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Objectives: To examine the efficacy of prophylactic desmopressin versus placebo among patients undergoing functional endoscopic sinus surgery (FESS)., Design: Systematic review and meta-analysis of randomised controlled trials (RCTs)., Setting: The Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Scopus, and Web of Science databases were screened from inception until 18 March 2022., Participants: Patients undergoing FESS., Main Outcome Measures: Primary efficacy endpoints comprised intraoperative blood loss, visual clarity, and operation time. Secondary endpoints comprised side effects. The efficacy endpoints were summarised as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI)., Results: Five RCTs comprising 380 patients (desmopressin = 191 patients and placebo = 189 patients) were included. Collectively, the included RCTs had an overall low risk of bias. The pooled results showed that the mean intraoperative blood loss (n = 5 RCTs, MD = -37.97 ml, 95% CI [-56.97, -18.96], p < .001), 5-point Boezaart scores (n = 2 RCTs, MD = -.97, 95% CI [-1.21, -.74], p < .001), and 10-point Boezaart scores (n = 2 RCTs, MD = -3.00, 95% CI [-3.61, -2.40], p < .001) were significantly reduced in favour of the desmopressin group compared with the placebo group. Operation time did not significantly differ between both groups (n = 5 RCTs, MD = -3.73 min, 95% CI [-14.65, 7.18], p = .50). No patient in both groups developed symptomatic hyponatremia (n = 3 RCTs, 194 patients) or thromboembolic events (n = 2 RCTs, 150 patients)., Conclusions: Among patients undergoing FESS, prophylactic administration of desmopressin does not correlate with significant clinical benefits. Data on safety is limited. Future research may explore the synergistic antihaemorrhagic efficacy and safety of tranexamic acid (TXA) plus desmopressin versus TXA alone among patients undergoing FESS., (© 2022 John Wiley & Sons Ltd.)

Controlled Environment Agriculture (CEA) is a method of increasing crop productivity per unit area of cultivated land by extending crop production into the vertical dimension and enabling year-round production. Light emitting diodes (LED) are frequently used as the source of light energy in CEA systems and light is commonly the limiting factor for production under CEA conditions. In the current study, the impact of different spectra was compared with the use of white LED light. The various spectra were white; white supplemented with ultraviolet b for a week before harvest; three combinations of red/blue lights (red 660 nm with blue 450 nm at 1:1 ratio; red 660 nm with blue 435 nm 1:1 ratio; red 660 nm with blue at mix of 450 nm and 435 nm 1:1 ratio); and red/blue supplemented with green and far red (B/R/G/FR, ratio: 1:1:0.07:0.64). The growth, yield, physiological and chemical profiles of two varieties of lettuce, Carmoli (red) and Locarno (green), responded differently to the various light treatments. However, white (control) appeared to perform the best overall. The B/R/G/FR promoted the growth and yield parameters in both varieties of lettuce but also increased the level of stem elongation (bolting), which impacted the quality of grown plants. There was no clear relationship between the various physiological parameters measured and final marketable yield in either variety. Various chemical traits, including vitamin C content, total phenol content, soluble sugar and total soluble solid contents responded differently to the light treatments, where each targeted chemical was promoted by a specific light spectrum. This highlights the importance of designing the light spectra in accordance with the intended outcomes. The current study has value in the field of commercial vertical farming of lettuce under CEA conditions.

Clinicians urgently need reliable and stable tools to predict the severity of COVID-19 infection for hospitalized patients to enhance the utilization of hospital resources and supplies. Published COVID-19 related guidelines are frequently being updated, which impacts its utilization as a stable go-to resource for informing clinical and operational decision-making processes. In addition, many COVID-19 patient-level severity prediction tools that were developed during the early stages of the pandemic failed to perform well in the hospital setting due to many challenges including data availability, model generalization, and clinical validation. This study describes the experience of a large tertiary hospital system network in the Middle East in developing a real-time severity prediction tool that can assist clinicians in matching patients with appropriate levels of needed care for better management of limited health care resources during COVID-19 surges. It also provides a new perspective for predicting patients' COVID-19 severity levels at the time of hospital admission using comprehensive data collected during the first year of the pandemic in the hospital. Unlike many previous studies for a similar population in the region, this study evaluated 4 machine learning models using a large training data set of 1386 patients collected between March 2020 and April 2021. The study uses comprehensive COVID-19 patient-level clinical data from the hospital electronic medical records (EMR), vital sign monitoring devices, and Polymerase Chain Reaction (PCR) machines. The data were collected, prepared, and leveraged by a panel of clinical and data experts to develop a multi-class data-driven framework to predict severity levels for COVID-19 infections at admission time. Finally, this study provides results from a prospective validation test conducted by clinical experts in the hospital. The proposed prediction framework shows excellent performance in concurrent validation (n=462 patients, March 2020-April 2021) with highest discrimination obtained with the random forest classification model, achieving a macro- and micro-average area under receiver operating characteristics curve (AUC) of 0.83 and 0.87, respectively. The prospective validation conducted by clinical experts (n=185 patients, April-May 2021) showed a promising overall prediction performance with a recall of 78.4-90.0% and a precision of 75.0-97.8% for different severity classes.

Spring wheat ( Triticum aestivum ) is a staple food providing sources of essential proteins for human. In fact, gene expressions of wheat play an important role in growth and productivity that are affected by drought stress. The objective of this work focused on analysis gene feature on spring wheat represented by nucleotide and gene expressions under drought stress. It was found that the higher codon adaptation index was in both wheat root and L-galactono-1, 4-lactone dehydrogenase. It was also found that guanine and cytosine content were high (55.56%) in wheat root. Whereas, guanine and cytosine content were low (41.28%) in L-galactono-1, 4-lactone dehydrogenase. Moreover, the higher relative synonymous codon usage value was observed in codon CAA (1.20), GAA (1.33), GAT (1.00), and ATG (1.00) in wheat root and thus about 62.95% of the total variation in relative synonymous codon was explained by principal component analysis. Additionally, high averages frequency number of codon were (above 15.76) in Met, Lys, Ala, Gly, Phe, Asp, Glu, His, and Tyr; whereas, low averages were in remaining amino acids and majority (90%) of modified relative codon bias values was between 0.40 and 0.90. Shortly, calculations and analysis of codon usage pattern under drought stress would help for genetic engineering, molecular evolution, and gene prediction in wheat studies for developing varieties that associate with drought tolerance., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 The Author(s).)

