Preterm, early term, and post-term infants from Riyadh mother and baby multicenter cohort study: The cohort profile

Background

Birth before 37 or beyond 42 gestational weeks is associated with adverse neonatal and maternal outcomes. Studies investigating determinants and outcomes of these deliveries are scarce. The objective of this study was to determine the neonatal birth profile in relation to the gestational age at delivery and to evaluate its influence on the immediate maternal and neonatal outcomes.

Methods

This is a multicenter cohort study of 13,403 women conducted in three hospitals in Riyadh. Collected data included sociodemographic characteristics, obstetric history, and physical and laboratory measurements. Regression models were developed to estimate the adjusted odds ratio (OR) and confidence intervals (CI) to determine factors associated with preterm, early term, and post-term births and to evaluate common maternal and neonatal risks imposed by deliveries outside the full term.

Results

The incidence of preterm, early term, and post-term delivery was 8.4%, 29.8%, and 1.4%, respectively. Hypertensive events during pregnancy consistently increased the risk of all grades of preterm births, from more than 3-fold for late preterm (OR = 3.40, 95% CI = 2.21-5.23) to nearly 7-fold for extremely early preterm (OR = 7.11, 95% CI = 2.24-22.60). Early term was more likely to occur in older mothers (OR = 1.30, 95% CI = 1.13-1.49), grand multiparous (OR = 1.21, 95% CI = 1.06-1.38), pregestational diabetes (OR = 1.91, 95% CI = 1.49-2.44), and gestational diabetes women (OR = 1.18, 95% CI = 1.05-1.33). The risk of post-term birth was higher in primiparous. In preterm births, the adverse outcome of neonates having an APGAR score of <7 at 5 min and admission to neonatal intensive care units increased progressively as the gestational age decreased. Post-term births are 2-fold more likely to need induction of labor; meanwhile, preterm births were more likely to deliver by cesarean section.

Conclusion

This large cohort study was the first in Saudi Arabia to assess the delivery profile across a continuum of gestational age and the associated maternal and neonatal adverse outcomes of deliveries outside the full-term period. The study showed that the prevalence of preterm and post-term birth in Saudi Arabia is similar to the prevalence in other high-income countries. The immediate adverse pregnancy outcomes inversely increased with the decrease in gestational age at delivery. In addition, maternal age, hypertension, diabetes, and parity influenced the gestational age at delivery.

Mental health impact of the first wave of the COVID-19 pandemic on healthcare workers in 12 Arab countries

Background: The COVID-19 pandemic has had a significant impact on public health and healthcare systems worldwide, including the psychological impact on healthcare workers (HCWs). Aims: To investigate the COVID-19-related psychological impact on HCWs in 12 Arab countries. Methods: This was a cross-sectional, hospital-based online survey conducted between May 4 and June 8, 2020. We evaluated stress, depression, anxiety and insomnia using the Depression Anxiety Stress Scale and Insomnia Severity Index. Results: A total of 2879 respondents from 12 Arab countries completed the survey. Anxiety, depression, stress and insomnia were identified in 48.9%, 50.6%, 41.4% and 72.1% of respondents, respectively. Lower-middle- and low-income countries had a significantly higher prevalence of all the psychological outcomes compared with high-income countries. The prevalence of mental health symptoms was higher in HCWs aged 30–39 years, those who worked > 44 hours/week, and those in contact with COVID-19 cases, as well as HCWs who were not satisfied with the preventive measures. The prevalence of mental health symptoms was lower among male HCWs. Conclusion: COVID-19 had a considerable impact on the mental and psychological health of HCWs in Arab countries. This was aggravated by the particular geopolitical positions of some Arab countries and social norms during the month of Ramadan. Physicians, young HCWs, and long working hours were all risk factors for greater psychological impact of the outbreak.

