Evaluation of Glibenclamide Quality and Stakeholders’ Perception of Medicine Quality in the Clinical Settings of the Ministry of Interior in Saudi Arabia

Aim: To explore medicine quality and perception among the stakeholders in the Ministry of Interior Medical Services (MOI-MSD) clinical settings in Saudi Arabia using glibenclamide as an indicator. Method: A mixed method approach was used in two phases. Phase one involved chemical analysis for identity and quantity of the active pharmaceutical ingredient (API), visual analysis and authentication of source of a popular diabetes medicine (glibenclamide) collected from MOI-MSD general warehouse in Riyadh, Saudi Arabia. Phase two contained a focus group discussion, self-completed survey questionnaires and semi-structured interviews to explore the perceptions of various stakeholders including commissioners, physicians, pharmacists and patients in the MOI-MSD settings in Saudi Arabia about medicine quality and related problems. Data analysis: Phase one collected quantitative data of API quantity from the chemical analysis of glibenclamide samples using a high performance liquid chromatography apparatus (HPLC) based on United States Pharmacopoeia (USP 36) method. The visual inspection of glibenclamide samples was performed using tool kit developed by The World Health Professions Alliance (WHPA) and The International Pharmaceutical Federation (FIP). The authentication of glibenclamide source was performed by on-site comparison of available samples in the general MOI-MSD warehouse with the available official reception documents. Phase two collected quantitative and qualitative data regarding perceptions about medicine quality and related problems and subsequently analysed them using SPSS for descriptive statistics and NVivo version 10 for thematic analysis following data coding and the development of themes and sub-themes. Subsequently, stakeholders’ data were triangulated to establish common and specific themes and sub-themes among MOI-MSD stakeholders. Findings: Phase one of the study found that all glibenclamide samples were within acceptable USP limits in terms of identity and quantity between 90-110%. It was also found that all available glibenclamide batch numbers were present in the official reception documents and the visual analysis of samples revealed no visible errors on the medicine samples or its packaging. Phase two of the study found that most stakeholders, particularly commissioners and physicians, believed that medicine quality was good or excellent in Saudi Arabia. However, the commissioners, physicians and pharmacists believed that the quality of medicines in the MOI-MSD was less than what is available in Saudi Arabia but patients mostly disagreed with these views. Most patients believed that the quality of medicines was high in both the Saudi Arabian market and in the MOI-MSD settings. Limited knowledge about good quality medicines and counterfeit medicines was found among most stakeholders where the quality of medicines was commonly associated with the effect rather than technical attributes of medicines including content, appearance and source. The stakeholders in this study reported a wide range of behaviour when in doubt about medicine quality such as reporting these doubts to authorities, finding alternative medicines, stopping the medicine use and taking no further action regarding these doubts. Furthermore, all stakeholders have identified medicine procurement focusing on price rather than quality, difficulty in reporting medicine quality problems and medicine storage conditions as challenges to medicine quality in the MOI-MSD. Patients, particularly chronic patients from Jeddah city, have complained about medicine non-availability in their local MOI-MSD primary clinic and expensive medicine prices. Conclusions: Glibenclamide quality in the MOI-MSD settings was found to be acceptable in terms of API identity and quantity, source and visual appearance. The perception about medicine quality in these settings seems to be low particularly from commissioners and pharmacists but not the patients. There is an urgent need to implement quality assurance steps to increase the commissioners and pharmacists trust in the quality of their medicines at the medicine selection, procurement, storage and transportation stages in addition to improving the accessibility to report medicine quality problems to all stakeholders. Subsequently, future research is needed to measure and evaluate the impact of these quality assurance steps on the confidence of commissioners and pharmacists trust in the quality of the MOI-MSD medicines. Furthermore, patients’ issues about medicine non-availability need to be addressed rapidly as it could result in patients’ acquiring medicines from unknown sources and/or cause additional financial burdens

Exploring mechanisms of fatigue during repeated exercise and the dose dependent effects of carbohydrate and protein ingestion:study protocol for a randomised controlled trial