Objectives: Tuberculosis is an important opportunist infection that can complicate the posttransplant course of solid-organ transplant recipients. Lung transplant recipients are at higher risk of tuberculosis after transplant than are other solid-organ transplant recipients. Significant drug-drug interactions between antituberculous medications, especially rifampin, and immunosuppressant medications render treatment in this patient population especially challenging. Data on the management of tuberculosis in lung transplant recipients with rifamycin-sparing regimens are so far limited. Therefore, we evaluated the incidence, clinical features, treatment, and outcomes of active tuberculosis in lung transplant patients from a single center in Riyadh, Saudi Arabia., Materials and Methods: Cases of active tuberculosis in lung transplant recipients diagnosed between January 2005 and December 2017 at our center were included. Data on patient demographics, clinical presentations, diagnosis, treatment regimens, and outcomes were collected., Results: Seven of 133 lung transplant recipients (5.3%) were diagnosed with active tuberculosis during the study period, corresponding to an incidence rate of 2147/100 000 person-years. Patients were diagnosed at median time of 94 days posttransplant. Fever and weight loss were the most common presenting symptoms. All patients were initially treated with a regimen consisting of isoniazid, ethambutol, pyrazinamide, and moxifloxacin. Isoniazid was later substituted with rifabutin in 2 patients with isoniazid-resistant tuberculosis. All patients were treated for a total of 9 to 12 months, without any adverse event-related interruptions. All patients were alive at 12 months after the diagnosis of tuberculosis. There was no evidence of relapse in any of the patients after a median of 32 (range, 9-51) months of follow-up after treatment., Conclusions: Rifamycin-sparing regimens appear to be safe and highly efficacious in the treatment of active tuberculosis in lung transplant recipients.

Background: Brucellosis, which has profound public health and economic consequences, is endemic to Saudi Arabia. Brucella is transmitted to humans by direct contact with infected animals or by consumption of unpasteurized dairy products. Manifestations of brucellosis are protean and require a combination of drugs to prevent the emergence of resistance. The WHO recommends the use of doxycycline with rifampicin or an aminoglycoside for brucellosis, but experts in Saudi Arabia prefer to avoid the use of rifampicin and aminoglycosides to lessen the possibility of emergence of drug-resistant tuberculosis., Objectives: Compare rifampicin and doxycycline in the treatment of human brucellosis versus various combinations of doxycycline, with either trimethoprim-sulfamethoxazole (co-trimoxazole), quinolones or aminoglycosides, and describe the clinical manifestations of brucellosis., Design: Retrospective medical record review., Setting: Single tertiary care center., Patients and Methods: Diagnosis of brucellosis was based on positive serology by standard agglutination test (SAT), or isolation by culture of Brucella species from blood, body fluid or tissue., Main Outcome Measures: Cure rate with the use of doxycycline in combination with either co-trimoxazole, quinolone or aminoglyco-sides in comparison to doxycycline/rifampicin and the clinical features of brucellosis., Sample Size: 123., Results: In 118 (96%) patients, the median IgG/IgM antibody titers at diagnosis and at 6 and 12 months were 1:1280/1:1280, 1:640/1:640, and 1:320/1:160, respectively. There were no differences in outcome between treatment regimens, as evidenced by a significant decrease in SAT titers and symptom resolution within six months. Five (4%) patients relapsed from non-adherence to treatment, but responded well to a second course of treatment. Blood cultures were positive in 50 patients (41%) patients. Fever, arthralgia and back pain were the most common symptoms. Good serological and clinical responses were achieved in 96% of patients. Relapse in 4% (n=5) was due to self-reported non-adherence., Limitations: Retrospective, relatively small sample size., Conclusions: Doxycycline with co-trimoxazole is as efficacious as doxycycline/rifampicin in non-focal brucellosis and is preferred in countries with a high prevalence of tuberculosis., Conflict of Interest: None.

Background: Nocardiosis is a rare infection that affects immunocompromised patients on immunosuppressive medications used for transplantation and cancer therapy. Such therapies are becoming more widely available in the Middle East region. Yet, reports on nocardiosis are scarce., Materials and Methods: This was a retrospective analysis of patients who were diagnosed with nocardiosis from 2004 to 2018 at a transplantation and cancer center. Nocardiosis were defined per the European Organization for Research and Treatment of Cancer criteria., Results: During the study period, 35 patients with nocardiosis (male: 68.5%) were identified. The most common underlying associated condition was transplantation 11 (31.4%), followed by malignancy 7 (20%), connective tissue disease and sarcoidosis 7 (20%), chronic lung disease 5 (14%), miscellaneous conditions 4 (11%), and one patient with human immunodeficiency virus. Nocardia was disseminated in 8 patients (22.9%) and isolated in 27 (77.1%); the latter included 13 patients (37.1%) with bronchial form, 11 (31.4%) with isolated visceral form, and 3 (8.6%) with cutaneous form. Pulmonary involvement occurred in 90% of the cases with cough, fever, and dyspnea being the most common symptoms. The main strain isolate was Nocardia asteroides , and the cure rate was 90%. Mortality related to nocardiosis occurred in 3 transplant patients (8.6%)., Conclusion: Wider use of immunosuppressive therapy warrants vigilance to nocardiosis, which can present in a myriad of clinical forms. In our series, mortality was confined to the transplantation group, probably because of the relatively heavy immunosuppression. Nonetheless, prognosis is favorable if the infection is recognized and treated early., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Global Infectious Diseases.)

