Emmanuel Larbi

Emergence of methicillin-resistant Staphylococcus aureus as a community pathogen

Methicillin-Resistant Staphylococcus aureus (MRSA) infection is an established nosocomial pathogen, with hospital-based outbreaks occurring worldwide. An increase in MRSA infections without risk factors has been recently documented in several reports. A prospective study was conducted over a 36-month period to determine the prevalence and risk factors for community-acquired MRSA infection at King Fahad Hospital of the University Al-Khobar, Saudi Arabia. Patients hospitalized within the previous 12 months or transfers from hospitals or nursing homes were excluded. The number of patients with community-acquired MRSA disease increased from a single patient in 1998 to fifteen patients in the year 2000 and the percentage of community-acquired MRSA/total number of MRSA increased from 5% to 33%. Fifteen (75%) of 20 patients with community-acquired MRSA infection had no discernible characteristics of MRSA infections. Skin and soft tissue infections were the predominant presentation. Most MRSA isolates (95%) were susceptible to multiple antibiotics. Our data suggest that MRSA is an emerging community pathogen. Hospital infection control strategies will have to be redefined and community approaches developed to reduce transmission.

Stroke Register: Experience from the Eastern Province of Saudi Arabia

A stroke registry was established in the Eastern Province of Saudi Arabia with an estimated population of 750,000 inhabitants of whom 545,000 are Saudi citizens. The register started in July 1989 and ended in July 1993. The Gulf war led to its interruption from August 1990 to August 1991. Four hundred eighty-eight cases (314 males, 174 females) of first-ever strokes affecting Saudi nationals were registered over the 3-year period. The crude incidence rate for first-ever strokes was 29.8/100,000/year (95% CI: 25.2–34.3/100,000 year). When standardized to the 1976 US population, it rose up to 125.8/100,000/year. Ischemic strokes (69%) predominated as in other studies but subarachnoid hemorrhage (SAH) was extremely rare (1.4%). The important risk factors were: systemic hypertension (38%), diabetes mellitus (37%), heart disease (27%), smoking (19%) and family history of stroke (14%). Previous transient ischemic attacks (3%) and carotid bruits (1%) were uncommon. The 30-day case fatality rate was 15%. The study showed that the age-adjusted stroke incidence rate for Saudis in this region is lower than the rates reported in developed countries but within the range reported worldwide. The pattern of stroke in Saudi Arabia is not different from that reported in other communities with the exception of the low incidence of SAH. The risk factors are similar to findings in other studies except for the high frequency of diabetes mellitus in our cases. The lower mortality rate was probably due to the younger age of the population and the availability of free medical services for management of cases.

Stroke in a Saudi Arabian national guard community : analysis of 500 consecutive cases from a population-based hospital

Background and Purpose We sought to determine the crude incidence rate, patterns, and risk factors associated with different types of stroke in a defined Saudi population. Methods Records of 500 (342 male, 158 female) consecutive patients with first-ever stroke admitted from December 1982 to June 1992 in a hospital that exclusively serves the Saudi Arabian National Guard community were reviewed. Diagnosis was confirmed by brain computed tomography, and the most likely etiology was determined on the basis of relevant clinical, radiological, and laboratory data. Results The mean age of the patients was 63 ± 17 years. Males predominated in all types of stroke (P<.001). The crude annual incidence rate was 43.8 per 100 000. Ischemic strokes accounted for 76.2%, and these included 52% with large and 24.2% with lacunar infarctions. Intracerebral hemorrhage was detected in 21.4%, whereas subarachnoid hemorrhage was rare (2.4%). Hypertension (56%), diabetes mellitus (42%), and cardiopathy (33%) were common risk factors. Sixty-one patients (12%) died during the first month after their stroke. Conclusions The study suggests that stroke incidence is low in Saudi Arabia compared with industrialized countries, which could be because of the predominance of young age groups. The overall distribution of stroke types was closer to that of Western populations than to the Japanese, in whom hemorrhagic strokes are highly prevalent. However, the high combined frequencies of lacunar infarctions and intracerebral hemorrhages suggest that disease of the small cerebral arteries played a more important role in Saudis than in Western populations. (Stroke. 1993;24:1635-1639.)

