Uncovering myocardial infarction genetic signatures using GWAS exploration in Saudi and European cohorts

Genome-wide association studies (GWAS) have yielded significant insights into the genetic architecture of myocardial infarction (MI), although studies in non-European populations are still lacking. Saudi Arabian cohorts offer an opportunity to discover novel genetic variants impacting disease risk due to a high rate of consanguinity. Genome-wide genotyping (GWG), imputation and GWAS followed by meta-analysis were performed based on two independent Saudi Arabian studies comprising 3950 MI patients and 2324 non-MI controls. Meta-analyses were then performed with these two Saudi MI studies and the CardioGRAMplusC4D and UK BioBank GWAS as controls. Meta-analyses of the two Saudi MI studies resulted in 17 SNPs with genome-wide significance. Meta-analyses of all 4 studies revealed 66 loci with genome-wide significance levels of p < 5 × 10-8. All of these variants, except rs2764203, have previously been reported as MI-associated loci or to have high linkage disequilibrium with known loci. One SNP association in Shisa family member 5 (SHISA5) (rs11707229) was evident at a much higher frequency in the Saudi MI populations (> 12% MAF). In conclusion, our results replicated many MI associations, whereas in Saudi-only GWAS (meta-analyses), several new loci were implicated that require future validation and functional analyses.

Gut microbiota analyses of Saudi populations for type 2 diabetes-related phenotypes reveals significant association

BACKGROUND

Large-scale gut microbiome sequencing has revealed key links between microbiome dysfunction and metabolic diseases such as type 2 diabetes (T2D). To date, these efforts have largely focused on Western populations, with few studies assessing T2D microbiota associations in Middle Eastern communities where T2D prevalence is now over 20%. We analyzed the composition of stool 16S rRNA from 461 T2D and 119 non-T2D participants from the Eastern Province of Saudi Arabia. We quantified the abundance of microbial communities to examine any significant differences between subpopulations of samples based on diabetes status and glucose level.

RESULTS

In this study we performed the largest microbiome study ever conducted in Saudi Arabia, as well as the first-ever characterization of gut microbiota T2D versus non-T2D in this population. We observed overall positive enrichment within diabetics compared to healthy individuals and amongst diabetic participants; those with high glucose levels exhibited slightly more positive enrichment compared to those at lower risk of fasting hyperglycemia. In particular, the genus Firmicutes was upregulated in diabetic individuals compared to non-diabetic individuals, and T2D was associated with an elevated Firmicutes/Bacteroidetes ratio, consistent with previous findings.

CONCLUSION

Based on diabetes status and glucose levels of Saudi participants, relatively stable differences in stool composition were perceived by differential abundance and alpha diversity measures. However, community level differences are evident in the Saudi population between T2D and non-T2D individuals, and diversity patterns appear to vary from well-characterized microbiota from Western cohorts. Comparing overlapping and varying patterns in gut microbiota with other studies is critical to assessing novel treatment options in light of a rapidly growing T2D health epidemic in the region. As a rapidly emerging chronic condition in Saudi Arabia and the Middle East, T2D burdens have grown more quickly and affect larger proportions of the population than any other global region, making a regional reference T2D-microbiome dataset critical to understanding the nuances of disease development on a global scale.

Clinical presentation, disease course, and outcome of COVID-19 in hospitalized patients with and without pre-existing cardiac disease: a cohort study across 18 countries

AIMS

Patients with cardiac disease are considered high risk for poor outcomes following hospitalization with COVID-19. The primary aim of this study was to evaluate heterogeneity in associations between various heart disease subtypes and in-hospital mortality.

METHODS AND RESULTS

We used data from the CAPACITY-COVID registry and LEOSS study. Multivariable Poisson regression models were fitted to assess the association between different types of pre-existing heart disease and in-hospital mortality. A total of 16 511 patients with COVID-19 were included (21.1% aged 66-75 years; 40.2% female) and 31.5% had a history of heart disease. Patients with heart disease were older, predominantly male, and often had other comorbid conditions when compared with those without. Mortality was higher in patients with cardiac disease (29.7%; n = 1545 vs. 15.9%; n = 1797). However, following multivariable adjustment, this difference was not significant [adjusted risk ratio (aRR) 1.08, 95% confidence interval (CI) 1.02-1.15; P = 0.12 (corrected for multiple testing)]. Associations with in-hospital mortality by heart disease subtypes differed considerably, with the strongest association for heart failure (aRR 1.19, 95% CI 1.10-1.30; P < 0.018) particularly for severe (New York Heart Association class III/IV) heart failure (aRR 1.41, 95% CI 1.20-1.64; P < 0.018). None of the other heart disease subtypes, including ischaemic heart disease, remained significant after multivariable adjustment. Serious cardiac complications were diagnosed in <1% of patients.