Purpose: Refractive errors (REs) are common and continue to increase globally, particularly myopia. Uncorrected REs are the second leading cause of preventable blindness and the most common cause of visual impairment. The main objective of this study is to assess the prevalence of REs and to investigate its associated risk factors among medical students of the Jazan region, Saudi Arabia., Methods: An observational analytical cross-sectional study was conducted among a random sample of 447 medical students at Jazan University. Eye examination was conducted using an autorefractor test (Huvitz HRK-8000A Autorefractor Keratometer) to measure spherical refraction (emmetropia, myopia, and hyperopia) and cylindrical refraction (astigmatism). Factors associated with myopia and hyperopia were evaluated using logistic regression models., Results: The overall prevalence of REs was 48.8% (95% confidence interval [CI] [44.2, 53.4]). The prevalence of REs among female medical students was 55.1% (95% CI [48.6, 61.5]), which was significantly higher than that among males (42.3%, 95% CI [36.0, 48.9]), with a P = 0.007. Of the 447 medical students examined, approximately one-third (33.8%) had myopia, 10.5% had astigmatism, and only 10.5% had hyperopia. The results of logistic regression indicated that females were 52% more myopic than males (odds ratios [OR] = 1.52, 95% CI [1.04, 2.22]), while participants with both parents having a history of REs were twofold more myopic than students with no family history of REs (OR = 2.01, 95% CI [1.2, 3.4]). A history of blurred vision also increases the risk of myopia by seven times (OR = 7.2, 95% CI [6.4, 11.3])., Conclusion: RE among medical students is a problem. Thus, it needs to be assessed carefully before students choose a specialty that may need very good near and far vision for postgraduate study., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Middle East African Journal of Ophthalmology.)

Objectives: To assess cerebral venous thrombosis risk factors, and associated clinical outcomes in Jazan region, Kingdom of Saudi Arabia., Methods: This study is a retrospective review of the medical records of patients diagnosed with cerebral venous thrombosis and admitted to King Fahad Central Hospital in Jazan between 2010 and 2019. Data concerning socio-demographics, clinical features, risk factors, laboratory, and imaging investigations were retrieved. Furthermore, data about cases management, and outcomes, including death, were collected and analysed., Results: A total of 51 medical records were identified. The majority of the patients were females (68.6%), and the mean age of the patients was 33.3 years, of which three patients were under 18 years old. The most frequently recorded symptom was headache (76.5%), followed by seizure (45.1%). The most commonly recorded risk factor was protein S deficiency (57%), followed by anaemia (51%). Venous infarction and haemorrhage were the most common acute complications (13.7%). The majority of the patients had a favourable prognosis where only 27.5% recovered with disability and only one patient died due to the disease., Conclusion: Clinical presentation of cerebral venous thrombosis in Jazan region is similar to other local and international studies. However, anaemia was recorded as a main risk factor for the disease, which might require further investigation to assess the possible association between prevalence of anaemia in Jazan region and the incidence of cerebral venous thrombosis., (Copyright: © Neurosciences.)

Objectives: Mycobacterium tuberculosis DNA has been detected in multiple organs in people without active tuberculosis or a history of tuberculosis. Molecular testing for metabolic activity has suggested that M tuberculosis DNA represents viable bacilli. Whether transplanted organs with M tuberculosis DNA can result in tuberculosis in recipients has not been assessed., Methods: Biopsies obtained at the time of living donor liver transplantation were tested for the presence of M tuberculosis DNA using in situ PCR. The cohort of recipients was longitudinally followed for the development of tuberculosis., Results: Living donor liver transplantation was performed for 270 patients. Mean age was 33 years (median: 41 years, range: 1-80 years). Recipients were followed for a mean of 68 months (median: 72 months, range: 1-138 months) after transplantation. Mycobacterium tuberculosis DNA was detected in 25 of 155 donated livers (16%) with liver biopsies available for testing. None of the recipients of these livers received tuberculosis chemoprophylaxis and only one (4%) developed tuberculosis 15 months after transplantation. Among the entire cohort of 270 patients, post-transplant tuberculosis was diagnosed in four patients (1.48%) at an incidence rate of 2.61 cases per 1000 transplant-years. No factors associated with developing tuberculosis were identified, including positive M tuberculosis DNA in transplanted livers., Conclusions: Mycobacterium tuberculosis DNA in living donor transplanted livers did not result in tuberculosis despite post-transplant immunosuppression., (© 2019 Wiley Periodicals, Inc.)

We describe the clinical and genetic characteristics of multi-drug resistant tuberculosis (MDR-TB) in a family cluster in the western region of Kingdom of Saudi Arabia diagnosed between 2012 and 2016. All cases had risk factors for tuberculosis acquisition and they were not household contacts of the index case. Genetic analysis detected both MDR-TB and pre-extensively drug-resistant tuberculosis (pre-XDR TB) strains in the index case and confirmed tuberculosis transmission between two cases. Lack of early diagnosis of MDR-TB by molecular testing and lack of extended contact tracing contributed to the transmission of MDR-TB among this family cluster over four years., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: To describe the clinical presentations, treatment regimen, and outcomes of Pneumocystis jiroveci pneumonia (PJP) among immunocompromised patients at King Faisal Specialist Hospital and Research Center in Saudi Arabia., Materials and Methods: In this retrospective cohort study, patients with a laboratory-confirmed diagnosis of PJP were included., Results: During the study, 42 patients with confirmed PJP were identified. Twenty (48%) patients were HIV-infected, while 22 (52%) were HIV negative. The median T-cell count (CD 4 ) was below 50 cells/mL in HIV patients with PJP at the time of HIV and PJP diagnoses. Graft rejection, cytomegalovirus (CMV) reactivation, and lymphopenia were associated with the development of PJP in transplant recipients; and high-dose steroids for non-transplant patients. The all-cause mortality at 90 days was lower in individuals with HIV-related PJP, compared to those with other predisposing conditions (10% and 32%, respectively; P=0.085). No specific risk factors were independently associated with the increased risk of mortality., Conclusion: PJP remains an important cause of morbidity and mortality in immunocompromised patients, with a higher mortality rate reported in non-HIV patients., (Copyright© 2019 National Research Institute of Tuberculosis and Lung Disease.)

