Isolated short stature as a presentation of celiac disease in Saudi children

The aim of this study is to assess the prevalence of isolated short stature as a clinical presentation of celiac disease in Saudi Arab children and whether some of the routine laboratory tests performed to determine the cause of short stature could suggest the diagnosis of celiac disease. A total of 91 children with short stature were included in the study. Extensive endocrine and biochemical assessments, including total protein, serum albumin, calcium phosphate and alkaline phosphatase assays; renal function tests; coagulation profile; anti-endomysial antibodies and anti-tissue transglutaminase antibody, growth hormone, thyroid stimulating hormone, free-thyroxin (FT4) assays; stool tests for giardiasis; bone age; and endoscopic intestinal biopsies, were done for all children. Ten of the 91 children had positive intestinal biopsies in the form of total villous atrophy, an increase in crypt height, and an increase in intra-epithelial lymphocyte (IEL) numbers up to >40 IEL/100 EC (Type 3C) according to the Oberhuber classification, confirming the diagnosis of celiac disease. Five children had mild villous atrophy according to this classification (Type 3A), and they were considered to have potential celiac disease. Seventy-six children had normal intestinal biopsies. Therefore, the prevalence of celiac disease among Saudi children with short stature was 10.9%, and 4.3% of the children were diagnosed as having potential celiac disease. After confirming the diagnosis of celiac disease, all children were kept on a gluten-free diet and all of them showed improvement in their growth rate. We concluded that celiac disease is a very important cause of short stature in children without gastrointestinal complaints in Saudi Arabia. We highly recommend anti-tissue transglutaminase and anti-endomysial antibody screening tests, and a small bowel biopsy to confirm the diagnosis of celiac disease irrespective of the results of the antibody assays, in children with short stature in Saudi Arabia. Once the diagnosis is confirmed, children should be kept on a gluten-free diet so they can catch up their growth early before they develop permanent short stature

Investigating the epidemiology of medication errors in adults using electronic health records in Riyadh, Saudi Arabia