Cardiovascular Risk Among Saudi Adults with Prediabetes: A Sub-Cohort Analysis from the Heart Health Promotion (HHP) Study

Background

This study aimed to estimate the prevalence of prediabetes among Saudi adults and to evaluate their risk of developing cardiovascular diseases.

Methods

This is a cohort of 2470 Saudi adults attending employee clinics in the university hospital. WHO-STEPs approach was used to collect sociodemographic (age, gender, and education), clinical (body mass index and blood pressure) and laboratory data (HbA1c, lipid profile and vitamin D concentration). Prediabetes was defined according to HbA1c level of 5.7–6.4%. Cardiovascular risk (CVR) scores were evaluated using the Framingham Risk Score. SPSS was used for data analysis to investigate the relation between different CVR and prediabetes.

Results

Prediabetes affected 25.1% of the study population. Males had higher rates of prediabetes than females (27.5% versus 23.5%). The prevalence of prediabetes increased from 11.6% among young individuals (18–29 years) to 56.0% among participants 60 years and older. Prediabetes patients exhibited considerably higher levels of all cardiovascular risk factors and nearly half of them (49.3%) had at least two risk factors. The prevalence of intermediate CVR among prediabetics was 13.2% compared to just 2.9% among the normal group, and high CVR was defined in 3.7% among prediabetics compared to only 1.7% in the normal group. Having prediabetes increased the odds to develop higher CVR of 2.64 times compared to those without prediabetes (OR = 2.64, 95% CI = 1.51–4.64) and the level of vitamin D did not affect the odds of CVR.

Conclusion

Prediabetes is quite prevalent among Saudi adults, and they are at a higher risk of cardiovascular diseases. Patients with prediabetes have higher cardiac risk scores when compared to normal participants across the whole spectrum of (25(OH)D) concentrations. Additionally, no significant correlation was observed between HbA1c and (25(OH)D) levels in prediabetics or normoglycemic subjects.

Independent effect of gestational weight gain and prepregnancy obesity on pregnancy outcomes among Saudi women: A sub-cohort analysis from Riyadh mother and baby cohort study (RAHMA)

Background

Gestational weight gain (GWG) and prepregnancy obesity are garnering more attention as determining factors of pregnancy outcomes when it comes to the wellbeing of both the mother and her baby. This study was conducted to describe the pattern of GWG among participants of Riyadh Mother and Baby Multicenter Cohort Study (RAHMA) and to investigate the detrimental effects of excessive GWG and prepregnancy obesity on pregnancy outcomes.

Methods

RAHMA is a multicentre cohort study conducted in three hospitals in Riyadh, Saudi Arabia. Participants were categorized according to the Institute of Medicine into inadequate, adequate, and excessive GWG, and stratified by body mass index (BMI) into under/normal weight, overweight, and obese. To examine the independent effect of maternal prepregnancy obesity and GWG, a multivariate regression model was used and adjusted odds ratio (AOR) and 95% Confidence Interval (CI) for each outcome were calculated.

Results

A total of 7029 participants were included in this study; 31.8% had adequate GWG, 25.9% had excessive GWG and 42.3% had inadequate GWG, while 29.7% had normal BMI, 33.3% were overweight, 34.8% were obese, and 2.2% were underweight. Excessive GWG was independently associated with increased risk of hypertensive events, (AOR = 1.77, 95% CI 1.20–2.63). Obesity was associated with higher risk of gestational diabetes (AOR 2.11, 95% CI 1.76–2.53), hypertensive events (AOR 2.06, 95% CI 1.48–3.01), and delivery by emergency caesarean section (AOR = 1.63, 95% CI 1.35–1.97). Infants of obese women had increased odds of macrosomia (AOR 3.11, 95% CI 1.94–4.99) and lower odds of low birth weight (AOR = 0.68, 95% CI 0.53–0.88).

Conclusion

In comparison to excessive GWG, which increases the risk of hypertensive events during pregnancy, prepregnancy obesity is associated with more adverse outcomes including GDM, hypertensive events in pregnancy and emergency CS.