This is the first guideline developed by the Saudi Thoracic Society for the diagnosis and management of noncystic fibrosis bronchiectasis. Local experts including pulmonologists, infectious disease specialists, thoracic surgeons, respiratory therapists, and others from adult and pediatric departments provided the best practice evidence recommendations based on the available international and local literature. The main objective of this guideline is to utilize the current published evidence to develop recommendations about management of bronchiectasis suitable to our local health-care system and available resources. We aim to provide clinicians with tools to standardize the diagnosis and management of bronchiectasis. This guideline targets primary care physicians, family medicine practitioners, practicing internists and respiratory physicians, and all other health-care providers involved in the care of the patients with bronchiectasis., Competing Interests: There are no conflicts of interest.

Background: Latent tuberculosis (TB) infection (LTBI) is screened by using clinical assessment, tuberculin skin test (TST), chest radiography, and recently by interferon-gamma release assays (IGRA). The objective of this study was to evaluate the diagnostic potential of QuantiFERON ® -TB Gold In-Tube test (QFT) for diagnosing LTBI in patients planned for kidney transplantation., Methods: All adult patients with end-stage renal disease, evaluated for kidney transplantation in a referral center from August 2008 till May 2013, were enrolled, after consenting in a prospective, observational, non-interventional study. LTBI diagnosis was conducted by TST, chest x-ray, and clinical assessment, followed by IGRA by QFT., Results: Overall, 278 patients were enrolled and kidney transplantation was performed in 173 patients. Contributed follow-up was 836.5 patient-years, and TB-free transplant duration was 478.5 patient-years. By standard methods, LTBI was diagnosed in 14 patients. Peri-transplant chemoprophylaxis was given to 53 patients, which included recipients of organs from all deceased donors and living donors with LTBI. QFT was positive in 70 patients, negative in 200 patients, and indeterminate in 8 patients. The agreement between LTBI diagnosis using standard methods and IGRA by QFT was poor (kappa: 0.089+0.046, P-value=.017). Twenty-seven of the QFT-positive patients were transplanted and only one was given isoniazid preventive therapy. None of the transplant recipients developed TB after a median follow-up of 25 months (range 2-58 months, mean 27 months)., Conclusions: The agreement of the QFT with standard diagnosis of LTBI in kidney transplant recipients was poor., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: The risk of tuberculosis is increased in solid organ transplantation. Rates remain high in developed and developing countries. We developed protocols to better identify transplant recipients at risk of tuberculosis and initiate interventions to prevent tuberculosis., Objectives: Report tuberculosis incidence in solid-organ transplant recipients and the results of expanded isoniazid prophylaxis in deceased-donor renal transplantation., Design: Retrospective cohort study, comparing two time periods., Setting: Large transplantation center in a WHO-medium endemicity country for tuberculosis., Methods: In a cohort of all solid-organ transplant recipients performed between 2003 and 2012, tuberculosis-free transplantation follow-up is used for incidence calculation. Rates of tuberculosis in renal transplant recipients are compared before and after implementation of expanded isoniazid prophylaxis., Main Outcome Measure(s): Active tuberculosis post-transplantation., Results: Of 1966 solid-organ transplant recipients (kidney: 1391, liver: 426, heart: 114, lung: 35), 20 recipients (1.02%) developed tuberculosis. Twelve cases (60%) developed tuberculosis within one year of transplantation. The incidence was 248 cases per 100 000 transplant-years. The proportion of transplant recipients (incidence of tuberculosis per 100 000 transplant-years) for specific organs were kidney 0.58% (127), liver 1.88% (594), heart: 1.75% (570), and lung 5.71% (4750). In the survival analysis, lung transplant recipients had significantly higher rates of tuberculosis compared to recipients of kidneys from living donors (P=.0001) with a rate ratio of 45.3 (95% CI: 7-313). Mortality was 5% among tuberculosis patients. After implementing expanded isoniazid prophylaxis among deceased-donor kidney recipients, no tuberculosis occurred in 177 recipients, compared to 3 out of 155 (2%) recipients before implementation., Conclusions: Rates of tuberculosis among our solid transplant recipients are decreasing. Universal iso-niazid prophylaxis in transplant recipients could reduce transplant-associated tuberculosis in endemic areas., Limitations: Donor data on tuberculosis exposure and prevention and tuberculosis prevention efforts before referral to our center are not available for all patients.

Objectives: To explore potential gender differences in the factors associated with asthma-specific quality of life (AQL)., Methods: A cross-sectional study of consecutive series of adult patients attending primary care centers at three major hospitals in Riyadh, Saudi Arabia, was performed. AQL was measured using a standardized version of the AQL questionnaire (min = 1, max = 7), with higher scores indicating a better AQL. Multiple linear regression analysis was performed., Results: The mean AQL was 4.3 (standard deviation [SD] = 1.5) for males and 4.0 (SD = 1.3) for females (p = 0.113). With each unit increase in asthma control, the AQL improved by 0.19 points (95% confidence interval [CI] = 0.14-0.23) in men and by 0.21 points (95% CI = 0.16-0.25) in women. Daily tobacco smoking was associated with a 0.72 point (95% CI = 0.14-1.30) decrease in the AQL among males. Women who had a household member who smoked inside the house had a significantly lower AQL (B = -0.59, 95% CI = -1.0 - -0.19). A monthly household income of 25,000 Saudi Riyals or more was associated with a better AQL among men (B = 0.51, 95% CI = 0.01-1.01), whereas being employed exhibited a protective effect in women (B = 0.48, 95% CI = 0.11-0.84). Higher levels of perceived asthma severity were associated with better AQL in women (B = 0.82, 95% CI = 0.36-1.28)., Conclusions: Our findings revealed gender-specific differences in the correlates of AQL in Saudi Arabia, particularly in tobacco exposure, socio-economic factors and perceived asthma severity.