Stroke in a Tertiary Hospital in Saudi Arabia: A Study of 372 Cases

Epidemiological studies have shown a consistent downward trend in the incidence and mortality of stroke in industrialized communities. There are however no reports on the pattern of stroke in Saudi nationals and expatriates in Saudi Arabia. The types and etiologies in 372 subjects (262 Saudis, 110 non-Saudis) are described. Males outnumbered females in the ratios of 2.2:1 and 8.2:1 for Saudis and non-Saudis, respectively. The frequency of stroke increased steadily with age until the 7th decade in Saudis but dropped sharply after the 6th in expatriates. The frequency of stroke types in Saudis was ischemic (61%), hemorrhagic (17%) and unspecified (22%) as against 46, 47, and 7% respectively in non-Saudis. Intracerebral hemorrhage was more frequent than subarachnoid hemorrhage (SAH) and was encountered more often in Saudis than in non-Saudis; SAH was 3 times more common in expatriates than in Saudis. The major predisposing factors for stroke were hypertension, diabetes mellitus, and cardiac disorders. Abnormal hemoglobinopathies, especially sickle cell anemia, were rare. The differences observed in the age and sex distribution and in the stroke pattern between Saudi nationals and expatriates most likely reflect the demographic structure existing in Saudi Arabia.

Obesity in a primary health care centre: A retrospective study.

In a retrospective study, the heights and weights of 1072 Saudis (477 men and 595 women), aged 18 to 74 years, were studied to determine the prevalence of obesity in Saudi patients attending the primary health care center of King Fahd Hospital of the University, Al-Khobar, in the Eastern Province of Saudi Arabia. Of the total group, 51.5% (95% confidence interval, 46.5 to 56.0) of the men and 65.4% (95% confidence interval, 61.5 to 69.2) of the women were considered obese, using as the criterion a body mass index (wt/ht(2)) of greater than 25 kg/m(2). Significantly more women were obese than men. An active detection program and campaign against obesity must be mounted in the community, and this should include advice on diet and the better education of patients with regard to obesity and its complications.

Angiographic patterns of carotid ischemic cerebrovascular disease in Saudi Arabia

The angiographic findings in 100 Saudi patients with carotid ischemic cerebrovascular disease (CVD) (transient ischemic attacks (TIA) or strokes) were retrospectively reviewed. These patients were representative of all patients with similar disorders in the terms of sex, frequency of diabetes mellitus and ischemic heart disease. They were, however, significantly younger, smoked more, had more cervical bruits and less atrial fibrillation. Analysis of the data showed that a significant stenosis (> 70%) of the carotid artery origin was found only in 12% of TIA cases, 4% in the lacunar infarction cases and 6% of the large infarction cases on the symptomatic side and only in one case of TIA in the asymptomatic side. These frequencies were significantly lower than those found in similar studies performed in western countries. This study suggests that stenoses and occlusions of extracranial carotid artery plays a smaller role in the pathogenesis of ischemic CVD in Saudis than in Caucasians. The low consumption of cigarettes among elderly and females may be one of the explanations.

Exome-Wide Association Analysis of Coronary Artery Disease in the Kingdom of Saudi Arabia Population.

Coronary Artery Disease (CAD) remains the leading cause of mortality worldwide. Mortality rates associated with CAD have shown an exceptional increase particularly in fast developing economies like the Kingdom of Saudi Arabia (KSA). Over the past twenty years, CAD has become the leading cause of death in KSA and has reached epidemic proportions. This rise is undoubtedly caused by fast urbanization that is associated with a life-style that promotes CAD. However, the question remains whether genetics play a significant role and whether genetic susceptibility is increased in KSA compared to the well-studied Western European populations. Therefore, we performed an Exome-wide association study (EWAS) in 832 patients and 1,076 controls of Saudi Arabian origin to test whether population specific, strong genetic risk factors for CAD exist, or whether the polygenic risk score for known genetic risk factors for CAD, lipids, and Type 2 Diabetes show evidence for an enriched genetic burden. Our results do not show significant associations for a single genetic locus. However, the heritability estimate for CAD for this population was high (h2 = 0.53, S.E. = 0.1, p = 4e-12) and we observed a significant association of the polygenic risk score for CAD that demonstrates that the population of KSA, at least in part, shares the genetic risk associated to CAD in Western populations.

