one, two, or three routine doses plus two mass campaign doses. Seroprevalences were consistently higher in subgroups that received two doses through mass campaigns than in subgroups that received all doses through the routine program, especially for poliovirus type 3. Geometric mean titers were also consistently higher for mass campaign subgroups, particularly for poliovirus type 3. The findings suggest that adding further doses of OPV to the routine schedule is unlikely to have as great an impact on the immune state of children as administering the same number of doses during mass campaigns.