We herein describe the nosocomial transmission of a pre-XDR or MDR case of pulmonary tuberculosis in a HIV-negative health care worker in an area endemic for MDR and XDR tuberculosis. Following inadequate therapy and non-compliance, he presented with extra-pulmonary XDR tuberculosis in the form of multi-focal osteomyelitis and encysted pleural effusion. He was cured after two years of treatment with various anti-tuberculous drugs in addition to interferon gamma., (Copyright © 2015 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved.)

Background: Clinical characteristics of HIV-1 infection in people inhabiting Western, Sub-Saharan African, and South-East Asian countries are well recognized. However, very little information is available with regard to HIV-1 infection and treatment outcome in MENA countries including the Gulf Cooperation Council (GCC) states., Methods: Clinical, demographic and epidemiologic characteristics of 602 HIV-1 infected patients followed in the adult Infectious Diseases Clinic of King Faisal Specialist Hospital and Research Centre, in Riyadh, Kingdom of Saudi Arabia a tertiary referral center were longitudinally collected from 1989 to 2010., Results: Of the 602 HIV-1 infected patients in this observation period, 70% were male. The major mode of HIV-1 transmission was heterosexual contact (55%). At diagnosis, opportunistic infections were found in 49% of patients, most commonly being pneumocysitis. AIDS associated neoplasia was also noted in 6% of patients. A hundred and forty-seven patients (24%) died from the cohort by the end of the observation period. The mortality rate peaked in 1992 at 90 deaths per 1000 person-year, whereas the mortality rate gradually decreased to <1% from 1993-2010. In 2010, 71% of the patients were receiving highly active retroviral therapy., Conclusions: These data describe the clinical characteristic of HIV-1-infected patients at a major tertiary referral hospital in KSA over a 20-year period. Initiation of antiretroviral therapy resulted in a significant reduction in both morbidity and mortality. Future studies are needed in the design and implementation of targeted treatment and prevention strategies for HIV-1 infection in KSA.

Background and Objectives: Hepatitis B and C are among the leading causes of death in human immunodeficiency virus (HIV)-infected patients. Prevalence data on viral hepatitis B and C in HIV-infected people in the region of Middle East and North Africa are scarce. We report the prevalence of viral hepatitis B and C in HIV-infected patients in Saudi Arabia., Design and Settings: Data on all HIV patients who attended HIV Program at King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia, were kept longitudinally. For the purpose of this report, patients enrolled in the program between January 1985 and December 2010 were included., Methods: Data on all HIV patients who received HIV care at age 18 and older between January 1985 and December 2010 were collected. Data were collected from patients' charts at our medical records department and electronically from the electronic health records and HIV database. We excluded patients who were de.ceased prior to completing work-up, lost follow-up, or acquired HIV perinatally., Results: Among 341 HIV-infected patients, hepatitis C infection was found in 41 (12%) patients. The commonest risk factor for hepatitis C virus and HIV acquisition was blood/blood product transfusion in 24 (60%) patients, of these 21 (88%) were hemophiliacs, followed by heterosexual transmission in 9 (22%) patients. The commonest genotype was genotype 1 observed in 18 patients (44%) followed by genotype 4 in 6 (15%) patients. Hepatitis B surface antigen was found in 11 (3%) patients. The commonest risk factor for hepatitis B virus and HIV acquisition was heterosexual transmission in 8 (73%) patients, followed by blood/blood product transfusion in 2 (18%) patients., Conclusion: The prevalence of hepatitis C virus and hepatitis B virus infections are, respectively,10 and 20 times higher among HIV-infected patients than in the general population.

Background: Mycobacterium abscessus is a rapidly growing Mycobacterium that is a common water contaminant in the environment. We report a case of M. abscessus infection with band erosion following laparoscopic gastric banding., Case Presentation: A 34-year-old woman developed insidiously progressing abdominal distension over a period of 1 year associated with abdominal pain, fatigue, night sweating and anorexia 4 years after laparoscopic gastric banding for obesity. Investigation revealed significant ascites with caseating granuloma in peritoneal biopsies from which M. abscessus was isolated. Band erosion with infection and multiple abdominal adhesions were confirmed during laparoscopic removal of the gastric band. To the best of our knowledge, this is the first reported case of M. abscessus infection after laparoscopic gastric banding surgery. We discuss the possible sources of infection, its indolent presentation, and therapeutic challenges., Conclusion: It is important to consider environmentally acquired infection in patients with signs and symptoms of infection in the presence of surgical prosthesis.