Introduction: The Harvard Medical Practice (Study II) identified medications as the most common source of injury resulting from medical care. The subsequent Institute Of Medicine (IOM; now renamed as the National Academy of Medicine) report “To Err Is Human: Building a Safer Health System” brought considerable national and international attention to the problem of errors in hospitals. Given that medication errors and error-related adverse drug events (ADEs) are overall much more common in ambulatory care, primary care and home (henceforth collectively referred to as community) settings than in hospital settings, it is also important to focus on these hitherto neglected sectors. There is, however, very limited research on the frequency of medication errors and error-related ADEs in Saudi Arabia’s (SA’s) community settings. Aims: To estimate the incidence and prevalence of medication errors and associated ADEs in community settings, and to identify the risk factors for these outcomes, with an emphasis on those that are potentially modifiable. Methods: I have undertaken a phased programme of work. In Phase 1, I undertook a systematic review of the existing research on the epidemiology of medication errors and error-related ADEs, and their risk factors in community settings. Phase 2 was a feasibility study to identify the ambulatory settings and electronic database, evaluate the feasibility of data extraction and data collection from electronic health records (EHRs) and to check the availability and assess the reliability of key outcome measures. Phase 3 was a pilot, retrospective cohort study using clinically important errors in medicine management that were extracted from EHRs. This third phase also focused on assessing the sample size calculations for undertaking a larger cohort study. A random sample of 200 records was selected; a list of all patients who visited the Family Medicine department two weeks before data collection was generated. Each record was given a code number and EHRs were selected using a random number table that was generated using the ‘simple random sample without replacement’ function in STATA. The final study, Phase 4 was a larger retrospective cohort study to estimate the period prevalence of clinically important errors in medicine management, identify risk factors associated with patients at risk of clinically important errors in medicine management and to compare the estimates from this SA-based study with QRESEARCH analysis of secular trends in the United Kingdom (UK). A random sample of 2000 records was selected using a similar process to Phase 3. All research participants were adults aged ≥18 years. Phases 2-4 were based on the methods used by Avery et al. (2012). Phases 3 and 4 were undertaken in randomly selected samples of 200 and 2000 patients, respectively. Statistical analyses in Phases 3 and 4 were undertaken using STATA (version 14) statistical software. Results: For Phase 1, I identified a total of 15,302 potentially eligible studies, of which 60 met the inclusion criteria: 53 studies focused on medication errors, three on error-related adverse events and four on risk factors only. None of these studies was undertaken in SA. The prevalence of prescribing errors was reported in 46 studies with prevalence estimates ranging widely from 2.0-94.0%. Inappropriate prescribing was the most common type of error reported. Only one study reported the prevalence of monitoring errors, finding that incomplete therapeutic/safety laboratory-test monitoring occurred in 73.0% of patients. The incidence of preventable ADEs was estimated as 15/1000 person-years, the prevalence of drug-drug interaction (DDI)-related adverse drug reactions (ADR) as 7.0% and the prevalence of preventable ADE as 0.4%. A number of patients, healthcare professionals and medicationrelated risk factors were identified, including the number of medications used by the patient, increased patient age (≥75 years), the number of multi-morbidities, the use of anticoagulants, cases where more than one physician was involved in patients’ care and care being provided by family physicians/general practitioners (GP). For Phase 2, I selected the EHRs of King Faisal Specialist Hospital & Research Centre (KFSH&RC) Family Medicine and Polyclinics, Riyadh, SA and the findings confirmed that the pilot study was feasible and likely to yield random samples. More specifically, all information needed for the outcome measures were available in one electronic system and were useable in Phases 3 and 4. In Phase 3, a random sample of 200 records was selected. The overall period prevalence of patients with at least one medication error over 15 months was 10.0% (95% confidence interval (CI) 5.8 to 14.2). The overall period prevalence of medication errors over 15 months was 16.0% (95% CI 8.2 to 23.8). Risk factors that significantly predicted the overall patients at risk of medication errors were patient’s age of ≥65 years and using over-the-counter (OTC) medications. In Phase 4, a random sample of 2000 records was selected using a similar process to Phase 3. The overall period prevalence of patients with at least one medication error over 15 months was 5.85% (95% CI 4.8 to 6.9). The overall period prevalence of medication errors over 15 months was 8.1% (95% CI 6.5 to 9.7). The overall period prevalence estimate of the first 12 clinically important errors in medicine management in the cohort study was more compared to the QRESEARCH analysis of secular trends. This may reflect the different types of healthcare services provided and the different methods of data extraction between both countries. Risk factors that significantly predicted the overall patients at risk of errors were patient’s age of ≥65 years, male gender, Saudi nationality and taking five or more concurrent drugs (polypharmacy). In both Phases 3 and 4, the highest risk of prescribing errors was found to be for ‘Outcome 2a: patients with asthma who had been prescribed a β-blocker’. For monitoring errors, the highest risk was in ‘Outcome 7: patients receiving lithium for at least three months who had not received a recorded check of their lithium concentrations in the previous three months’. Conclusions: This is the first study to investigate medication errors in community settings in SA. This research has revealed that clinically important medication errors are common with a period prevalence estimate of 8.1% and are seen both in relation to the prescribing and monitoring of drugs. Future research should replicate this work in different community contexts in SA and other countries, in order to investigate in greater depth the error-related adverse events and develop and evaluate interventions to decrease clinically important errors in medicine management

Investigating the epidemiology of medication errors and error-related adverse drug events (ADEs) in primary care, ambulatory care and home settings:a systematic review protocol