CONCLUSION

Considerable heterogeneity exists in the strength of association between heart disease subtypes and in-hospital mortality. Of all patients with heart disease, those with heart failure are at greatest risk of death when hospitalized with COVID-19. Serious cardiac complications are rare during hospitalization.

Bedside testing of CYP2C19 vs. conventional clopidogrel treatment to guide antiplatelet therapy in ST-segment elevation myocardial infarction patients

BACKGROUND

ST-segment elevation myocardial infarction (STEMI) patients are treated with dual antiplatelet therapy comprising aspirin and a P2Y₁₂ inhibitor. Clopidogrel is widely used in these patients in several areas worldwide, such as Middle East, but is associated to sub-optimal platelet inhibition in up to 1/3 of treated patients. We investigated a CYP2C19 genotype-guided strategy to select the optimal P2Y₁₂ inhibitor.

METHODS

This prospective randomized clinical trial included STEMI patients. The standard-treatment group received clopidogrel, while the genotype-guided group were genotyped for CYP2C19 loss-of-function alleles and carriers were prescribed ticagrelor and noncarriers were prescribed clopidogrel. Primary outcome was a combined ischemic and bleeding outcome, comprising myocardial infarction, non-fatal stroke, cardiovascular death, or Platelet Inhibition and Patient Outcomes major bleeding one year after STEMI.

RESULTS

STEMI patients (755) were randomized into a genotype-guided- (383) and standard-treatment group (372). In the genotype-guided group, 31 patients carrying a loss-of-function allele were treated with ticagrelor, while all other patients in both groups were treated with clopidogrel. Patients in the genotype-guided group had a significantly lower risk of primary outcome (odds ratio (OR) 0.34, 95% confidence interval (CI) 0.20-0.59,), recurrent myocardial infarction (OR 0.25, 95%CI 0.11-0.53), cardiovascular death (OR 0.16, 95%CI0.06-0.42) and major bleeding (OR 0.49, 95%CI 0.32-0.74). There was no significant difference in the rate of stent thrombosis (OR 0.85, 95%CI 0.43-1.71).

CONCLUSION

A genotype-guided escalation of P2Y12 inhibitor strategy is feasible in STEMI patients treated with clopidogrel and undergoing PCI and is associated with a reduction of primary outcomes compared to conventional antiplatelet therapy.

Prevalence of CYP2C19*2 carriers in Saudi ischemic stroke patients and the suitability of using genotyping to guide antiplatelet therapy in a university hospital setup

OBJECTIVES

To mitigate the incidence of recurrent stroke in patients, dual antiplatelet therapy comprising aspirin and clopidogrel is usually administered. Clopidogrel is a prodrug and its bioactivation is catalyzed by cytochrome P450 (CYP)2C19. The main objective of this work was to determine the prevalence of CYP2C19*2 carriers in Saudi ischemic stroke patients and assess the suitability of using genotyping to guide antiplatelet therapy in a university hospital setup.

METHODS

This prospective (2018-2019) study was conducted on 256 patients (age 61 ± 12.5) clinically diagnosed with ischemic stroke who were genotyped using Spartan RX CYP2C19 assay.

RESULTS

From the total patient group (256), upon admission, 210 patients were prescribed either aspirin, clopidogrel or dual antiplatelet therapy. Of the 27 patients with the CYP2C19*2 allele who were prescribed clopidogrel (18) or dual antiplatelet therapy (9), only 21 patients could be followed up for a period of six months post stroke event, in addition to 21 age- and sex-matched patients with the normal allele. The CYP2C19*2 allele carriers had a statistically significant increased risk of recurrent stroke compared to patients carrying the normal allele.

CONCLUSIONS

This study shows the suitability of using genotyping to guide antiplatelet therapy in ischemic stroke patients in a clinical setting.

Prevalence of CYP2C19*2 carriers in Saudi ischemic stroke patients and the suitability of using genotyping to guide antiplatelet therapy in a university hospital setup

OBJECTIVES

To mitigate the incidence of recurrent stroke in patients, dual antiplatelet therapy comprising aspirin and clopidogrel is usually administered. Clopidogrel is a prodrug and its bioactivation is catalyzed by cytochrome P450 (CYP)2C19. The main objective of this work was to determine the prevalence of CYP2C19*2 carriers in Saudi ischemic stroke patients and assess the suitability of using genotyping to guide antiplatelet therapy in a university hospital setup.

METHODS

This prospective (2018-2019) study was conducted on 256 patients (age 61 ± 12.5) clinically diagnosed with ischemic stroke who were genotyped using Spartan RX CYP2C19 assay.

RESULTS

From the total patient group (256), upon admission, 210 patients were prescribed either aspirin, clopidogrel or dual antiplatelet therapy. Of the 27 patients with the CYP2C19*2 allele who were prescribed clopidogrel (18) or dual antiplatelet therapy (9), only 21 patients could be followed up for a period of six months post stroke event, in addition to 21 age- and sex-matched patients with the normal allele. The CYP2C19*2 allele carriers had a statistically significant increased risk of recurrent stroke compared to patients carrying the normal allele.