Background and Objectives: Human immunodeficiency virus-associated nephropathy (HIVAN) is the most common cause of chronic renal failure in HIV patients with African descent. It usually presents with proteinuria, enlarged kidneys, and rapidly progressive renal failure, often over several weeks to months. We conducted this study to determine the prevalence of HIVAN in our HIV population., Design and Settings: Cross-sectional observational study in a referral center covering the period of 1990- 2010., Methods: Proteinuria and estimated glomerular filtration rate (e-GFR) were used to identify renal disease and suspicious cases of HIVAN with abnormal proteinuria and e-GFR of < 60 mL/min/1.73 m2., Results: Of 585 HIV-positive patients, 248 were eligible to inclusion criteria. Most of the patients were male, that is, 165 (67%) were male compared to 83 (33%) female with the mean age 39 years; 240 (96.7%) were on antiretroviral therapy. Thirty (12%) patients had abnormal proteinuria and 218 (88%) had normal urinary protein and e-GFR. No significant differences were observed in demographic data, CD4+ T-lymphocyte count, viral load, creatinine level, and e-GFR among both groups. Significant differences were observed in the prevalence of diabetes mellitus in the abnormal proteinuria group (10 patients [33.3%] compared to 30 patients [13.8%] in the normal group (P=.0139) and the prevalence of hypertension in the abnormal proteinuria group (11 patients [36.7%] compared to 22 patients [10%] in the normal group (P=.002). Sixteen patients (6.6% of the cohort) met the study definition of HIVAN., Conclusion: The prevalence of abnormal proteinuria and HIVAN among HIV-infected patients in Saudi Arabia is higher than that of non-African patients in developed countries.

The real magnitude of antituberculosis (anti-TB) drug resistance in Saudi Arabia is still unknown because the available data are based on retrospective laboratory studies that were limited to hospitals or cities. A representative national survey was therefore conducted to investigate the levels and patterns of anti-TB drug resistance and explore risk factors. Between August 2009 and July 2010, all culture-positive TB patients diagnosed in any of the tuberculosis reference laboratories of the country were enrolled. Isolates obtained from each patient were tested for susceptibility to first-line anti-TB drugs by the automated Bactec MGIT 960 method. Of the 2,235 patients enrolled, 75 cases (3.4%) were lost due to culture contamination and 256 (11.5%) yielded nontuberculous mycobacteria (NTM). Finally, 1,904 patients (85.2% of those enrolled) had available drug susceptibility testing results. Monoresistance to streptomycin (8.1%; 95% confidence interval [CI], 7.2 to 9.1), isoniazid (5.4%; 95% CI, 4.7 to 6.2), rifampin (1%; 95% CI, 0.7 to 1.3) and ethambutol (0.8%; 95% CI, 0.5 to 1.2) were observed. Multidrug-resistant TB (MDR-TB) was found in 1.8% (95% CI, 1.4 to 2.4) and 15.9% (95% CI, 15.4 to 16.5) of new and previously treated TB cases, respectively. A treatment history of active TB, being foreign-born, having pulmonary TB, and living in the Western part of the country were the strongest independent predictors of MDR-TB. Results from the first representative national anti-TB drug resistance survey in Saudi Arabia suggest that the proportion of MDR-TB is relatively low, though there is a higher primary drug resistance. A strengthened continuous surveillance system to monitor trends over time and second-line anti-TB drug resistance as well as implementation of innovative control measures, particularly among immigrants, is warranted.

Background: Epilepsy is relatively common in CNS tuberculomas, but its natural course is unclear., Aim: To determine the prevalence and prognosis of epilepsy in patients with seizures related to CNS tuberculomas., Methods: We retrospectively reviewed the charts of patients with CNS tuberculomas who presented at our institution between 1983 and 2001., Results: Seizures occurred in 22 of 93 (23.6%) of the patients with CNS tuberculomas. These patients were treated with standard antituberculous therapy for a period varying between 6 and 20 months. Sixty-three out of 93 patients were cured of tuberculosis, and 21 of the 63 (33%) who had concomitant epilepsy became seizure-free. TB recurred in 3 patients, and 1 out of 22 who had concomitant epilepsy continued to have seizures; 3 died and 24 were lost to follow-up. Anti-epileptic medications were discontinued after completion of the anti-TB course., Conclusion: Seizures are commonly associated with CNS tuberculomas and most often resolve after successful treatment of the underlying CNS tuberculosis., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Objective: To identify the incidence of tuberculosis (TB) in people living with the human immunodeficiency virus (HIV) (PLWH) followed at an HIV referral and care facility., Design: Observational longitudinal cohort., Methods: Data were collected longitudinally as patients were admitted to the HIV programme and included demographics, TB diagnosis and treatment, CD4+ T lymphocyte count and TB treatment outcomes. The TB-free follow-up period of all patients was used to calculate TB incidence rates., Results: Between 1997 and 2007, 217 new adult patients joined the HIV programme. TB was diagnosed in 16 patients (7.4%), all of whom had acquired immune-deficiency syndrome at the time of TB diagnosis. Seven developed extra-pulmonary disease (44%), six had pulmonary TB (37%), while three had both (19%). The TB incidence rate was 1354 per 100,000 person-years (py) among the HIV-infected cohort. The incidence rate of pulmonary TB was 762/100,000 py and for extra-pulmonary TB it was 592/100,000 py. Seven patients (44%) died despite early diagnosis and treatment for TB., Conclusion: Among PLWH in Saudi Arabia, TB incidence is 30 times higher than in the general population, with significant mortality despite early diagnosis, treatment and tertiary care support.

Background and Objectives: The rate of mother-to-child transmission of human immunodeficiency virus (HIV) type 1 has been reported to be high in Saudi Arabia. We report the rate of such transmission among a cohort of HIV-infected women enrolled in an HIV program at a tertiary care facility in Riyadh., Methods: All HIV-infected women who became pregnant and delivered during their follow-up between January 1994 and June 2006 were included in this study. HIV viral load and CD4+ T-lymphocyte count near-term, the mode of delivery, and the HIV status of the newborn at 18 months were recorded. All women were counseled and managed according to the three-step PACTG 076 protocol., Results: Of 68 HIV-infected women in the cohort, 31 had 40 pregnancies; one aborted at 13 weeks gestation. The mode of delivery was elective cesarean delivery in 28 pregnancies (70%) at 36 weeks gestation, and 11 (27.5%) had normal spontaneous vaginal delivery. The median CD4+ T-lymphocyte count near-term was 536 cells per cubic millimeter and the median viral load for 25 pregnancies was 1646 copies/mL, with only nine pregnancies (22.5%) having viral loads of more than 1000 copies/mL. Fourteen pregnancies (35%) had undetectable HIV prior to delivery. All patients were taking antiretroviral therapy during pregnancy and delivery. All 39 newborns tested negative for HIV infection at the age of 18 months; none of the newborns was breastfed., Conclusions: Contrary to previous local experience, diagnosis, management, and antiretroviral therapy almost eliminated mother-to-child transmission of HIV-1 in our patient population.