International alliance and AGREE-ment of 71 clinical practice guidelines on the management of critical care patients with COVID-19: a living systematic review

OBJECTIVE

We aimed to systematically identify and critically assess the clinical practice guidelines (CPGs) for the management of critically ill patients with COVID-19 with the AGREE II instrument.

STUDY DESIGN AND SETTING

We searched Medline, CINAHL, EMBASE, CNKI, CBM, WanFang, and grey literature from November 2019 - November 2020. We did not apply language restrictions. One reviewer independently screened the retrieved titles and abstracts, and a second reviewer confirmed the decisions. Full texts were assessed independently and in duplicate. Disagreements were resolved by consensus. We included any guideline that provided recommendations on the management of critically ill patients with COVID-19. Data extraction was performed independently and in duplicate by two reviewers. We descriptively summarized CPGs characteristics. We assessed the quality with the AGREE II instrument and we summarized relevant therapeutic interventions.

RESULTS

We retrieved 3,907 records and 71 CPGs were included. Means (Standard Deviations) of the scores for the 6 domains of the AGREE II instrument were 65%(SD19.56%), 39%(SD19.64%), 27%(SD19.48%), 70%(SD15.74%), 26%(SD18.49%), 42%(SD34.91) for the scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, editorial independence domains, respectively. Most of the CPGs showed a low overall quality (less than 40%).

CONCLUSION

Future CPGs for COVID-19 need to rely, for their development, on standard evidence-based methods and tools.

Effectiveness of health education in reducing secondhand smoke exposure among pregnant women visiting the antenatal clinic in Saudi Arabia: A randomized controlled trial

Background

Pregnant women's exposure to secondhand smoking (SHS) is associated with detrimental effects on the pregnancy outcomes.

Objectives

The objective of the study was to compare the effectiveness of face-to-face counseling, based on health belief model (HBM), combined with a written educational pamphlet, and health education using written pamphlet only, in improving pregnant women's perception, behavior to avoid SHS and change in exposure to SHS.

Methods

A randomized controlled trial was conducted in 2016. The intervention group received face-to-face health counseling on SHS, while the control group received only written educational pamphlets. Outcomes were the change in the perception of mother on the four constructs of the HBM and the change in mothers' behavior of avoidance of SHS exposure.

Results

A total of 100 women were recruited for the study, of whom 93 (47 intervention and 46 control) women completed the study. All women identified their spouse as a source of SHS exposure. Following the intervention, the intervention group had significantly higher scores in the perception of susceptibility (21 ± 4 vs. 16 ± 7, P < 0.01) and severity (15 ± 3 vs. 12 ± 4, P < 0.01) and reduced perception scores of barriers to avoid SHS exposure (11 ± 4 vs. 9 ± 5, P = 0.03), compared to the control group. However, there was an insignificant change in the exposure to SHS after the intervention in both the groups; where 25 (53.2%) women in the intervention group and 31 (67.4%) in the control group (P = 0.16), continued to being exposed to SHS.

Conclusion

Counselling of pregnant women, based on HBM, has insignificant effect in reducing their exposure to SHS; however it is effective in improving their knowledge and perception about SHS exposure.

Adapting evidence-based clinical practice guidelines for people with attention deficit hyperactivity disorder in Saudi Arabia: process and outputs of a national initiative

BACKGROUND

We recently adapted the published National Institute for Health and Care Excellence (NICE) Attention deficit hyperactivity disorder (ADHD) diagnosis and management guideline to the Saudi Arabian context. It has been postulated that adaptation of evidence-based clinical practice guidelines to the local healthcare context rather than de-novo development will improve their adoption and implementation without imposing a significant burden on resources. The objective of this paper is to describe the adaptation process methodology utilized for the generation of the first national guideline for management of people with ADHD in Saudi Arabia.