CONCLUSIONS

This study shows the suitability of using genotyping to guide antiplatelet therapy in ischemic stroke patients in a clinical setting.

Evaluating the molecular diagnostic yield of joint genotyping-based approach for detecting rare germline pathogenic and putative loss-of-function variants

PURPOSE

Cohort-based germline variant characterization is the standard approach for pathogenic variant discovery in clinical and research samples. However, the impact of cohort size on the molecular diagnostic yield of joint genotyping is largely unknown.

METHODS

Head-to-head comparison of the molecular diagnostic yield of joint genotyping in two cohorts of 239 cancer patients in the absence and then in the presence of 100 additional germline exomes.

RESULTS

In 239 testicular cancer patients, 4 (7.4%, 95% confidence interval [CI]: 2.1-17.9) of 54 pathogenic variants in the cancer predisposition and American College of Medical Genetics and Genomics (ACMG) genes were missed by one or both computational runs of joint genotyping. Similarly, 8 (12.1%, 95% CI: 5.4-22.5) of 66 pathogenic variants in these genes were undetected by joint genotyping in another independent cohort of 239 breast cancer patients. An exome-wide analysis of putative loss-of-function (pLOF) variants in the testicular cancer cohort showed that 162 (8.2%, 95% CI: 7.1-9.6) pLOF variants were only detected in one analysis run but not the other, while 433 (22.0%, 95% CI: 20.2-23.9%) pLOF variants were filtered out by both analyses despite having sufficient sequencing coverage.

CONCLUSION

Our analysis of the standard germline variant detection method highlighted a substantial impact of concurrently analyzing additional genomic data sets on the ability to detect clinically relevant germline pathogenic variants.

Detection of Pathogenic Variants With Germline Genetic Testing Using Deep Learning vs Standard Methods in Patients With Prostate Cancer and Melanoma

Importance

Less than 10% of patients with cancer have detectable pathogenic germline alterations, which may be partially due to incomplete pathogenic variant detection.

Objective

To evaluate if deep learning approaches identify more germline pathogenic variants in patients with cancer.

Design, Setting, and Participants

A cross-sectional study of a standard germline detection method and a deep learning method in 2 convenience cohorts with prostate cancer and melanoma enrolled in the US and Europe between 2010 and 2017. The final date of clinical data collection was December 2017.

Exposures

Germline variant detection using standard or deep learning methods.

Main Outcomes and Measures

The primary outcomes included pathogenic variant detection performance in 118 cancer-predisposition genes estimated as sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). The secondary outcomes were pathogenic variant detection performance in 59 genes deemed actionable by the American College of Medical Genetics and Genomics (ACMG) and 5197 clinically relevant mendelian genes. True sensitivity and true specificity could not be calculated due to lack of a criterion reference standard, but were estimated as the proportion of true-positive variants and true-negative variants, respectively, identified by each method in a reference variant set that consisted of all variants judged to be valid from either approach.

Results

The prostate cancer cohort included 1072 men (mean [SD] age at diagnosis, 63.7 [7.9] years; 857 [79.9%] with European ancestry) and the melanoma cohort included 1295 patients (mean [SD] age at diagnosis, 59.8 [15.6] years; 488 [37.7%] women; 1060 [81.9%] with European ancestry). The deep learning method identified more patients with pathogenic variants in cancer-predisposition genes than the standard method (prostate cancer: 198 vs 182; melanoma: 93 vs 74); sensitivity (prostate cancer: 94.7% vs 87.1% [difference, 7.6%; 95% CI, 2.2% to 13.1%]; melanoma: 74.4% vs 59.2% [difference, 15.2%; 95% CI, 3.7% to 26.7%]), specificity (prostate cancer: 64.0% vs 36.0% [difference, 28.0%; 95% CI, 1.4% to 54.6%]; melanoma: 63.4% vs 36.6% [difference, 26.8%; 95% CI, 17.6% to 35.9%]), PPV (prostate cancer: 95.7% vs 91.9% [difference, 3.8%; 95% CI, -1.0% to 8.4%]; melanoma: 54.4% vs 35.4% [difference, 19.0%; 95% CI, 9.1% to 28.9%]), and NPV (prostate cancer: 59.3% vs 25.0% [difference, 34.3%; 95% CI, 10.9% to 57.6%]; melanoma: 80.8% vs 60.5% [difference, 20.3%; 95% CI, 10.0% to 30.7%]). For the ACMG genes, the sensitivity of the 2 methods was not significantly different in the prostate cancer cohort (94.9% vs 90.6% [difference, 4.3%; 95% CI, -2.3% to 10.9%]), but the deep learning method had a higher sensitivity in the melanoma cohort (71.6% vs 53.7% [difference, 17.9%; 95% CI, 1.82% to 34.0%]). The deep learning method had higher sensitivity in the mendelian genes (prostate cancer: 99.7% vs 95.1% [difference, 4.6%; 95% CI, 3.0% to 6.3%]; melanoma: 91.7% vs 86.2% [difference, 5.5%; 95% CI, 2.2% to 8.8%]).

