BACKGROUNDCoronary artery disease (CAD) is one of the leading causes of death in Malaysia. However, the prevalence of CAD in males is higher than in females and mortality rates are also different between the two genders. This suggest that risk factors associated with mortality between males and females are different, so we compared the clinical characteristics and outcome between male and female STEMI patients.OBJECTIVESTo identify the risk factors associated with mortality for each gender and compare differences, if any, among ST-elevation myocardial infarction (STEMI) patients.DESIGNRetrospective analysis.SETTINGSHospitals across Malaysia.PATIENTS AND METHODSWe analyzed data on all STEMI patients in the National Cardiovascular Database-Acute coronary syndrome (NCVD-ACS) registry for the years 2006 to 2013 (8 years). We collected demographic and risk factor data (diabetes mellitus, hypertension, smoking status, dyslipidaemia and family history of CAD). Significant variables from the univariate analysis were further analysed by a multivariate logistic analysis to identify risk factors and compare by gender.MAIN OUTCOME MEASURESDifferential risk factors for each gender.RESULTSFor the 19 484 patients included in the analysis, the mortality rate over the 8 years was significantly higher in females (15.4%) than males (7.5%) (P<.001). The univariate analysis showed that the majority of male patients <65 years while females were ≥65 years. The most prevalent risk factors for male patients were smoking (79.3%), followed by hypertension (54.9%) and diabetes mellitus (40.4%), while the most prevalent risk factors for female patients were hypertension (76.8%), followed by diabetes mellitus (60%) and dyslipidaemia (38.1%). The final model for male STEMI patients had seven significant variables: Killip class, age group, hypertension, renal disease, percutaneous coronary intervention and family history of CVD. For female STEMI patients, the significant variables were renal disease, smoking status, Killip class and age group.CONCLUSIONGender differences existed in the baseline characteristics, associated risk factors, clinical presentation and outcomes among STEMI patients. For STEMI females, the rate of mortality was twice that of males. Once they reach menopausal age, when there is less protection from the estrogen hormone and there are other risk factors, menopausal females are at increased risk for STEMI.LIMITATIONRetrospective registry data with inter-hospital variation.

BACKGROUNDPromising clinical and humanistic outcomes are associated with the use of new oral agents in the treatment of relapsing-remitting multiple sclerosis (RRMS). This is the first cost-effectiveness study comparing these medications in Saudi Arabia.OBJECTIVESWe aimed to compare the cost-effectiveness of fingolimod, teriflunomide, dimethyl fumarate, and interferon (IFN)-β1a products (Avonex and Rebif) as first-line therapies in the treatment of patients with RRMS from a Saudi payer perspective.DESIGNCohort Simulation Model (Markov Model).SETTINGTertiary care hospital.METHODSA hypothetical cohort of 1000 RRMS Saudi patients was assumed to enter a Markov model model with a time horizon of 20 years and an annual cycle length. The model was developed based on an expanded disability status scale (EDSS) to evaluate the cost-effectiveness of the five disease-modifying drugs (DMDs) from a healthcare system perspective. Data on EDSS progression and relapse rates were obtained from the literature; cost data were obtained from King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia. Results were expressed as incremental cost-effectiveness ratios (ICERs) and net monetary benefits (NMB) in Saudi Riyals and converted to equivalent $US. The base-case willingness-to-pay (WTP) threshold was assumed to be $100 000 (SAR375 000). One-way sensitivity analysis and probabilistic sensitivity analysis were conducted to test the robustness of the model.MAIN OUTCOME MEASURESICERs and NMB.RESULTSThe base-case analysis results showed Rebif as the optimal therapy at a WTP threshold of $100 000. Avonex had the lowest ICER value of $337 282/QALY when compared to Rebif. One-way sensitivity analysis demonstrated that the results were sensitive to utility weights of health state three and four and the cost of Rebif.CONCLUSIONNone of the DMDs were found to be cost-effective in the treatment of RRMS at a WTP threshold of $100 000 in this analysis. The DMDs would only be cost-effective at a WTP above $300 000.LIMITATIONSThe current analysis did not reflect the Saudi population preference in valuation of health states and did not consider the societal perspective in terms of cost.