INTRODUCTION: There is a need to better understand the epidemiology of medication errors and error-related adverse events in community care contexts. METHODS AND ANALYSIS: We will systematically search the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Eastern Mediterranean Regional Office of the WHO (EMRO), MEDLINE, PsycINFO and Web of Science. In addition, we will search Google Scholar and contact an international panel of experts to search for unpublished and in progress work. The searches will cover the time period January 1990–December 2015 and will yield data on the incidence or prevalence of and risk factors for medication errors and error-related adverse drug events in adults living in community settings (ie, primary care, ambulatory and home). Study quality will be assessed using the Critical Appraisal Skills Program quality assessment tool for cohort and case–control studies, and cross-sectional studies will be assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Descriptive Studies. Meta-analyses will be undertaken using random-effects modelling using STATA (V.14) statistical software. ETHICS AND DISSEMINATION: This protocol will be registered with PROSPERO, an international prospective register of systematic reviews, and the systematic review will be reported in the peer-reviewed literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Anti-hyperlipidemic effects of Caralluma edulis (Asclepiadaceae) and Verbena officinalis (Verbenaceae) whole plants against high-fat diet-induced hyperlipidemia in mice

Purpose: To investigate the anti-hyperlipidemic effect of Caralluma edulis and  Verbena officinalis.Methods: Phytochemical analysis of crude extracts of Caralluma edulis (Ce.Cr) and Verbena officinalis (Vo.Cr) were carried out. Hyperlipidemia was induced in mice with high-fat diet (HFD, 1.25 % w/w cholesterol, 0.5 % w/w cholic acid and 10 % v/w coconut oil). All the groups, except the saline-treated group, were fed on HFD for 4 weeks (lead-in period) to induce hyperlipidemia. Thereafter, the groups were treated with varying doses of the plant extract for 2 weeks (treatment period) as well as atorvastatin (10 mg/kg) reference standard. Body weight was measured fortnightly for all groups. Total cholesterol (TC), triglyceride (TGs) and low density lipoprotein (LDL) were assayed using Merck diagnostic kits. For histopathological analysis, liver slices were fixed in 10 % formalin and embedded in paraffin wax and was examined with the aid of hematoxylin and eosin staining (H & E).Results: Caralluma edulis (Ce.Cr) contains saponins, alkaloids, tannins, phenol, glycosides, terpenoids and flavonoids while Verbena officinalis (Vo.Cr) tested  positive for the presence of alkaloids, carbohydrates, flavonoids, saponins and tannins. HFD increased total cholesterol (TC), triglyceride (TGs), low density  lipoprotein (LDL) and very low density lipoprotein (VLDL) compared to regulator diet (p < 0.001). Treatment of the animals with Ce.Cr and Vo.Cr dose-dependently (500 - 1000 mg/kg) reduced serum TC, TGs, LDL and VLDL (p < 0.05, p < 0.01, p < 0.001, vs. HFD group) and raised high density lipoprotein (HDL) (p < 0.01, vs. HFD group), similar to that observed with atorvastatin (10 mg/kg). The  anti-hyperlipidemic effects of Ce.Cr and Vo.Cr were also confirmed via liver  histopathology results, showing improved structure with no hepatocellular necrosis and fat accumulation.Conclusion: These results indicate that Caralluma edulis and Verbena officinalis  exhibit antihyperlipidemic effect; thus, the plants have therapeutic potentials for the management of lipid disorders.Keywords: Caralluma edulis, Verbena officinalis, Anti-hyperlipidemia,   Hepatocellular necrosi