Conclusions and Relevance

Among a convenience sample of 2 independent cohorts of patients with prostate cancer and melanoma, germline genetic testing using deep learning, compared with the current standard genetic testing method, was associated with higher sensitivity and specificity for detection of pathogenic variants. Further research is needed to understand the relevance of these findings with regard to clinical outcomes.

Bedside testing of CYP2C19 gene for treatment of patients with PCI with antiplatelet therapy

Background

To mitigate the risk of stent thrombosis, patients treated by percutaneous coronary intervention (PCI) are administered dual anti-platelet therapy comprising aspirin and a platelet P2Y₁₂ receptor inhibitor. Clopidogrel is a prodrug requiring activation by the cytochrome P450 enzyme, CYP2C19. In Saudi Arabia, it has been reported that approximately 26% of the population carries CYP2C19*2 and/or *3 loss-of-function polymorphisms in addition to a high prevalence of CVD.

Methods

This prospective (April 2013–December 2020) parallel assignment clinical trial focuses on ST-Elevation Myocardial Infarction (STEMI) patient outcomes. The clinical trial includes 1500 STEMI patients from two hospitals in the Eastern Province of Saudi Arabia. Patients are assigned to one of two groups; the control arm receives conventional therapy with clopidogrel, while in the active arm the Spartan RX CYP2C19 assay is used to determine the *2 genotype. Carriers of a CYP2C19*2 loss-of-function allele receive prasugrel or ticagrelor, while non-carriers are treated with clopidogrel. Follow-up is one year after primary PCI. The primary end point is the number of patients who develop an adverse major cardiovascular event, including recurrent MI, non-fatal stroke, cardiovascular death, or major bleeding one year after PCI.

Discussion

The risk of stent thrombosis in PCI patients is usually reduced by dual anti-platelet therapy, comprising aspirin and a P2Y12 inhibitor, such as clopidogrel. However, clopidogrel requires activation by the cytochrome P450 enzyme, CYP2C19. Approximately 20% of the population are unable to activate clopidogrel as they possess the CYP2C19*2 loss-of function (LoF) allele. The primary goal of this trial is to study the benefits of treating only those patients that cannot activate clopidogrel with an alternative that has shown to be a more effective platelet inhibitor and does not require bioactivation by the cytochrome P450 enzyme. We expect an improvement in net clinical benefit outcome in the active arm patients, thus supporting pharmacogenetic testing in PCI patients post STEMI.

Trial registration

Trial registration name is “Bedside Testing of CYP2C19 Gene for Treatment of Patients with PCI with Antiplatelet Therapy” (number NCT01823185) retrospectively registered with clinicaltrials.gov on April 4, 2013. This trial is currently at the patient recruitment stage.

Exome sequencing of Saudi Arabian patients with ADPKD

Purpose: Autosomal dominant polycystic kidney disease (ADPKD) is characterized by progressive development of kidney cysts and enlargement and dysfunction of the kidneys. The Consortium of Radiologic Imaging Studies of the Polycystic Kidney Disease (CRISP) cohort revealed that 89.1% had either a PKD1 or PKD2 mutation. Of the CRISP patients with a genetic cause detected, mutations in PKD1 accounted for 85%, while mutations in the PKD2 accounted for the remaining 15%. Here, we report exome sequencing of 16 Saudi patients diagnosed with ADPKD and 16 ethnically matched controls.

Methods: Exome sequencing was performed using combinatorial probe-anchor synthesis and improved DNA Nanoballs technology on BGISEQ-500 sequencers (BGI, China) using the BGI Exome V4 (59 Mb) Kit. Identified variants were validated with Sanger sequencing.

Results: With the exception of GC-rich exon 1, we obtained excellent coverage of PKD1 (mean read depth = 88) including both duplicated and non-duplicated regions. Of nine patients with typical ADPKD presentations (bilateral symmetrical kidney involvement, positive family history, concordant imaging, and kidney function), four had protein truncating PKD1 mutations, one had a PKD1 missense mutation, and one had a PKD2 mutation. These variants have not been previously observed in the Saudi population. In seven clinically diagnosed ADPKD cases but with atypical features, no PKD1 or PKD2 mutations were identified, but rare predicted pathogenic heterozygous variants were found in cystogenic candidate genes including PKHD1, PKD1L3, EGF, CFTR, and TSC2.

Conclusions: Mutations in PKD1 and PKD2 are the most common cause of ADPKD in Saudi patients with typical ADPKD.

