Waleed Tamimi

Low-dose hydrocortisone in patients with cirrhosis and septic shock: a randomized controlled trial

Background Recent studies have reported a high prevalence of relative adrenal insufficiency in patients with liver cirrhosis. However, the effect of corticosteroid replacement on mortality in this high-risk group remains unclear. We examined the effect of low-dose hydrocortisone in patients with cirrhosis who presented with septic shock. Methods We enrolled patients with cirrhosis and septic shock aged 18 years or older in a randomized double-blind placebo-controlled trial. Relative adrenal insufficiency was defined as a serum cortisol increase of less than 250 nmol/L or 9 μg/dL from baseline after stimulation with 250 μg of intravenous corticotropin. Patients were assigned to receive 50 mg of intravenous hydrocortisone or placebo every six hours until hemodynamic stability was achieved, followed by steroid tapering over eight days. The primary outcome was 28-day all-cause mortality. Results The trial was stopped for futility at interim analysis after 75 patients were enrolled. Relative adrenal insufficiency was diagnosed in 76% of patients. Compared with the placebo group (n = 36), patients in the hydrocortisone group (n = 39) had a significant reduction in vasopressor doses and higher rates of shock reversal (relative risk [RR] 1.58, 95% confidence interval [CI] 0.98–2.55, p = 0.05). Hydrocortisone use was not associated with a reduction in 28-day mortality (RR 1.17, 95% CI 0.92–1.49, p = 0.19) but was associated with an increase in shock relapse (RR 2.58, 95% CI 1.04–6.45, p = 0.03) and gastrointestinal bleeding (RR 3.00, 95% CI 1.08–8.36, p = 0.02). Interpretation Relative adrenal insufficiency was very common in patients with cirrhosis presenting with septic shock. Despite initial favourable effects on hemodynamic parameters, hydrocortisone therapy did not reduce mortality and was associated with an increase in adverse effects. (Current Controlled Trials registry no. ISRCTN99675218.)

Year-round vitamin D deficiency among Saudi female out-patients.

OBJECTIVE The aim of the present study was to investigate vitamin D status among female out-patients in Saudi Arabia during the summer and winter seasons. DESIGN Data were retrospectively collected using medical record abstraction. SETTING A multidisciplinary hospital in Riyadh between January and December 2009. SUBJECTS Saudi females (age ≥19 years; n 1556) attending out-patient clinics for various complaints comprised the studied population. The population was subdivided into two groups depending on the date of their visit where blood samples were collected: summer (n 659) and winter groups (n 897). The summer group was further subdivided into premenopausal (age 19-49 years; n 425) and postmenopausal subgroups (age ≥50 years; n 234). Similarly, the winter group was subdivided into premenopausal (n 543) and postmenopausal subgroups (n 354). Serum levels of 25-hydroxyvitamin D (25(OH)D) were measured using HPLC. RESULTS The prevalence of vitamin D deficiency (25(OH)D <50 nmol/l) was high in both premenopausal and postmenopausal groups (80 % and 68 %, respectively) during the summer, as well as during the winter (85 % and 76 %, respectively). CONCLUSIONS A high prevalence of vitamin D deficiency among Saudi female out-patients was observed throughout the year despite the routine supplementation with 10-20 μg vitamin D3 for postmenopausal women. Clinicians should seriously consider determining the vitamin D status of Saudi females routinely and prescribing them proper supplementation.

Time for an Adolescent Health Surveillance System in Saudi Arabia: Findings From “Jeeluna”

PURPOSE With the increasing burden of noncommunicable disease, adolescence is viewed as an opportune time to prevent the onset of certain behaviors and promote healthy states. Although adolescents comprise a considerable portion of Saudi Arabias population, they have received insufficient attention and indicators of their health status, as a first step in a prevention cycle are unavailable. This study was carried out with the aim of identifying the health risk behaviors and health status of adolescents in Saudi Arabia. METHODS This cross-sectional, school-based study was carried out in all 13 regions of Saudi Arabia. Through multistage, cluster, random sampling, intermediate, and secondary school students were invited to participate. Data were collected by means of a self-administered questionnaire addressing health risk behaviors and health status, clinical anthropometric measurements, and laboratory investigations. RESULTS A total of 12,575 adolescents participated. Various health risk behaviors, including dietary and sedentary behaviors, lack of safety measures, tobacco use, bullying, and violence were highly prevalent. Twenty-eight percent of adolescents reported having a chronic health condition, 14.3% reported having symptoms suggestive of depression, 30.0% were overweight/obese, and 95.6% were vitamin D deficient. CONCLUSION Behaviors and conditions known to persist into adulthood and result in morbidity and premature mortality are prevalent among adolescents in Saudi Arabia. Preventive measures and local health policies are urgently needed and can impact adolescents and future adults. Establishing adolescent health surveillance is necessary to monitor trends and impacts of such measures.