Pulmonary tuberculosis is a common disease in Saudi Arabia. As most cases of tuberculosis are due to reactivation of latent infection, identification of individuals with latent tuberculosis infection (LTBI) who are at increased risk of progression to active disease, is a key element of tuberculosis control programs. Whereas general screening of individuals for LTBI is not cost-effective, targeted testing of individuals at high risk of disease progression is the right approach. Treatment of those patients with LTBI can diminish the risk of progression to active tuberculosis disease in the majority of treated patients. This statement is the first Saudi guideline for testing and treatment of LTBI and is a result of the cooperative efforts of four local Saudi scientific societies. This Guideline is intended to provide physicians and allied health workers in Saudi Arabia with the standard of care for testing and treatment of LTBI.

Objectives: To validate the World Health Organization (WHO) clinical staging and classification of HIV/AIDS using CD4+ T-lymphocyte counts in the setting of a developing country., Methods: This was a retrospective chart review of HIV-infected adults at the national HIV referral clinic in the Kingdom of Saudi Arabia. Four hundred HIV-infected individuals were reviewed. All individuals under the age of 15 years and those who had received antiretroviral therapy were excluded. WHO clinical stage at presentation was determined by a single reviewer. The first CD4+ T-lymphocyte count within 6 months of diagnosis of HIV infection was then abstracted by a different reviewer. The main outcome measure was the comparison of the WHO clinical stages of HIV/AIDS at the time of diagnosis and the CD4+ T-lymphocyte counts., Results: Data were available for 191 individuals, of whom 123 were men and 68 were women. The mean CD4+ T-lymphocyte count was 281/mm(3) in the men and 425/mm(3) in the women. The distribution of individuals at the WHO clinical stages was 110 at stage I, 10 at stage II, 36 at stage III, and 35 at stage IV. Mean CD4+ T-lymphocyte counts were 457, 337, 188, and 86/mm(3) at the respective stages. The difference between the mean CD4+ T-lymphocyte count in patients at stage IV and at each of the other stages was significant; p<0.0001. The correlation between the stages and the mean CD4+ T-lymphocyte counts was -0.65., Conclusion: The WHO clinical staging and classification of HIV/AIDS correlates well with CD4+ T-lymphocyte counts.

Clinical presentation, CD4+ T lymphocyte count at diagnosis, and reasons for HIV-1 testing reflect the attitudes towards HIV testing and also the ability of the health-care system to diagnose HIV early. In a cross-sectional study from the HIV database in a large HIV-referral centre in Saudi Arabia, all 410 HIV-infected patients were included, 276 men and 134 women. Women were younger at diagnosis (mean age 25.5 compared with 29 years for men, P < 0.04) and had higher CD4+ T lymphocytes (mean 461 for women and 223 for men, P < 0.001). Out of 276 men, 90 (33%) were identified as HIV infected when they presented with AIDS. Fifty-five percent of the infected women were tested for HIV-1 because of contact with an infected person compared with 8% of the infected men, odds ratio (OR) 13.8 (95% confidence interval [CI]: 7.7-24.9). AIDS remains the main presentation for HIV-infected men. Women are diagnosed earlier and younger than men.

Objective: To study the clinical and pathological patterns of tuberculosis (TB) involving the bone marrow in a tertiary care setting., Methods: A retrospective study of cases of bone marrow TB diagnosed and treated at King Faisal Specialist Hospital and Research Center from 1990 to 2002. The main criterion for inclusion was the isolation of Mycobacterium tuberculosis from a bone marrow specimen., Results: We identified 22 patients with culture-proven M. tuberculosis infection of the bone marrow. Underlying conditions found in this series include solid organ transplantation in 4 patients (18%), HIV infection in 2 (9%), and diabetes in 3 (14%). No risk factor was identified in 12 patients (55%). Histopathological findings were reported as granuloma in 19 patients (86%) and caseating granuloma in 3 (14%). The outcome was favourable for 11 patients (50%), while 10 (45%) died during hospitalisation and one was lost to follow-up. For patients who completed their regimens, the duration of treatment was 12 months., Conclusion: The isolation of M. tuberculosis from a bone marrow specimen is an indication of disseminated disease which carries a high mortality rate and requires prompt initiation of appropriate treatment.

Mycobacterium szulgai is a rare human pathogen that mainly causes pulmonary diseases. We report the first case of M. szulgai causing septic arthritis in a patient with human immunodeficiency virus. A culture from the joint aspiration was needed to isolate and identify this organism. The patient was treated successfully with ciprofloxacin, clarithromycin, and ethambutol.

Background: Since the medical record is the major source of health information, it is necessary to maintain accurate, comprehensive and properly coded patient data. We reviewed 300 medical records from patients at King Faisal Specialist Hospital and Research Center, representing four departments (medicine, surgery, pediatrics and obstetrics and gynecology)., Methods: The records were audited following the guidelines of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) for accuracy and completeness of documentation and coding of primary and secondary diagnoses and procedures performed., Results: Of 1051 items abstracted, 876 (83.3%) were accurately documented, 41 (3.9%) were inaccurately documented, and 134 (12.7%) were not documented. Of the items abstracted, 736 (70%) were assigned a correct code, 110 (10.5%) were assigned an incorrect code, and 205 (19.5%) were not coded. More items classified as accurately documented were coded correctly (71.1%) than items inaccurately documented (49.7%) (P < 0.0001). The difference in comprehensiveness of documentation, which reflects physician performance, was not statistically significant among the four departments (P value < 0.234). The difference in the accuracy of coding, which reflects coder performance, was statistically significant (P value < 0.036)., Conclusions: Only 60% of the audited records met the benchmark for good quality medical records with regards to documentation and coding. A positive correlation between the accurate documentation and correct coding was noted, which supports the conclusion that high quality documentation enhances coding accuracy. These data, although encouraging, suggest room for improvement, which can be achieved through the collaboration of clinicians, who have extensive clinical experience, and coding professionals, who have comprehensive classification system expertise.