Abbreviations: ADPKD: Autosomal dominant polycystic kidney disease; CFTR: Cystic fibrosis transmembrane conductance regulator; EGF: Epidermal growth factor; MCIC: Mayo Clinic Imaging Classification; PKD: Polycystic kidney disease; TSC2: Tuberous sclerosis complex 2

BCL11A enhancer haplotypes and fetal hemoglobin in sickle cell anemia

BACKGROUND

Fetal hemoglobin (HbF) levels in sickle cell anemia patients vary. We genotyped polymorphisms in the erythroid-specific enhancer of BCL11A to see if they might account for the very high HbF associated with the Arab-Indian (AI) haplotype and Benin haplotype of sickle cell anemia.

METHODS AND RESULTS

Six BCL112A enhancer SNPs and their haplotypes were studied in Saudi Arabs from the Eastern Province and Indian patients with AI haplotype (HbF ~20%), African Americans (HbF ~7%), and Saudi Arabs from the Southwestern Province (HbF ~12%). Four SNPs (rs1427407, rs6706648, rs6738440, and rs7606173) and their haplotypes were consistently associated with HbF levels. The distributions of haplotypes differ in the 3 cohorts but not their genetic effects: the haplotype TCAG was associated with the lowest HbF level and the haplotype GTAC was associated with the highest HbF level and differences in HbF levels between carriers of these haplotypes in all cohorts were approximately 6%.

CONCLUSIONS

Common HbF BCL11A enhancer haplotypes in patients with African origin and AI sickle cell anemia have similar effects on HbF but they do not explain their differences in HbF.

Lack of MERS coronavirus neutralizing antibodies in humans, eastern province, Saudi Arabia

We used a lentiviral vector bearing the viral spike protein to detect neutralizing antibodies against Middle East respiratory syndrome coronavirus (MERS-CoV) in persons from the Eastern Province of Saudi Arabia. None of the 268 samples tested displayed neutralizing activity, which suggests that MERS-CoV infections in humans are infrequent in this province.

Association of beta(2)-adrenergic receptor gene polymorphisms and nocturnal asthma in Saudi patients

BACKGROUND AND OBJECTIVES:

Two polymorphisms of beta₂-adrenergic receptor (β₂-AR) gene, namely the substitution from arginine (Arg) to glycine (Gly) at codon 16 and from glutamine (Gln) to glutamic (Glu) at codon 27, are linked with functional changes in the β₂-AR in the respiratory system even though they are not deemed to be susceptibility genes for asthma per se. The objective of this study was to investigate this association in a subset of asthmatic patients, namely those with nocturnal asthma.

METHODS:

The β₂-AR gene polymorphisms at codon 16 and 27 were assessed in 40 patients clinically diagnosed with nocturnal asthma and 96 normal controls. Genomic DNA was obtained from whole blood and genotyping was carried out by a PCR based restriction fragment length polymorphism technique.

RESULTS:

There was a statistically significant difference in genotype frequencies at codon 16 (Arg/Gly) between nocturnal asthmatic patients and normal control subjects (P < 0.05). However, there was no statistically significant difference in allele frequencies between the two groups. In addition, there was a significant association between Arg16-Gly genotype with nocturnal asthma compared to homozygous Gly16 (codominant model P = 0.0033, OR = 3.69: 95% CI: 1.49-9.12). However, there were no statistically significant differences in genotype and allele frequencies at codon 27 (Gln/Glu) between the normal control and nocturnal asthmatic groups (χ² = 1.81, P = 0.41). The results also indicate that linkage disequilibrium existed between the β₂-AR codon 16 and β₂-AR codon 27 polymorphism (|D´| = 0.577). The data for all haplotypes did not show a statistically significant association.

CONCLUSION:

We present the genotype and allele frequencies of β₂-AR gene polymorphisms in normal Saudi subjects and nocturnal asthmatic patients. There was a significant difference in genotype frequencies at codon 16 (Arg/Gly). However, our study indicates a poor association of individual single nuceotide polymorphisms with nocturnal asthma.

Developing questionnaires for students' evaluation of individual faculty's teaching skills: A Saudi Arabian pilot study

Background:

The National Commission for Academic Accreditation and Assessment is responsible for the academic accreditation of universities in the Kingdom of Saudi Arabia (KSA). Requirements for this include evaluation of teaching effectiveness, evidence-based conclusions, and external benchmarks.

Aims:

To develop a questionnaire for students’ evaluation of the teaching skills of individual instructors and provide a tool for benchmarking.

Setting:

College of Nursing, University of Dammam [UoD], May-June 2009.

Materials and Methods:

The original questionnaire was “Monash Questionnaire Series on Teaching (MonQueST) - Clinical Nursing. The UoD modification retained four areas and seven responses, but reduced items from 26 to 20. Outcome measures were factor analysis and Cronbach’s alpha coefficient.