METHODS

We used the KSU-Modified-ADAPTE methodology for the guideline adaptation process. We describe the full process in detail including the three phases of set-up, adaptation, and finalization. The process was conducted by a multidisciplinary guideline adaptation group in addition to an external review for the clinical content and methodology.

RESULTS

The group adapted ten main categories of recommendations from one source CPG (NICE). The recommendations include: (i) service organisation and training, (ii) recognition, identification and referral, (iii) diagnosis, (iv) support, (v) managing ADHD, (vi) dietary advice, (vii) medication, (viii) maintenance and monitoring, (ix) adherence to treatment, and (x) review of medication and discontinuation. Several implementation tools were compiled and developed to enhance implementability including a clinical algorithm, quality measures, coding system, medication tables, translations, patient information, and online resources.

CONCLUSIONS

The finalized clinical practice guideline provides healthcare providers with applicable evidence-based guidance for the management of people with ADHD in Saudi Arabia. The project also demonstrated the effectiveness of KSU-Modified-ADAPTE, and emphasized the value of a collaborative clinical and methodological expert group for adaptation of national guidelines.

Systematic review and meta-analysis of the effectiveness of pre-pregnancy care for women with diabetes for improving maternal and perinatal outcomes

Background

Pre-gestational diabetes mellitus is associated with increased risk of maternal and perinatal adverse outcomes. This systematic review was conducted to evaluate the effectiveness and safety of pre-conception care (PCC) in improving maternal and perinatal outcomes.

Methods

Databases from MEDLINE, EMBASE, WEB OF SCIENCE, and Cochrane Library were searched, including the CENTRAL register of controlled trials, and CINHAL up until March 2019, without any language restrictions, for any pre-pregnancy care aiming at health promotion, glycemic control, and screening and treatment of diabetes complications in women with type I or type II pre-gestational diabetes. Trials and observational studies were included in the review. Newcastle-Ottawa scale and the Cochrane collaboration methodology for data synthesis and analysis were used, along with the GRADE tool to evaluate the body of evidence.

Results

The search identified 8500 potentially relevant citations of which 40 reports of 36 studies were included. The meta-analysis results show that PCC reduced congenital malformations risk by 71%, (Risk ratio (RR) 0.29; 95% CI: 0.21–0.40, 25 studies; 5903 women; high-certainty evidence). The results also show that PCC may lower HbA1c in the first trimester of pregnancy by an average of 1.27% (Mean difference (MD) 1.27; 95% CI: 1.33–1.22; 4927 women; 24 studies, moderate-certainty evidence). Furthermore, the results suggest that PCC may lead to a slight reduction in the risk of preterm delivery of 15%, (RR 0.85; 95% CI: 0.73–0.99; nine studies, 2414 women; moderate-certainty evidence). Moreover, PCC may result in risk reduction of perinatal mortality by 54%, (RR 0.46; 95% CI: 0.30–0.73; ten studies; 3071 women; moderate-certainty evidence). There is uncertainty about the effects of PCC on the early booking for antenatal care (MD 1.31; 95% CI: 1.40–1.23; five studies, 1081 women; very low-certainty evidence) and maternal hypoglycemia in the first trimester, (RR 1.38; 95% CI: 1.07–1.79; three studies; 686 women; very low- certainty evidence). In addition, results of the meta-analysis indicate that PCC may lead to 48% reduction in the risk of small for gestational age (SGA) (RR 0.52; 95% CI: 0.37–0.75; six studies, 2261 women; moderate-certainty evidence). PCC may reduce the risk of neonatal admission to intensive care unit (NICU) by 25% (RR 0.75; 95% CI: 0.67–0.84; four studies; 1322 women; moderate-certainty evidence). However, PCC may have little or no effect in reducing the cesarean section rate (RR 1.02; 95% CI: 0.96–1.07; 14 studies; 3641 women; low-certainty evidence); miscarriage rate (RR 0.86; 95% CI: 0.70–1.06; 11 studies; 2698 women; low-certainty evidence); macrosomia rate (RR 1.06; 95% CI: 0.97–1.15; nine studies; 2787 women, low-certainty evidence); neonatal hypoglycemia (RR 0.93; 95% CI: 0.74–1.18; five studies; 880 women; low-certainty evidence); respiratory distress syndrome (RR 0.78; 95% CI: 0.47–1.29; four studies; 466 women; very low-certainty evidence); or shoulder dystocia (RR 0.28; 95% CI: 0.07–1.12; 2 studies; 530 women; very low-certainty evidence).