The human immunodeficiency virus HIV type 1 has evolved as one of the most important global infectious pathogens. Although the virus had initially emerged among certain high risk groups in developed countries, it quickly gained momentum in developing countries threatening most population groups. The first case of acquired immunodeficiency syndrome from the Kingdom of Saudi Arabia was diagnosed in 1984. Twenty years later, by the end of 2003, 1509 patients have been reported to have acquired HIV 1. The majority of the early infected patients have acquired HIV 1 from blood product transfusion. Subsequently, the most prevalent mode of transmission became heterosexual. In this review, the distribution of HIV infected persons, prevalence data, and future outlook are presented. Communities considered conservative are not immune from a sexually transmissible virus that has infected 60,000,000 people globally.

Objective: To determine the rate and type of anti-tuberculosis drug resistance at King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia., Design: Review of microbiology and infection control databases for all patients with culture-positive Mycobacterium tuberculosis between June 1981 and May 2003 at the hospital. BACTEC 460TB radiometry then MGIT 960 were used for both mycobacterial detection and antimicrobial susceptibility testing., Results: A total of 764 M. tuberculosis isolates were obtained from 764 patients. Resistance to first-line agents (isoniazid, rifampicin, ethambutol and streptomycin) was noted in 65 (8.5%). Resistance to isoniazid was the highest, noted in 54 (7.1%); resistance to rifampicin, streptomycin and ethambutol was found in respectively 21 (2.7%), 29 (3.8%) and 12 (1.6%) isolates. Polyresistance was noted in eight (1%) isolates and monoresistance in 38 (5%) isolates. Multidrug-resistant M. tuberculosis was found in 19 (2.5%) isolates. There were 54 primary resistant isolates (7.6%), and 11 (22%) with acquired resistance. The median age of patients with resistant isolates was 38 years compared to 48 years for patients with sensitive isolates (P = 0.002)., Conclusion: Resistance to first-line anti-tuberculosis agents and multidrug-resistant M. tuberculosis remain relatively low in Saudi Arabia.

The mode of HIV-1 transmission was determined for 410 Saudi patients. Heterosexual transmission occurred in 189 patients (46%), blood product transfusion in 107 (26%), and perinatal transmission in 47 (12%). Men who have sex with men and injection drug users represented 5% and 2%,respectively. Sixty-three of 65 heterosexually infected women acquired HIV-1 from their spouses, whereas 111 of 124 heterosexually infected men acquired the virus from commercial sex workers. Heterosexual transmission is the main mode in Saudi patients.

Objective: To identify patterns, features, and outcome of extrapulmonary tuberculosis in a tertiary care setting., Methods: A retrospective case-series was carried out of all cases diagnosed and treated as extrapulmonary tuberculosis during 1991 through to 2000 at King Faisal Specialist Hospital and Research Centre (KFSH and RC), Riyadh, Kingdom of Saudi Arabia. Demographic, clinical, laboratory, and outcome data were abstracted from medical records., Results: Over a 10-year period, 394 cases of extrapulmonary tuberculosis were diagnosed and treated at KFSH and RC. Isolated extrapulmonary tuberculosis was identified in 339 (86%) patients, 55 cases (14%) had both pulmonary and extrapulmonary tuberculosis. Mean age was 45-years, and 188 patients (47%) had co-morbidities, most commonly diabetes mellitus in 14.2% of patients. Laboratory confirmation of extrapulmonary tuberculosis was available on 386 patients. The most frequent site involvement was lymphadenopathy in 41% of the time. Chest x-ray was normal in 75% of patients. Among 298 patients with follow up data, 10 (3.4%) had documented relapse and 50 (16%) died. Death was related to tuberculosis in 24 (48%) patients., Conclusion: A high level of clinical suspicion is essential for early diagnosis and treatment of extrapulmonary tuberculosis to reduce the significant morbidity and mortality.

Cutaneous Leishmaniasis is a vector-borne protozoal infection of the skin. Several species of Leishmania cause this disease in the Old World. It is manifested as chronic nodular to ulcerative lesions of the skin, which last for many months and may be disfiguring. They eventually heal leaving a scar. Local care of the lesion and treatment of secondary bacterial infection are essential for healing. Antileishmania therapy is indicated in immunocompromised hosts, patients with progressive, multiple, or critically located lesions. Pentavalent antimony compounds remain the main therapeutic option for all species. They are given intravenously (i.v.), intramuscularly (i.m.), or intralesionally. Cryotherapy, and some systemic antifungal agents have been used successfully. Oral azoles are promising new treatments for lesions caused by L. Major. Several other alternatives and their evidence are also presented.

Our study determined the rate of screening tuberculosis patients for HIV co-infection and the HIV seroprevalence among them. We retrospectively reviewed medical charts of 437 patients diagnosed with tuberculosis from 1995-2000 in Riyadh, Saudi Arabia. Screening was done for 178 (41%) patients: 2 (1.1%) of these were found to be HIV positive. Prior to screening, 4 patients were already known to be HIV positive. Males were screened more often than females (45% and 36% respectively). All HIV positive patients were males. Screening was not affected by origin of the patient, history of prior tuberculosis or treatment, type of tuberculosis involvement or resistance to first line anti-tuberculosis agents. In Saudi Arabia, screening for HIV in tuberculosis patients remains underutilized. Among screened patients, seropositivity was low.