Results:

Seven Nursing courses were studied, viz.: Fundamentals, Medical, Surgical, Psychiatric and Mental Health, Obstetrics and Gynecology, Pediatrics, and Family and Community Health. Total number of students was 74; missing data ranged from 5 to 27%. The explained variance ranged from 66.9% to 78.7%. The observed Cornbach’s α coefficients ranged from 0.78 to 0.93, indicating an exceptionally high reliability. The students in the study were found to be fair and frank in their evaluation.

Academic job satisfaction questionnaire: Construction and validation in Saudi Arabia

Background:

Colleges and universities are becoming increasingly accountable for teaching outcomes in order to meet rigorous accreditation standards. Job satisfaction (JS) seems more difficult to measure in the academic field in view of the complexity of roles, duties and responsibilities.

Objectives:

To compile and determine the psychometric properties of a proposed Academic Job Satisfaction Questionnaire (AJSQ) suitable for university faculty, and amenable to future upgrading.

Materials and Methods:

A 46-item five-option Likert-type draft questionnaire on JS was distributed for anonymous self-reporting by all the academic staff of five colleges in University of Dammam (n=340). The outcome measures were (1) factor analysis of the questionnaire items, (2) intra-factor α-Coefficient of Internal Consistency Reliability, (3) inter-factor correlations, (4) comparison of psychometric properties in separately analyzed main faculty subgroups.

Results:

The response rate was 72.9 percent. Factor analysis extracted eight factors which conjointly explained 60.3 percent of the variance in JS. These factors, in descending order of eigenvalue, were labeled “Authority”, “Supervision”, “Policies and Facilities”, “My Work Itself”, “Interpersonal Relationships”, “Commitment”, “Salary” and “Workload”. Cronbach's-α ranged from 0.90 in Supervision to 0.63 in Salary and Workload. All inter-factor correlations were positive and significant, ranging from 0.65 to 0.23. The psychometric properties of the instrument in separately analyzed subgroups divided by sex, nationality, college and clinical duties produced fairly comparable findings.

Conclusion:

The AJSQ demonstrated good overall psychometric properties in terms of construct validity and internal consistency reliability in both the overall sample and its separately analyzed subgroups. Recommendation: To replicate these findings in larger multicenter samples of academic staff.

Medical students' perception of professionalism: a qualitative study from Saudi Arabia

BACKGROUND

Professionalism has emerged as a core competency for the medical professionals globally. However, few studies have been reported from the Gulf region to assess the situation and take steps to promote professionalism.

AIM

To elicit the views of final year medical students, interns, and residents to explore what professionalism meant to them, what problems they encountered, and what can be done to promote professionalism.

METHOD

We adopted qualitative approach including 10 focus group discussions. The proceedings were tape-recorded, transcribed, and analyzed independently by two researchers.

RESULTS

The respondents admitted that that they were deficient in the acquisition of professional values. According to them, professionalism was not taught or assessed. They followed "hidden curriculum". They considered very few teachers as positive role models. The deficiencies could be attributed to negative role modeling by the faculty or deficiencies in the curriculum such as lack of rich clinical experiences, limited interaction with health team, and absence of feedback besides organizational issues.

CONCLUSION

The students' views should be tallied with other sources of evidences. Nevertheless, they have policy implications on faculty recruitment, development, curriculum reform, and an organizational culture that supports professionalism.

Osteoarticular tuberculosis: how often is it missed?

This study was carried out to analyze the clinical presentations and outcomes of osteoarticular tuberculosis (OAT) at a university hospital in AlKhobar, Saudi Arabia. A prospective observational study was carried out between 1 January 1998 and 31 December 2007. Patients demographic characteristics were recorded, including age, gender, nationality, clinical manifestation, delay in diagnosis, laboratory results, findings on imaging studies, histological and bacteriological studies of biopsy specimens, treatment modalities, surgical interventions and final outcomes. Fifty-two patients were diagnosed with OAT during the study period. The majority were males (64%), about half were below age 30 years. The mean age at diagnosis was 33 years. There were 32 Saudis (64%), and 18 non-Saudis (36%). Pyrexia, loss of appetite and night sweats were the presenting symptoms in 44, 38 and 36%, respectively. The average time from onset of symptoms to diagnosis was 185 days (7-730 days). On admission, the average erythrocyte sedimentation rate (ESR) was 68 mm/h (4-142). A Mantoux test was performed, in 48 patients the results were positive. The vertebral column was the site of infection in 88% of patients. All patients were managed with standard antituberculous therapy. Forty-two patients (84%) had a favorable outcome.