Conclusion

PCC for women with pre-gestational type 1 or type 2 diabetes mellitus is effective in improving rates of congenital malformations. In addition, it may improve the risk of preterm delivery and admission to NICU. PCC probably reduces maternal HbA1C in the first trimester of pregnancy, perinatal mortality and SGA. There is uncertainty regarding the effects of PCC on early booking for antenatal care or maternal hypoglycemia during the first trimester of pregnancy. PCC has little or no effect on other maternal and perinatal outcomes.

Adapting evidence-based clinical practice guidelines at university teaching hospitals: A model for the Eastern Mediterranean Region

RATIONALE, AIMS, AND OBJECTIVES

Clinical practice guidelines (CPGs) are significant tools for evidence-based health care quality improvement. The CPG program at King Saud University was launched as a quality improvement program to fulfil the international accreditation standards. This program was a collaboration between the Research Chair for Evidence-Based Healthcare and Knowledge Translation and the Quality Management Department. This study aims to develop a fast-track method for adaptation of evidence-based CPGs and describe results of the program.

METHODS

Twenty-two clinical departments participated in the program. Following a CPGs awareness week directed to all health care professionals (HCPs), 22 teams were trained to set priorities, search, screen, assess, select, and customize the best available CPGs. The teams were technically supported by the program's CPG advisors. To address the local health care context, a modified version of the ADAPTE was used where recommendations were either accepted or rejected but not changed. A strict peer-review process for clinical content and methodology was employed.

RESULTS

In addition to raising awareness and building capacity, 35 CPGs were approved for implementation by March 2018. These CPGs were integrated with other existing projects such as accreditation, electronic medical records, performance management, and training and education. Preliminary implementation audits suggest a positive impact on patient outcomes. Leadership commitment was a strength, but the high turnover of the team members required frequent and extensive training for HCPs.

CONCLUSION

This model for CPG adaptation represents a quick, practical, economical method with a sense of ownership by staff. Using this modified version can be replicated in other countries to assess its validity.

Management of convulsive status epilepticus in children: an adapted clinical practice guideline for pediatricians in Saudi Arabia

Objective:

To increase the use of evidence-based approaches in the diagnosis, investigations and treatment of Convulsive Status Epilepticus (CSE) in children in relevant care settings.

Method:

A Clinical Practice Guideline (CPG) adaptation group was formulated at a university hospital in Riyadh. The group utilized 2 CPG validated tools including the ADAPTE method and the AGREE II instrument.

Results:

The group adapted 3 main categories of recommendations from one Source CPG. The recommendations cover; (i)first-line treatment of CSE in the community; (ii)treatment of CSE in the hospital; and (iii)refractory CSE. Implementation tools were built to enhance knowledge translation of these recommendations including a clinical algorithm, audit criteria, and a computerized provider order entry.

Conclusion:

A clinical practice guideline for the Saudi healthcare context was formulated using a guideline adaptation process to support relevant clinicians managing CSE in children.

Progestogen for treating threatened miscarriage

BACKGROUND

Miscarriage is a common complication encountered during pregnancy. It is defined as spontaneous pregnancy loss before 20 weeks' gestation. Progesterone's physiological role is to prepare the uterus for the implantation of the embryo, enhance uterine quiescence and suppress uterine contractions, hence, it may play a role in preventing rejection of the embryo. Inadequate secretion of progesterone in early pregnancy has been linked to the aetiology of miscarriage and progesterone supplementation has been used as a treatment for threatened miscarriage to prevent spontaneous pregnancy loss. This update of the Cochrane Review first published in 2007, and previously updated in 2011, investigates the evidence base for this practice.