BACKGROUND: Muscle glycogen has been well established as the primary metabolic energy substrate during physical exercise of moderate- to high-intensity and has accordingly been implicated as a limiting factor when such activity is sustained for a prolonged duration. However, the role of this substrate during repeated exercise after limited recovery is less clear, with ongoing debate regarding how recovery processes can best be supported via nutritional intervention. The aim of this project is to examine the causes of fatigue during repeated exercise bouts via manipulation of glycogen availability through nutritional intervention, thus simultaneously informing aspects of the optimal feeding strategy for recovery from prolonged exercise. METHODS/DESIGN: The project involves two phases with each involving two treatment arms administered in a repeated measures design. For each treatment, participants will be required to exercise to the point of volitional exhaustion on a motorised treadmill at 70% of previously determined maximal oxygen uptake, before a four hour recovery period in which participants will be prescribed solutions providing 1.2 grams of sucrose per kilogram of body mass per hour of recovery (g.kg(-1).h(-1)) relative to either a lower rate of sucrose ingestion (that is, 0.3 g.kg(-1). h(-1); Phase I) or a moderate dose (that is, 0.8 g.kg(-1).h(-1)) rendered isocaloric via the addition of 0.4 g.kg(-1).h(-1) whey protein hydrolysate (Phase II); the latter administered in a double blind manner as part of a randomised and counterbalanced design. Muscle biopsies will be sampled at the beginning and end of recovery for determination of muscle glycogen resynthesis rates, with further biopsies taken following a second bout of exhaustive exercise to determine differences in substrate availability relative to the initial sample taken following the first exercise bout. DISCUSSION: Phase I will inform whether a dose–response relationship exists between carbohydrate ingestion rate and muscle glycogen availability and/or the subsequent capacity for physical exercise. Phase II will determine whether such effects are dependent on glycogen availability per se or energy intake, potentially via protein mediated mechanisms. TRIAL REGISTRATION: ISRCTN87937960

Impact of muscle glycogen availability on the capacity for repeated exercise in man

Purpose: To examine whether muscle glycogen availability is associated with fatigue in a repeated exercise bout following short-term recovery. Methods: Ten endurance-trained individuals underwent two trials in a repeated measures design, each involving an initial run to exhaustion at 70% (Run-1) followed by a 4-h recovery and a subsequent run to exhaustion at 70% (Run-2). A low-carbohydrate (L-CHO; 0.3 g·kg BM-1·h-1) or high-carbohydrate (H-CHO; 1.2 g·kg BM-1·h-1) beverage was ingested at 30-min intervals during recovery. Muscle biopsies were taken upon cessation of Run-1, post-recovery and fatigue during Run-2 in L-CHO (F2). In H-CHO, the muscle biopsies were obtained post-recovery, the time point coincident with fatigue in L-CHO (F2) and the point of fatigue during the subsequent exercise bout (F3).Results: Run-2 was more prolonged for every participant in H-CHO (80±16 min) than L-CHO (48±11 min; p< 0.001). Muscle glycogen concentrations were higher at the end of recovery in H-CHO (269±84 mmol·kg dm-1) versus L-CHO (157±37 mmol·kg dm-1; p= 0.001). The rate of muscle glycogen degradation during Run-2 was higher in H-CHO (3.1±1.5 mmol·kg dm-1·min-1) than L-CHO (1.6±1.3 mmol·kg dm-1·min-1; p= 0.05). The concentration of muscle glycogen was higher in H-CHO than L-CHO at F2 (123±28 mmol·kg dm-1; p< 0.01) but no differences were observed between treatments at the respective points of exhaustion (78±22 versus 72±21 mmol·kg dm-1·min-1; H-CHO and L-CHO, respectively). Conclusion: Increasing carbohydrate intake during short-term recovery accelerates glycogen repletion in previously exercised muscle and thus improves the capacity for repeated exercise. The availability of skeletal muscle glycogen is therefore an important factor in the restoration of endurance capacity because fatigue during repeated exercise is associated with a critically low absolute muscle glycogen concentration