BACKGROUNDAllergic rhinitis (AR) is a common inflammation of the nasal mucosa in response to allergen exposure. We translated and validated the Score for Allergic Rhinitis (SFAR) into an Arabic version so that the disease can be studied in an Arabic population.OBJECTIVESSFAR is a non-invasive self-administered tool that evaluates eight items related to AR. This study aimed to translate and culturally adapt the SFAR questionnaire into Arabic, and assess the validity, consistency, and reliability of the translated version in an Arabic-speaking population of patients with suspected AR.STUDY DESIGNCross-sectional.SETTINGTertiary care hospital in Riyadh.PARTICIPANTS AND METHODSThe Arabic version of the SFAR was administered to patients with suspected AR and control participants.MAIN OUTCOME MEASUREComparison of the AR and control groups to determine the test-retest reliability and internal consistency of the instrument.RESULTSThe AR (n=173) and control (n=75) groups had significantly different Arabic SFAR scores (P<.0001). The instrument provided satisfactory internal consistency (Cronbach’s alpha value of 0.7). The test-retest reliability was excellent for the total Arabic SFAR score (r =0.836, P<.0001).CONCLUSIONThese findings demonstrate that the Arabic version of the SFAR is a valid tool that can be used to screen Arabic speakers with suspected AR.LIMITATIONSThe absence of objective allergy testing

BACKGROUNDThe relationship between body mass index (BMI) and dental caries is still undetermined.OBJECTIVEThis study aimed to assess the relationship between the dental status by decayed, missed, filled teeth index (DMFT), and BMI by age and gender among healthy adults.DESIGNAnalytical, cross-sectional study.SETTINGSUniversity dental hospital in Riyadh.SUBJECTS AND METHODSHealthy adults aged between 18 and 35 years were recruited during the 10-month period from March 2015 to December 2015. Dental caries severity was estimated using the DMFT index.MAIN OUTCOME MEASUREThe prevalence of overweight/obesity and the association of BMI category with the DMFT index.RESULTSThe mean age of 502 subjects was 24.3 (4.9) years. The caries severity of the study population was considered moderate according to the WHO caries severity scale (mean [standard deviation] DMFT 13.3 [3.8]). The mean (SD) DMFT of male and female subjects was 13.1 (4.0) and 13.36 (3.7), respectively. No significant association was seen between dental caries and BMI. Logistic regression analysis showed that males had two times more risk of developing dental caries compared to females. In addition, the risk of caries development was increased by about 5 times for every year of age.CONCLUSIONDental caries was not associated with BMI but age significantly influenced the DMFT index and gender was associated with more missing teeth. Further longitudinal studies with larger cohorts from several geographic regions are warranted.LIMITATIONConvenience sampling and recruitment from a single dental center may have some impact on the generalization of data.

BACKGROUNDThe impact of preoperative thrombocytosis as a prognostic factor in endometrial carcinoma (EC) remains uncertain and has never been examined in Saudi Arabia.OBJECTIVESTo determine the prevalence of preoperative thrombocytosis (platelet count >400 000/μL), and its prognostic significance for clinicopathological factors and survival in Saudi patients with endometrioid-type EC.DESIGNA retrospective cross-sectional study from January 2010 to December 2013.SETTINGA referral tertiary healthcare institute.PATIENTS AND METHODSPatients who underwent staging surgery for primary endometrioid-type EC were retrospectively analyzed for perioperative details: age, preoperative platelet count, International Federation of Gynecology and Obstetrics (FIGO) stage, endometrioid grade, recurrence, disease-free survival (DFS) and overall survival (OS). Survival analysis was conducted using Kaplan-Meier estimates and a Cox proportional hazards model.MAIN OUTCOME MEASURESPrevalence of preoperative thrombocytosis, DFS and OS. RESULTS: In 162 patients who met inclusion criteria, the frequency of preoperative thrombocytosis was 8.6% (n=14). Patients with advanced FIGO disease (stages III–IV) and recurrence had significantly higher mean preoperative platelet counts than patients with early FIGO disease (stages I–II) and no recurrence (P=.0080 and P=.0063, respectively). Patients with thrombocytosis had statistically significant higher rates of advanced FIGO stages III–IV disease, unfavorable grades II–III endometrioid histology and recurrence than patients with preoperative platelet counts ≤400 000/μL (P<.001, P<.0105 and P<.001, respectively). In a univariate analysis, patients with preoperative thrombocytosis had statistically lower mean DFS and OS rates than patients without thrombocytosis (P<.0001 and P<.0001, respectively). In a multivariate analysis, thrombocytosis was not an independent prognostic factor of DFS and OS.CONCLUSIONThe frequency of preoperative thrombocytosis is not uncommon. Also, preoperative thrombocytosis is associated with poor clinicopathological prognostic factors, and poor survival outcomes in a univariate but not multivariate analysis.LIMITATIONThe retrospective study design, sample size and lack of exploration of other clinicopathological factors.