OBJECTIVES

To determine the efficacy and the safety of progestogens in the treatment of threatened miscarriage.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (8 August 2017) and reference lists of retrieved trials.

SELECTION CRITERIA

Randomised, quasi-randomised or cluster-randomised controlled trials, that compared progestogen with placebo, no treatment or any other treatment for the treatment of threatened miscarriage in women carrying singleton pregnancy.

DATA COLLECTION AND ANALYSIS

At least two review authors assessed the trials for inclusion in the review, assessed trial quality and extracted the data and graded the body of evidence.

MAIN RESULTS

We included seven trials (involving 696 participants) in this update of the review. The included trials were conducted in different countries, covering the full spectrum of the World Bank's economic classification, which enhances the applicability of evidence drawn from this review. Two trials were conducted in Germany and Italy which are high-income countries, while four trials were conducted in upper-middle income countries; two in Iran, one in Malaysia and the fourth in Turkey, and the seventh trial was conducted in Jordan, which is a lower-middle income country. In six trials all the participants met the inclusion criteria and in the seventh study, we included in the meta-analysis only the subgroup of participants who met the inclusion criteria. We assessed the body of evidence for the main outcomes using the GRADE tool and the quality of the evidence ranged from very low to moderate. Downgrading of evidence was based on the high risk of bias in six of the seven included trials and a small number of events and wide confidence intervals for some outcomes.Treatment of miscarriage with progestogens compared to placebo or no treatment probably reduces the risk of miscarriage; (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.47 to 0.87; 7 trials; 696 women; moderate-quality evidence). Treatment with oral progestogen compared to no treatment also probably reduces the miscarriage rate (RR 0.57, 95% CI 0.38 to 0.85; 3 trials; 408 women; moderate-quality evidence). However treatment with vaginal progesterone compared to placebo, probably has little or no effect in reducing the miscarriage rate (RR 0.75, 95% CI 0.47 to 1.21; 4 trials; 288 women; moderate-quality evidence). The subgroup interaction test indicated no difference according to route of administration between the oral and vaginal subgroups of progesterone.Treatment of preterm birth with the use of progestogens compared to placebo or no treatment may have little or no effect in reducing the rate of preterm birth (RR 0.86, 95% CI 0.52 to 1.44; 5 trials; 588 women; low-quality evidence).We are uncertain if treatment of threatened miscarriage with progestogens compared to placebo or no treatment has any effect on the rate of congenital abnormalities because the quality of the evidence is very low (RR 0.70, 95% CI 0.10 to 4.82; 2 trials; 337 infants; very-low quality evidence).

AUTHORS' CONCLUSIONS

The results of this Cochrane Review suggest that progestogens are probably effective in the treatment of threatened miscarriage but may have little or no effect in the rate of preterm birth. The evidence on congenital abnormalities is uncertain, because the quality of the evidence for this outcome was based on only two small trials with very few events and was found to be of very low quality.

Failure Mode and Effect Analysis (FMEA) may enhance implementation of clinical practice guidelines: An experience from the Middle East

RATIONALE, AIMS, AND OBJECTIVES

Implementation of clinical practice guidelines (CPGs) has been shown to reduce variation in practice and improve health care quality and patients' safety. There is a limited experience of CPG implementation (CPGI) in the Middle East. The CPG program in our institution was launched in 2009. The Quality Management department conducted a Failure Mode and Effect Analysis (FMEA) for further improvement of CPGI.