Fungal dysbiosis predicts the diagnosis of pediatric Crohn's disease

AIM: To investigate the accuracy of fungal dysbiosis in mucosa and stool for predicting the diagnosis of Crohn’s disease (CD). METHODS: Children were prospectively enrolled in two medical centers: one university hospital and one private gastroenterology clinic in the city of Riyadh, Kingdom of Saudi Arabia. The children with confirmed diagnosis of CD by standard guidelines were considered cases, and the others were considered non-inflammatory bowel disease controls. Mucosal and stool samples were sequenced utilizing Illumina MiSeq chemistry following the manufacturer’s protocols, and abundance and diversity of fungal taxa in mucosa and stool were analyzed. Sparse logistic regression was used to predict the diagnosis of CD. The accuracy of the classifier was tested by computing the receiver operating characteristic curves with 5-fold stratified cross-validation under 100 permutations of the training data partition and the mean area under the curve (AUC) was calculated. RESULTS: All the children were Saudi nationals. There were 15 children with CD and 20 controls. The mean age was 13.9 (range: 6.7-17.8) years for CD children and 13.9 (3.25-18.6) years for controls, and 10/15 (67%) of the CD and 13/20 (65%) of the control subjects were boys. CD locations at diagnosis were ileal (L1) in 4 and colonic (L3) in 11 children, while CD behavior was non-stricturing and non-penetrating (B1) in 12 and stricturing (B2) in 3 children. The mean AUC for the fungal dysbiosis classifier was significantly higher in stools (AUC = 0.85 ± 0.057) than in mucosa (AUC = 0.71 ± 0.067) (P < 0.001). Most fungal species were significantly more depleted in stools than mucosal samples, except for Saccharomyces cerevisiae and S. bayanus, which were significantly more abundant. Diversity was significantly more reduced in stools than in mucosa. CONCLUSION: We found high AUC of fungal dysbiosis in fecal samples of children with CD, suggesting high accuracy in predicting diagnosis of CD. Key Words: Fungiome, Mycobiome, Crohn’s disease, Inflammation, Saudi children Core tip: We found high accuracy of fungal dysbiosis in predicting diagnosis of Crohn’s disease (CD), a finding similar to bacterial dysbiosis. However, the higher area under the curve for the fungal dysbiosis classifier in stool (0.85 ± 0.057) than in mucosa (0.71 ± 0.067) (P < 0.001), contrasts with bacterial studies, suggesting higher accuracy of stool samples. Although the clinical application of this finding is limited at present by the high cost of fungal analysis, such information is important from a scientific viewpoint, to increase the understanding of the role of fungal flora in CD and to stimulate further studies.The authors extend their appreciations to the Deanship of Scientific Research at King Saud University in Riyadh, Kingdom of Saudi Arabia for funding this work through Research Group No [RGP-1436-007]. This work was also supported by a grant from the Simons Foundation [No. 409704] to Kirill Korolev) and by the startup fund from Boston University to Kirill Korolev. Simulations were carried out on Shared Computing Cluster at Boston University. Rajita Menon was partially supported by a Hariri Graduate Fellowship from Boston University. Harland Winter, MD received support from Martin Schlaff and the Diane and Dorothy Brooks Foundation. (RGP-1436-007 - King Saud University in Riyadh, Kingdom of Saudi Arabia; 409704 - Simons Foundation; Boston University; Hariri Graduate Fellowship from Boston University; Diane and Dorothy Brooks Foundation)Published versio

disease in Saudi children

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The Prevalence of High-Risk Prescribing of Oral Non-Steroidal Anti-Inflammatory Drugs in Primary Healthcare: A Single-Centre Retrospective Chart Review Study

The quality and safety of prescribed drugs can be assessed using prescribing safety indicators (PSIs). This study aimed to estimate the prevalence of PSIs of oral non-steroidal anti-inflammatory drugs (NSAIDs) at primary care clinics of a tertiary care hospital in Saudi Arabia and to identify the risk factors associated with positive PSIs for patients. In this retrospective chart review study, data from the medical records of 450 patients aged ≥18 years, who were prescribed oral NSAIDs, were reviewed and collected manually. Seven PSIs were chosen and defined as follows: prescription of an oral NSAID to any patient with a peptic ulcer; aged ≥75 years; aged ≥65 years with a glomerular filtration rate p-value p-value 0.022, respectively). Patients at risk of harm from high-risk NSAID prescriptions are common in primary care. The elderly and patients on polypharmacy are at increased risk of having at least one positive PSI. Therefore, when NSAIDs are prescribed, it is recommended to weigh the benefits versus the risks for high-risk patients, such as the elderly and those with multiple-drug therapy