BACKGROUNDAssessment of growth using Z-score methods is important for clinical care and research, yet growth reference Z-score data for preschool Saudi children are not available.OBJECTIVEEstablish Z-score tables and corresponding growth charts.DESIGNUses data from a national survey in 2004–2005.SETTINGCommunity-based random sample of preschool Saudi children.SUBJECTS AND METHODSRaw data from the previous nationally representative sample were analyzed using the L, M, and S statistical methods to calculate Z-scores of growth.MAIN OUTCOME MEASURE(S)Z-scores reference values for weight, length/height, head circumference, weight for length/height, and body mass index for age for boys and girls from birth to 60 months of age.RESULTSFor 15 601 Saudi children (7896, 50.6 % boys) Z-score tables and graphs from birth to 60 months of age were derived for boys and girls. The tables and graphs include weight for age, length/height for age, head circumference for age, weight for length/height, and BMI for age.CONCLUSIONZ-score reference data on the growth of preschool Saudi infants and children is essential for healthcare and research.LIMITATIONDoes not include regional variations.

BACKGROUNDCentral venous cannulation is a necessary invasive procedure for fluid management, haemodynamic monitoring and vasoactive drug therapy. The right internal jugular vein (RIJV) is the preferred site. Enlargement of the jugular vein area facilitates catheterization and reduces complication rates. Common methods to enlarge the RIJV cross-sectional area are the Trendelenburg position and the Valsalva maneuver.OBJECTIVECompare the Trendelenburg position with upper-extremity venous return blockage using the tourniquet technique.DESIGNProspective clinical study.SETTINGUniversity hospital.SUBJECTS AND METHODSHealthy adult volunteers (American Society of Anesthesiologists class I) aged 18–45 years were included in the study. The first measurement was made when the volunteers were in the supine position. The RIJV diameter and cross-sectional area were measured from the apex of the triangle formed by the clavicle and the two ends of the sternocleidomastoid muscle, which is used for the conventional approach. The second measurement was performed in a 20° Trendelenburg position. After the drainage of the veins using an Esbach bandage both arms were cuffed. The third measurement was made when tourniquets were inflated.MAIN OUTCOME MEASURE(S)Hemodynamic measurements and RIJV dimensions.RESULTSIn 65 volunteers the diameter and cross-sectional area of the RIJV were significantly widened in both Trendelenburg and tourniquet measurements compared with the supine position (P<.001 for both measures). Measurements using the upper extremity tourniquet were significantly larger than Trendelenburg measurements (P=.002 and <.001 for cross-sectional area and diameter, respectively).CONCLUSIONChannelling of the upper-extremity venous return to the jugular vein was significantly superior when compared with the Trendelenburg position and the supine position.LIMITATIONSNo catheterization and study limited to healthy volunteers.

BACKGROUNDDiabetic patients with hypertension and dyslipidemia are at a high risk of cardiovascular complications.OBJECTIVESTo determine the effect of Nigella sativa supplementation on the lipid profile, mean arterial pressure, and heart rate in persons with type 2 diabetes on oral hypoglycemic agents (OHA).DESIGNSingle-blind, nonrandomized.SETTINGDiabetes clinic of a university hospital in Saudi Arabia.PATIENTS AND METHODSType-2 diabetic patients were recruited by purposive sampling and assigned to treatment or control at the discretion of the investigator with the patient blinded to treatment. Before the intervention and every 3 months thereafter until the end of the treatment period, the following parameters were measured: triglycerides (TG), total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR), and body mass index (BMI). Results at the baseline and each subsequent visit were compared between the two groups.MAIN OUTCOME MEASURE(S)Lipid and cardiovascular parameters, and BMI.RESULTSFifty-seven patients were assigned to receive N sativa 2 g daily for one year and 57 were assigned to receive an identical regimen of placebo, along with OHA. A significant decrease in HDL-C and increase in the TC/HDL-C and LDL-C/HDL-C ratios were seen in the control group. The N sativa group had a significant decline in TC, LDL-C, TC/HDL-C and LDL-C/HDL-C ratios, compared with the respective baseline data and the control group. HDL-C was significantly elevated in the N sativa group. The control group showed a significant elevation in MAP. The N sativa group had a significant reduction in SBP, DBP, MAP and HR and a significant decrease in DBP, MAP and HR as compared with the control group.CONCLUSIONN sativa supplementation improves total cholesterol, mean arterial pressure and heart rate in type 2 diabetes patients on oral hypoglycemic agents.LIMITATIONSThere were 9 subjects in each group lost to follow up; thus the sample size could not be maintained as per the sample size calculation. The study was nonrandomized and thus there was a possibility of allocation bias. (Clinical trial registration number: CTRI/2013/06/003781, Clinical Trial Registry of India).

