Views on Bioethics Statements among Medical Students from Three Different Saudi Universities

Objective To investigate the level of agreement with ethics statements amongst medical students from different Saudi Universities that use traditional or problem based learning (PBL) methods. Methods The respondents enrolled were medical students from Saud Bin Abdulaziz University for Health Sciences (KSAU-HS) which utilizes PBL methods, King Saud University in Riyadh (KSU), and King Abdulaziz University in Jeddah (KAU), both of which utilize traditional methods. As all KSAU-HS medical students are applied medical science graduates, a fourth group consisting of applied medical science graduates from KSU and KAU were included as controls. The respondents were asked to grade their degree of agreement with 19 statements on different bioethical issues by using a Likert type scale from 1 to 5 (1= I completely disagree, 5= I completely agree). The 19 statements were further divided into 5 summative ethical domains: –(a) goals of medicine (3 questions), (b) autonomy and informed consent (9 questions), (c) quality of life (1 question), (d)resource allocation (4 questions), and (e)withdrawal and withholding of treatment (2 questions). To avoid gender bias, only male students were sampled as KSAU-HS has only male students. Overall mean scores and mean scores for each statement and for each domain by each university were compared using unpaired two-tailed t test and Wilcoxon rank sum test. Results There were 43 students from KSAU-HS, 36 from KSU, 47 from KAU and 43 applied medical science graduates. There were significant differences between the overall mean scores by KSAU-HS on one hand (4.03 +/-0.69) and those by the other three groups on the other, being 3.75 +/- 0.66 (p=0.001) for KSU students, 3.76+/- 0.7 (p=0.015) for KAU students and 3,63 +/- 0.51 (p=0.0001) for the applied medical science graduates. The main differences between KSAU-HS students and the students from KSU and KAU were seen in the areas of objectives of medical care (p=0.05), autonomy (p=0.0001), patient centeredness (p=0.02), and informed consent (p=0.05). These differences could not be explained by the older age of KSAU-HS students or their being postgraduates as revealed by the different results seen with the applied medical science graduates. Conclusion The most paternalistic attitudes were held by the applied medical science graduates followed by KSU and KAU students. The least paternalistic were the students of KSAU-HS. We speculate that these differences are related to the different bioethics teaching and training methods used in the 3 universities

Shifting paradigm: From “No Code” and “Do-Not-Resuscitate” to “Goals of Care” policies

Policies addressing limitations of medical therapy in patients with advanced medical conditions are typically referred to as Code Status (No Code) policies or Do-Not-Resuscitate (DNR) status polices. Inconsistencies in implementation, understanding, decision-making, communication and management of No Code or DNR orders have led to delivery of poorer care to some patients. Several experts have called for a change in the current approach. The new approach, Goals of Care paradigm, aims to contextualize the decisions about resuscitation and advanced life support within the overall plan of care, focusing on choices of treatments to be given rather than specifically on treatments not to be given. Adopting “Goals of Care” paradigm is a big step forward on the journey for optimizing the care for patients with advanced medical conditions; a journey that requires collaborative approach and is of high importance for patients, community and healthcare systems

Attendees’ feedback on king abdulaziz medical city pilot chronic kidney disease education class

Despite similar or better patient outcomes, peritoneal dialysis and pre-emptive kidney transplantation are underutilized in Saudi Arabia. Moreover, most patients with end-stage renal disease begin dialysis in unplanned fashion necessitating the commencement of dialysis using central venous catheter access. We aimed to investigate if early patient education can help in overcoming these barriers. The study is a survey-based study at King Abdulaziz Medical City, Riyadh Dialysis Center. In January 2017, we started a monthly Chronic Kidney Disease Education Class in our center. Since then, 14 classes have taken place attended by 54 patients referred from outpatient nephrology clinics with chronic kidney disease (CKD) stages IV and V. The mean age was 51.6 years (16–85); 32 of the attendees were male and 22 were female. The class consisted of a slide informative presentation, a display of educational materials, and interactions with a multidisciplinary team from dialysis, transplantation, vascular access, and dietician services. A feedback survey was given to attendees at the conclusion of the class covering three domains; speakers, the program, and their personal reflections. Feedback options were laid out as “excellent, very good, good, fair, and poor.” All class attendees responded to the questionnaire (100% response rate). The overall class evaluation was positive with the majority of attendees giving “excellent” rating for the speakers and the educational materials covered. Most thought that the class made them understand CKD nature better and helped them choose the right modality of renal replacement therapy. This initiative proves the feasibility of a sustained and attendee-gratifying education class to inform patients with advanced CKD about different options of renal replacement therapy and the need for timely preparation. To objectively measure the class’s effect, the next phase of this review will define the ultimate outcome of each of its attendees

Antibody-mediated rejection and aHUS in renal graft recipient

A 46-year-old female who lost her native kidney function due a biopsy proven collapsing type of FSGS, had a living kidney transplant after which, she developed acute renal allograft dysfunction, thrombocytopenia and microangiopathichemolytic anemia five days post-transplant. Renal biopsy revealed acute antibody-mediated rejection (AMR). Genetic studies showed that this patient has a homozygous mutation of complement factor B (CFB) gene and heterozygous variant of C 3 gene consistent with atypical hemolytic uremic syndrome type 4. Intravenous immunoglobulin (IV IG) and plasma exchange did not resolve these abnormalities. Eculizumab and bortezomib, on other hand, were very effective