β 2 -adrenergic receptor gene polymorphisms in normal and in patients with myocardial infarction in the eastern province of Saudi Arabia

Introduction: Single nucleotide polymorphisms (SNPs) of the β2 -adrenergic receptor (β2 -AR) gene have been implicated in the pathogenesis of cardiovascular diseases. This study evaluated two β2 -AR SNPs in association with myocardial infarction (MI), namely arginine-glycine (G16R) substitution at codon 16 and glutamine-glutamic (Q27E) substitution at condon 27. Objectives: Therefore, our main objective was to determine the association of these two SNPs among patients with MI with and without type 2 diabetes (T2D). Materials and Methods: Blood samples were collected from 201 MI patients with and without diabetes and from 115 controls and the β2 -AR gene polymorphisms at codon 16 and codon 27 were assessed by restriction fragment length polymorphism. The χ2 test was used to compare differences between groups. Results: The SNPs did not deviate significantly from Hardy-Weinberg equilibrium in the control population. The allele and genotype frequencies of the β2 -AR gene polymorphism at codon 16 (G16R) was significantly different between MI cases and controls (χ2 = 10.495, P < 0.05 and χ2 = 8.849, P < 0.05, respectively). No significant difference in genotype and allele frequencies at codon 27 was shown between these two groups (χ2 = 2.661, P ≥ 0.05 and χ2 = 1.587, P ≥ 0.05, respectively). When the MI patients with and without T2D were pooled together, genotype distribution was different between cases and controls at codon 16 (χ2 = 4.631, P = 0.099) and codon 27 (χ2 = 7.247, P = 0.027). However, no significant differences were found in allele frequencies for codon 16 and codon 27 between the two groups (χ2 = 0.628, P = 0.428; χ2 = 0.33, P = 0.565, respectively). Conclusion: Our findings indicate a moderate association of the β2 -AR G16R gene polymorphism with MI suggesting that this gene plays a universal role in the development of MI across ethnicities. However, there was no association of β2 -AR G16R gene polymorphism with diabetic patients with MI.

Clinical presentation of spontaneous primary hypothyroidism in adults.

In a retrospective study of 309 cases of hypothyroidism seen at King Fahd Hospital of the University (KFHU), Al-Khobar, 124 (90 Saudis and 34 non-Saudis) adult patients with spontaneous primary hypothyroidism satisfied the inclusion criteria for detailed analysis. Their male:female ratios for Saudis and non-Saudis were 1:4.6 and 1:3.9 respectively. The majority were diagnosed in their third and fourth decades. The prevalence of previously undiagnosed spontaneous and biochemically overt primary hypothyroidism in Saudis was 5.2/1000 females and 0.94/1000 males. FT4I was normal in 43 (35%) and low in 81 (65%). FT4I correlated with cold intolerance, constipation, dry skin, hoarseness, delayed reflex relaxation, and coarse and cold skin. In rank order, presenting symptoms in those with low FT4I were tiredness (56%), cold intolerance (38%), constipation, weight gain, menstrual disturbance - especially amenorrhea - (36% each), dry skin (35%), hoarseness (31%); signs were coarse skin (53%), delayed reflex relaxation (32%), cold skin and goiter (24% each). The above clinical findings may help physicians in the early detection of primary hypothyroidism. Population-based studies are necessary to provide more data on this disease in this country.

Chest Roentgenography in Medical Emergency

ABSTRACT To evaluate indication for chest roentgenograms and their contributions to the management of Saudi patients admitted through the emergency room to medical wards, the medical records of all...