Vitamin D status among patients visiting a tertiary care center in Riyadh, Saudi Arabia: a retrospective review of 3475 cases

BackgroundVitamin D deficiency has been implicated in several chronic, non-communicable diseases independent of its conventional role in bone and calcium homeostasis. In this retrospective study, we determined the prevalence of vitamin D deficiency and its association to several cardiometabolic indices among patients visiting King Abdulaziz Medical City (KAMC), a tertiary hospital in Riyadh, Saudi Arabia.MethodsA total of 3475 charts of out-patient subjects who visited KAMC from September 2009 until December 2010 were reviewed and included. Variables of interest included measurements of vitamin D status, glycemic and renal profile, as well as trace elements (calcium and phosphorous).ResultsThe over-all prevalence of vitamin D deficiency in the cohort studied was 78.1% in females and 72.4% in males. 25(OH) vitamin D was significantly associated with increasing age and weight (p-values < 0.0001 and 0.005, respectively). It was also positively associated with albumin, calcium and phosphorous (p-values < 0.0001, < 0.0001 and 0.0007, respectively) and negatively associated with alkaline phosphatase as well as circulating levels of PTH (p-values 0.0002 and 0.0007, respectively).ConclusionIn conclusion, vitamin D deficiency is overwhelmingly common among patients seen at KAMC regardless of the medical condition, and it is significantly associated with increasing age, weight and markers of calcium homeostasis. Findings of the present study further stress the spotlight on vitamin D deficiency epidemic in the country and region in general.

Etomidate and mortality in cirrhotic patients with septic shock.

BackgroundClinical effects and outcomes of a single dose etomidate prior to intubation in the intensive care setting is controversial. The aim of this study is to evaluate the association of a single dose effect of etomidate prior to intubation on the mortality of septic cirrhotic patients and the impact of the subsequent use of low dose hydrocortisone.MethodsThis is a nested-cohort study within a randomized double blind placebo controlled study evaluating the use of low dose hydrocortisone in cirrhotic septic patients. Cirrhotic septic patients ≥ 18 years were included in the study. Patients who received etomidate prior to intubation were compared to those who did not receive etomidate for all cause 28-day mortality as a primary outcome.ResultsSixty two intubated patients out of the 75 patients randomized in the initial trial were eligible for this study. Twenty three of the 62 intubated patients received etomidate dose prior to intubation. Etomidate use was not associated with all cause 28-day mortality or hospital mortality but was associated with significantly higher ICU mortality (91% vs. 64% for etomidate and controls groups, respectively; p = 0.02). Etomidate patients who received subsequent doses of hydrocortisone required lower doses of vasopressors and had more vasopressor-free days but no improvement in mortality.ConclusionsIn this group of septic cirrhotic patients with very high mortality, etomidate increased ICU mortality. Subsequent use of hydrocortisone appears to have no benefit beyond decreasing vasopressor requirements. The lowest mortality was observed in patients who did not receive etomidate but received hydrocortisone.

Effect of body mass index on clinical manifestations in patients with polycystic ovary syndrome

To determine whether there is a correlation between body mass index (BMI) and blood pressure or clinical features such as hirsutism in women with polycystic ovary syndrome (PCOS).

Vitamin D status correction in Saudi Arabia: an experts’ consensus under the auspices of the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis, and Musculoskeletal Diseases (ESCEO)