Scores of awareness and altruism in organ transplantation among Saudi health colleges students-impact of gender, year of study, and field of specialization

This study aimed to evaluate the awareness of organ transplantation and willingness to donate among Saudi Health Colleges students and the impact of gender, year of study, and field of specialization on this. This is a cross-sectional survey-based study. The survey was distributed to all the students attending the annual national conference of Saudi Health Colleges students held in 2018. The survey had two parts. The first part collected the information about gender, university, college of specialization, and year of study. The second part asked 10 questions, seven of which were about the types, causes, treatment of organ failure (awareness questions), and three of which were about their willingness to donate (altruism questions). The participants had three response options: “Yes”, “No” and “I don’t know. Descriptive statistics (mean, standard) and the frequencies were generated for each parameter. Categorical data were compared using Chi-square and continuous data using an independent t-test or paired t-test. A total of 821 respondents completed the questionnaire; 58.1% were female, 41.3% studying medicine, 25.1% applied medical sciences, 12.7% pharmacy, 9.6% dentistry, and 4.5% nursing 4.5%. The overall awareness of the correct responses constituted 60.4% while 12.3 % gave incorrect responses and 27.3% did not know what the answers were. The highest awareness score was about the concept of brain death (86.4%). The overall awareness score was significantly higher than the altruism score (62.7% and 45.7% respectively (P = 0.0001). Female respondents proved more aware than the male respondents in all the questions did. However, the differences reached the significant levels in four of the ten questions. If we split and summate the responses into “awareness” questions and “altruism” questions, we find that, although female students score higher in both categories, this reaches the significant level for the altruism score (59.90% vs. 45.60% (P = 0.0001). Final year students were significantly more aware than the freshmen in seven of the 10 questions posed with the biggest gap seen in the awareness that Islamic Sharia permits donating organs after death (82.3% vs. 49.6% (P = 0.0001). When we compare of responses by the college, we find that significant differences between the College of Medicine students and applied medical sciences in two questions with the former having a higher awareness score. The overall awareness score was significantly higher than the altruism score (62.7% and 45.7% respectively). Female students have higher altruistic score than male students. The scores are significantly higher in the senior students than in the junior ones

Variables affecting darbepoetin resistance index in hemodialysis patients

Erythropoietin resistance index calculation has been used as a tool to evaluate anemia response to erythropoietin therapy. Very little has been reported in its use when using darbepoetin and factors influencing in Arab patients. Darbepoetin resistance index (DRI) was calculated in all our patients using darbepoetin. This was correlated to demographic, clinical, and laboratory parameters. Of the 250 patients, 40.4% were diabetic, 71.1% on hemodialysis, and 28.6% on hemodiafiltration), 23.9% with PermCaths (PC), and 76.1 % with arteriovenous fistula (AVF). The mean DRI was 10.96 ± 12.9 I. Females had 45% higher DRI than males (P = 0.005), and patients with PC had a 66% higher DRI than those with AVF (P = 0.029). Patients with Vitamin D level below the 50th percentile had 55.9% higher DRI than those above it (P = 0.05). DRI was negatively correlated with age (P = 0.018), dialysis vintage (P = 0.039), interdialytic weight gain P = 0.007), Vitamin D level, and serum albumin (P = 0.005) and positively correlate with parathyroid hormone (PTH) level (P = 0.000). No impact was seen by the mode of dialysis, being diabetic, using anti-hypertensive therapy, body mass index, Kt/V, serum iron, total iron binding capacity, transferrin saturation, ferritin, C-reactive protein, Ca, or P. DRI in our Arab patients was comparable to erythropoietin resistance indices reported in other communities. Higher DRI was observed in females, PC users, lower serum albumin, lower Vitamin D, and shorter dialysis vintage. A negative correlation existed between DRI and age, dialysis vintage, interdialytic weight, and serum albumin and a positive correlation with PTH level

Atypical antiglomerular basement membranes disease with nephrotic-range proteinuria, mesangial proliferation, and membranoproliferative glomerulonephritis pattern of injury

Antiglomerular basement membrane (anti-GBM) disease is an uncommon autoimmune disease characterized by the presence of IgG autoantibodies targeting the alpha-3 chain of type IV collagen. Some of the atypical forms of the disease have been described. Herein, we describe a case of atypical anti-GBM in a 27-year-old Saudi male who presented with lower limb edema, gross hematuria, elevated serum creatinine concentration, and nephrotic-range proteinuria. All serology tests were negative, except for anti-GBM which was weakly positive. Renal biopsy showed proliferative glomerulonephritis (GN) with nodular transformation of the glomerular tufts, mesangial hypercellularity (mesangial cell proliferation), segmental endocapillary hypercellularity and three incomplete cellular crescents, and recapitulating membranoproliferative GN pattern of glomerular injury. Direct immunofluorescence microscopy demonstrated diffuse, intense linear positivity for IgG and Kappa and Lambda light chains, and compatible with anti-GBM disease. The patient was treated with cyclophosphamide and corticosteroids in addition to therapeutic plasma exchange which resulted in mild improvement in renal function over a period of six weeks. We emphasize the importance of recognition of atypical pathological and serological patterns of anti-GBM disease, which is crucial for proper and early diagnosis and possibly improved clinical outcome and we highlight the importance of clinicopathological correlation in cases with atypical clinical and pathological presentations