Delayed presentation of a duodenal web

Duodenal atresia and web are common causes of intestinal obstruction in early infancy. Their incidence ranges between 1 in 10,000 to 1 in 40,000 live births. Unlike duodenal atresia which is diagnosed early, even antenatally; A web presents later depending on the size of the aperture in the web. It usually presents with bilious or non bilious vomiting. We present an unusual presentation of duodenal web in a three and a half years old boy who presented with a 12 months history of abdominal distension and vomiting every 2nd or 3rd day. Plain abdominal imaging showed radiopaque foreign bodies below the diaphragm. As the natural history for majority of ingested foreign bodies is natural passage; He was managed expectantly elsewhere. Eventually, 12 months later, the patient presented to our center where further investigation provided the diagnosis. He was treated surgically by excision of the web. Post operatively, TPN and a trans-anastomotic tube (TAT) were used until full recovery was achieved. A high index of suspicion is the key to reaching the true diagnosis in patients presenting after the neonatal period

Restoration of Muscle Glycogen and Functional Capacity: Role of Post-Exercise Carbohydrate and Protein Co-Ingestion

The importance of post-exercise recovery nutrition has been well described in recent years, leading to its incorporation as an integral part of training regimes in both athletes and active individuals. Muscle glycogen depletion during an initial prolonged exercise bout is a main factor in the onset of fatigue and so the replenishment of glycogen stores may be important for recovery of functional capacity. Nevertheless, nutritional considerations for optimal short-term (3–6 h) recovery remain incompletely elucidated, particularly surrounding the precise amount of specific types of nutrients required. Current nutritional guidelines to maximise muscle glycogen availability within limited recovery are provided under the assumption that similar fatigue mechanisms (i.e., muscle glycogen depletion) are involved during a repeated exercise bout. Indeed, recent data support the notion that muscle glycogen availability is a determinant of subsequent endurance capacity following limited recovery. Thus, carbohydrate ingestion can be utilised to influence the restoration of endurance capacity following exhaustive exercise. One strategy with the potential to accelerate muscle glycogen resynthesis and/or functional capacity beyond merely ingesting adequate carbohydrate is the co-ingestion of added protein. While numerous studies have been instigated, a consensus that is related to the influence of carbohydrate-protein ingestion in maximising muscle glycogen during short-term recovery and repeated exercise capacity has not been established. When considered collectively, carbohydrate intake during limited recovery appears to primarily determine muscle glycogen resynthesis and repeated exercise capacity. Thus, when the goal is to optimise repeated exercise capacity following short-term recovery, ingesting carbohydrate at an amount of ≥1.2 g kg body mass−1·h−1 can maximise muscle glycogen repletion. The addition of protein to carbohydrate during post-exercise recovery may be beneficial under circumstances when carbohydrate ingestion is sub-optimal (≤0.8 g kg body mass−1·h−1) for effective restoration of muscle glycogen and repeated exercise capacity

Anthropometric Measurements, Sociodemographics, and Lifestyle Behaviors among Saudi Adolescents Living in Riyadh Relative to Sex and Activity Energy Expenditure: Findings from the Arab Teens Lifestyle Study 2 (ATLS-2)

The aim of the study was to examine the anthropometric measurements, sociodemographics, and lifestyle behaviors among Saudi adolescents relative to sex and physical activity (PA). A random cross-sectional survey conducted on Saudi adolescents from secondary schools in Riyadh, using a multistage stratified cluster sampling technique. Measurements included demographics, weight, height, waist circumference, PA, sedentary behaviors (SB), sleep duration, and dietary habits using a validated questionnaire. A total of 1262 adolescents (16.4 ± 0.95 years; 52.4% males) were studied. Overweight/obesity was more than 40%. Physical inactivity among adolescents was 53%, which indicates some improvement over the past years, especially among females. More than 80% of adolescents had over three hours/day of screen time, with no significant sex differences. Insufficient sleep was highly prevalent with gender differences. A large proportion of the participants did not consume daily breakfast (65.7%), vegetables (73.2%), fruits (84.2%), or milk/dairy products (62.4%), whereas significant proportions of the adolescents consumed sugar-sweetened drinks, fast food, French fries/potato chips, cake/donuts, and chocolates/candy on at least three days or more per week. It was concluded that non-daily intake of breakfast and vegetables was significantly associated with lower PA. The updated information can aid in effectively planning and implementing promotional programs toward improving the lifestyle behaviors of Saudi adolescent