BackgroundVitamin D deficiency is common in the Middle East and in Saudi Arabia, in particular. While several international recommendations on the management of vitamin D deficiency have been documented and practiced globally, these recommendations should be adapted to the conditions of the Middle Eastern region. To address this challenge, the Prince Mutaib Chair for Biomarkers of Osteoporosis (PMCO) in King Saud University (KSU), Riyadh, KSA, together with local experts and in cooperation with the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO), organized a panel that formulated unified recommendations in the diagnosis and treatment of vitamin D deficiency in the region.MethodsThe selection of local and international experts commenced during the 2nd International Vitamin D Symposium conducted in Riyadh, Saudi Arabia, last January 20-–21, 2016. Reviews of the most recent literature were done, and face-to-face meetings were conducted for revisions and final recommendations.Results: Vitamin D sufficiency is defined as circulating serum 25(OH)D ≥50 nmol (≥20 ng/ml) for the general population and vitamin D adequacy as serum 25(OH)D >75 nmol/L l (>30 ng/ml) for the frail and osteoporotic elderly. Despite overwhelming prevalence of vitamin D deficiency, universal screening is not recommended. Recommendations for the general population, children, pregnant/lactating women, post-menopausal women, the elderly, and those with subsequent metabolic diseases were provided.ResultsVitamin D sufficiency is defined as circulating serum 25(OH)D ≥50 nmol (≥20 ng/ml) for the general population and vitamin D adequacy as serum 25(OH)D >75 nmol/L l (>30 ng/ml) for the frail and osteoporotic elderly. Despite overwhelming prevalence of vitamin D deficiency, universal screening is not recommended. Recommendations for the general population, children, pregnant/lactating women, post-menopausal women, the elderly, and those with subsequent metabolic diseases were provided.ConclusionVitamin D supplementation/correction is advised in all persons whose serum 25(OH)D falls below 50 nmol/l (20 ng/ml), and achieving a target of 75 nmol/l (30 ng/ml) is particularly suited for frail, osteoporotic, and older patients. Conducting well-designed clinical trials in the region that will address economic implications and investigations on the treatment persistence and compliance to vitamin D treatment in the region are encouraged.

Antioxidant Properties of Nigella sativa

Molecular oxygen (O2) is essential in all species for the production of energy within mitochondria; a process known as oxidative phosphorylation. The end products of this process include adenosine triphosphate (ATP), water (H2O) and carbon dioxide (CO2). In addition, very small amounts of reactive oxygen species (ROS) or free radicals are continuously produced as a consequence of normal metabolism of oxygen but which, on occasions when they become overabundant, may toxically damage cells, and therefore need to be biochemically neutralized or extruded from cells. Antioxidants are defined as substances capable of delaying or inhibiting production of ROS intermediates. Cells can either make these antioxidants endogenously, or receive them through the diet.

Influence of adiposity-related genetic markers in a population of saudi arabians where other variables influencing obesity may be reduced.

Large scale studies in Europeans have clearly identified common polymorphism affecting BMI and obesity. We undertook a genotype study to examine the impact of variants, known to influence obesity, in a sample from the Saudi Arabian population, notable for its profound combination of low mean physical activity indices and high energy intake. Anthropometry measures and genotypes were obtained for 367 Saudis, taken from King Saud University and Biomarker Screening Project in Riyadh (Riyadh Cohort). We observed large effect sizes with obesity for rs10767664 (BDNF) (OR = 1.923, P = 0.00072) and rs3751812 (FTO) (OR = 1.523, P = 0.016) in our sample and, using weighted genetic risk scores, we found strong evidence of a cumulative effect using 11 SNPs taken predominantly from loci principally affecting appetite (OR = 2.57, P = 0.00092). We used conditional analyses to discern which of our three highly correlated FTO SNPs were responsible for the observed signal, although we were unable to determine with confidence which best marked the causal site. Our analysis indicates that markers located in loci known to influence fat mass through increased appetite affect obesity in Saudi Arabians to an extent possibly greater than in Europeans. Larger scale studies will be necessary to obtain a precise comparison.

Biomarkers of oxidative stress in women with pre-eclampsia

AIM The potential role of oxidative stress in the pathophysiology of pre-eclampsia has been reported in the literature. There are only a few studies that have investigated changes in malondialdehyde (MDA), vitamin E and total blood glutathione together in pre-eclampsia. Therefore, the aim of this study was to measure the levels of MDA, vitamin E and total glutathione as putative circulatory markers of oxidative stress for the early detection of pre-eclampsia. PATIENTS & METHODS In this case-control study, blood samples were collected from 40 pre-eclamptic and 80 normal pregnant females at the department of obstetrics and gynecology at King Abdulaziz Medical City (Riyadh, Saudi Arabia) between February 2009 and January 2010. Circulating markers of oxidative stress were evaluated, including MDA, total glutathione and vitamin E, by high-performance liquid chromatography. RESULTS Markers of oxidative stress including serum MDA, total glutathione and vitamin E were found to be significantly different in both groups. CONCLUSION MDA, vitamin E and blood total glutathione are possible candidate markers to predict pre-eclampsia.