BACKGROUNDNigella sativa and its derivatives have been reported to have anti-inflammatory and bronchodilator effects, but the effects have been evaluated in only a few clinical studies.OBJECTIVESTo determine the effect of N sativa supplementation on inflammation of the airways and limitation of airflow in partly controlled asthma patients.DESIGNSingle-blind, placebo-controlled, randomized study.SETTINGAsthma and allergy clinic of a university hospital in eastern Saudi Arabia.PATIENTS AND METHODSPatients were divided into three groups. A control group (n=24) received the placebo, while NS-1 and NS-2 groups (n=26 each) received 1 and 2 g/day of N sativa, respectively, for 3 months along with maintenance inhaled therapy.MAIN OUTCOME MEASURE(S)Asthma control test (ACT) score, fractional exhaled nitric oxide (FeNO), peak expiratory flow (PEF) variability and other pulmonary function tests, IgE, serum cytokines, and frequency of exacerbations.RESULTSFEF25-75% and FEV1 (% predicted) increased significantly (P<.05) at both 6 and 12 weeks in the NS-2 group. PEF variability significantly improved in both NS-1 and NS-2 groups at 6 and 12 weeks as compared with the controls (P<.05). FeNO and serum IgE decreased significantly after 12 weeks in both the NS-1 and NS-2 groups vs baseline (P<.05). Both doses of N sativa produced a significant increase in the serum IFN-γ at 12 weeks vs baseline (P<.05) as well as a significant improvement in the ACT score at 6 and 12 weeks vs baseline (P<.001, <.01). Significantly fewer patients had exacerbations in the NS-1 group (P<.05).CONCLUSIONN sativa supplementation with inhaled maintenance therapy improves some measures of pulmonary function and inflammation in partly controlled asthma.LIMITATIONSNo bronchoalveolar lavage or sputum samples taken for measurement of asthma markers.

BACKGROUNDHospital accreditation assesses hospital performance against explicit standards. Studies of the efficacy of accreditation are limited, but suggest that Joint Commission International (JCI) accreditation is efficient in improving the safety and quality of care in accredited hospitals.OBJECTIVESThis study aimed to assess the perceptions of health professionals on the impact of JCI accreditation and implementation of change towards the delivery of quality patient care.DESIGNCross-sectional survey.SETTINGSKing Abdulaziz Medical City in Jeddah, Saudi Arabia.SUBJECTSBetween June 2016 and September 2016, a validated questionnaire was distributed to physicians, nurses, medical technologists, dietitians, and other allied healthcare professionals. The questionnaire consisted of 19 items covering participation in accreditation, benefits of accreditation, and the quality of results of accreditation. Demographic data collected on the participants included age, gender, educational attainment, profession, length of service, and department.MAIN OUTCOME MEASURE(S)Participation in accreditation, benefits of accreditation, and quality of results of accreditation.RESULTSHospital accreditation was given a worthy response from the general view of 901 health professionals. The mean (standard deviation) of scores on a 5-point Likert scale were 3.79 (0.68) for participation in accreditation, 3.85 (0.84) for benefits, and 3.54 (1.01) for quality of results.CONCLUSIONAs perceived by health professionals in our survey, accrediation had a positive impact on the process and implementation of change in the hospital that resulted in improvement in the delivery of patient care and other health services.LIMITATIONSSingle institution study with no comparison made to other small, medium, or large-sized JCI-accredited hospitals in Saudi Arabia. Patient satisfaction before and after accreditation was not included.