Thunderstorm-associated bronchial asthma: a forgotten but very present epidemic

Acute episodes of bronchial asthma are associated with specific etiological factors such as air pollutants and meteorological conditions including thunderstorms. Evidence suggests that thunderstorm-associated asthma (TAA) may be a distinct subset of asthmatics, and, epidemics have been reported, but none from Saudi Arabia.The trigger for this review was the TAA epidemic in November 2002, Eastern Saudi Arabia. The bulk of patients were seen in the King Fahd Hospital of the University, Al-Khobar. The steady influx of acute cases were managed effectively and involved all neighboring hospitals, without evoking any "Major Incident Plan".THREE GROUPS OF FACTORS ARE IMPLICATED AS CAUSES OF TAA: pollutants (aerobiologic or chemical) and meteorological conditions. Aerobiological pollutants include air-borne allergens: pollen and spores of molds. Their asthma-inducing effect is augmented during thunderstorms.Chemical pollutants include greenhouse gases, heavy metals, ozone, nitrogen dioxide, sulfur dioxide, fumes from engines and particulate matter. Their relation to rain-associated asthma is mediated by sulfuric and nitric acid.Outbreaks of non-epidemic asthma are associated with high rainfall, drop in maximum air temperature and pressure, lightning strikes and increased humidity. Thunderstorm can cause all of these and it seems to be related to the onset of asthma epidemic.Patients in epidemics of TAA are usually young atopic adults not on prophylaxis steroid inhalers. The epidemic is usually their first known attack. These features are consistent with the hypothesis that TAA is related to both aero-allergens and weather effects. Subjects allergic to pollen who are in the path of thunderstorm can inhale air loaded with pollen allergen and so have acute asthmatic response. TAA runs a benign courseDoctors should be aware of this phenomenon and the potential outbreak of asthma during heavy rains. A & E departments and ICU should be alert for possible rush of asthmatic admissions and reinforce ventilators and requirements of cardio-pulmonary resuscitation. Scientific approach should be adopted to investigate such outbreaks in the future and must include meteorological, bio-aerosole pollutants and chemical pollutant assessment. Regional team work is mandatory.

An audit of assessment tools in a medical school in eastern saudi arabia

BACKGROUND

Assessment has a powerful influence on curriculum delivery. Medical instructors must use tools which conform to educational principles, and audit them as part of curriculum review.

AIM

To generate information to support recommendations for improving curriculum delivery.

SETTING

Pre-clinical and clinical departments in a College of Medicine, Saudi Arabia.

METHOD

A self-administered questionnaire was used in a cross-sectional survey to see if assessment tools being used met basic standards of validity, reliability and currency, and if feedback to students was adequate. Excluded were cost, feasibility and tool combinations.

RESULTS

Thirty-one (out of 34) courses were evaluated. All 31 respondents used MCQs, especially one-best (28/31) and true/false (13/31). Groups of teachers selected test questions mostly. Pre-clinical departments sourced equally from "new" (10/14) and "used" (10/14) MCQs; clinical departments relied on 'banked' MCQs (16/17). Departments decided pass marks (28/31) and chose the College-set 60%; the timing was pre-examination in 13/17 clinical but post-examination in 5/14 pre-clinical departments. Of six essay users, five used model answers but only one did double marking. OSCE was used by 7/17 clinical departments; five provided checklist. Only 3/31 used optical reader. Post-marking review was done by 13/14 pre-clinical but 10/17 clinical departments. Difficulty and discriminating indices were determined by only 4/31 departments. Feedback was provided by 12/14 pre-clinical and 7/17 clinical departments. Only 10/31 course coordinators had copies of examination regulations.

RECOMMENDATIONS

MCQ with single-best answer, if properly constructed and adequately critiqued, is the preferred tool for assessing theory domain. However, there should be fresh questions, item analyses, comparisons with pervious results, optical reader systems and double marking. Departments should use OSCE or OSPE more often. Long essays, true/false, fill-in-the-blank-spaces and more-than-one-correct-answer can be safely abolished. Departments or teams should set test papers and collectively take decisions. Feedback rates should be improved. A Center of Medical Education, including an Examination Center is required. Fruitful future studies can be repeat audit, use of "negative questions" and the number of MCQs per test paper. Comparative audit involving other regional medical schools may be of general interest.

Physicians' knowledge, attitude and practice towards erectile dysfunction in Saudi Arabia

We aimed to test the knowledge, attitude and practice (KAP) of physicians towards erectile dysfunction in the Eastern province of Saudi Arabia. At a scientific meeting about erectile dysfunction, 159 physicians from both government and private sectors answered a 34-item questionnaire in private. The mean total KAP score for the group was below the expected standard of 60%. Male physicians scored significantly higher than females. Urologists scored the highest, followed by andrologists. Surprisingly, physicians with higher qualifications scored lower than those with intermediate qualifications and even less than general practitioners. Those who had practised for > or = 10 years scored better than those with < 10 years practice. The role of cardiologists in the diagnosis and management of erectile dysfunction is discussed.

Gastroesophageal reflux in bronchial asthma patients. A clinical note

OBJECTIVE

The objective is to correlate the symptoms of gastroesophageal reflux with the results of esophageal reflux with the results of esophageal pH metry in asthmatic patients.

METHODS

A prospective study was carried out in King Fahd Hospital of the University, Al-Khobar, Kingdom of Saudi Arabia (KSA), during the period January 2000 through to February 2001, whereby 50 patients (34 females and 16 females) with primary diagnosis of bronchial asthma were consecutively enrolled, their mean age + SD was 38.01 + 9.8 years. Twenty-two subjects who were not suffering from asthma or gastroesophageal reflux (GER) (13 females and 9 males) constituted the control group. A questionnaire was administered to all participants and demographic data; asthma and GER symptoms were obtained. Esophageal manometry was performed, whereby the location, length and resting pressure of the lower esophageal sphincter (LES) were determined, pH catheter was inserted nasogastrically, and ambulatory pH data over 24 hours were collected. Pulmonary function tests were also performed.

RESULTS

Twenty-two (44%) patients with asthma had a Demeester score greater than 14.7 and were therefore diagnosed as having pathological GER. Accordingly, the asthma patients were divided into 2 groups, asthma patients with GER (n=22) and those without GER (n=28). Multiple logistic regression analysis revealed that age did not significantly influence occurrence of GER, but it indicated that hoarseness of voice and nocturnal symptoms were significant predictors for the presence of GER in asthmatic patients, hence, the probability of having GER in an asthma patient is nearly 8 times if he/she has nocturnal symptoms and about 7 times if they have hoarseness of voice. However 36.4% of asthmatic patients diagnosed by esophageal ph metry as having GER did not complain of heartburn and hoarseness of voice; such as the reflux was silent.

CONCLUSION

The frequency of GER among 50 patients with asthma reporting to KFHU, Al-Khobar, KSA is 44%. The presence of nocturnal symptoms and hoarseness of voice are significant clinical predictors of GER in asthmatic patients. Patients with difficult to treat asthma should be subjected to esophageal pH metry since a substantial proportion of them may have silent reflux.

Obstructive sleep apnea syndrome among a snoring community

OBJECTIVE

To evaluate the relation between snoring and the presence of obstructive sleep apnea (OSA) in terms of relevant health parameters and questionnaire responses.

METHODS

Selective random sampling within a household survey in the cities of Al-Khobar and Dammam, Kingdom of Saudi Arabia over a 3 month period during the year 2000, was carried out. One hundred and fifty-two persons, aged 17-62 years, with a positive history of snoring as determined by the spouse or other members of the family were selected.

RESULTS

The presence of OSA was determined using the Epworth sleepiness scale (ESS). The predictors included age, gender and body mass index. Snoring was found to be more associated with OSA as suggested by ESS in the study sample. The severity of snoring and its pattern are more associated with apneic patients.

CONCLUSION

Snoring is common and may be a serious medical problem. This study revealed that snoring is associated with symptoms suggesting OSA syndrome as detected by ESS. The family doctor and his team should be aware of the condition, using simple screening test such as ESS, improves the patient care, and finding of suspected cases.

Drug resistance pulmonary tuberculosis in the Eastern Province of Saudi Arabia

OBJECTIVE

To evaluate the prevalence and pattern of antituberculous drug resistance and patients with pulmonary tuberculosis in the Eastern Province and its impact on the tuberculosis control program.

METHODS

Patients with pulmonary tuberculosis, proven by culture, admitted to Dammam Chest Hospital from November 1993 through May 1996 were reviewed. Patients who had at least one documented isolate of mycobacterium tuberculosis resistant to at least one standard anti-tuberculosis drug were identified. Medical records were reviewed and information was retrieved regarding age, sex, nationality, history of previous tuberculosis, human immune deficiency status, and results of direct smear and chest radiograph abnormalities.

RESULTS

A total of 411 cases of culture positive pulmonary tuberculosis with drug susceptibility testing, were identified during the period mentioned, of these 123 (30%) were Saudi nationals and 228 (70%) were non-Saudis. Drug resistance to at least one drug was observed in 43 (10.5%) patients, resistance to isoniazid alone was observed in 25 (6%) patients, whereas resistance to rifampicin was noted in only one (0.2%) patient, and to streptomycin in 3 (1%) patients, multidrug resistance was observed in 11 (3%) patients.

CONCLUSION

The study has shown that the overall drug resistance rate of 10.5% in the Eastern Province of Saudi Arabia is the lowest reported in the Kingdom, compared with Riyadh (13%), Taif (23%) and Gizan (44%). However, it appears to be similar to that reported in neighboring countries. In light of the study findings, and as per the recommendation of the World Health Organization, we suggest that a 4-drug regimen, as an initial treatment for pulmonary tuberculosis should be maintained, as resistance to isoniazid is still higher than the cut off value of 4%, and susceptibility testing for first line antituberculosis drugs should be carried out whenever possible. We also recommend applying stricter medical criteria for tuberculosis screening in newcomers, and for Saudi nationals, application of directly observed therapy should be a priority.