METHODS

This is a prospective study of a qualitative/quantitative design. Our FMEA included (1) process review and recording of the steps and activities of CPGI; (2) hazard analysis by recording activity-related failure modes and their effects, identification of actions required, assigned severity, occurrence, and detection scores for each failure mode and calculated the risk priority number (RPN) by using an online interactive FMEA tool; (3) planning: RPNs were prioritized, recommendations, and further planning for new interventions were identified; and (4) monitoring: after reduction or elimination of the failure mode. The calculated RPN will be compared with subsequent analysis in post-implementation phase.

RESULTS

The data were scrutinized from a feedback of quality team members using a FMEA framework to enhance the implementation of 29 adapted CPGs. The identified potential common failure modes with the highest RPN (≥ 80) included awareness/training activities, accessibility of CPGs, fewer advocates from clinical champions, and CPGs auditing. Actions included (1) organizing regular awareness activities, (2) making CPGs printed and electronic copies accessible, (3) encouraging senior practitioners to get involved in CPGI, and (4) enhancing CPGs auditing as part of the quality sustainability plan.

CONCLUSION

In our experience, FMEA could be a useful tool to enhance CPGI. It helped us to identify potential barriers and prepare relevant solutions.

Elective surgery cancelation on day of surgery: An endless dilemma

Background:

Cancelation of surgery is a constant agonizing dilemma for nearly all healthcare services that has been intensively investigated to find out its roots, consequences, and possible solutions. The rates of cancelation of surgery vary between centers and more so among surgical specialties with numerous reasons standing behind this phenomenon.

Patients and Methods:

In the current study, analysis of monthly cancelation rates from January 2009 to December 2012, and assessment of establishing new operating rooms (ORs) using statistical process control charts was conducted. A detailed review of a total of 1813 cases canceled on the day of surgery from January to December 2012, to examine the various reasons of cancelation among surgical specialties.

Results:

The average cancelation rate was 11.1%, which dropped to 9.0% after launching of new theaters. Four reasons explained about 80% of cancelations; Patients “no show” was the leading cause of cancelation (27%). One-fourth of cancelations (24.3%) were due to the need for further optimization, and the third most prominent cause of cancelation was a lack of OR time (19.5%). Unavailability of staff/equipment/implants accounted for only 0.7% of cancelations. The no show was the most common cause of cancelation among all surgical specialties ranging from 21% for plastic surgery to 32% in ophthalmic surgeries.

Conclusion:

It was confirmed that there is a unique profile of cancelation of surgery problem for every institute, an extension of infrastructure may not be the only solution. Control charts helped to enhance the general picture and are functional in monitoring and evaluating changes in the cancelation of surgery.

The independent effects of maternal obesity and gestational diabetes on the pregnancy outcomes

BACKGROUND

Obesity and gestational diabetes (GDM) in pregnancy are recognized risk factors for adverse outcomes, including cesarean section (CS), macrosomia and preeclampsia. The aim of this study was to investigate the independent effect of GDM and obesity on the adverse pregnancy outcomes at term.

METHODS

A retrospective cohort of postpartum women, in King Khalid University Hospital, were stratified according to body mass index (obese ≥30 kg/m2, non-obese <30 kg/m2) and the results of GDM screening into the following groups, women with no obesity and no GDM (reference group), women with no obesity but with GDM, women with obesity but no GDM and women with both GDM and obesity. Adverse pregnancy outcomes included high birth weight, macrosomia, CS delivery and preeclampsia. Multiple logistic regression used to examine independent associations of GDM and obesity with macrosomia and CS.

RESULTS

2701 women were included, 44% of them were obese and 15% had GDM. 63% of the women with GDM were obese. There was significant increase in the percentage of macrosomia, P < 0.001, high birth weight, P < 0.001, CS, P < 0.001 and preeclampsia, P < 0.001 in women with GDM and obesity compared to the reference group. Obesity increased the estimated risk of CS delivery, odds ratio (OR) 2.16, confidence intervals (CI) 1.74-2.67. The combination of GDM and obesity increased the risk of macrosomia OR 3.45, CI 2.05-5.81 and the risk of CS delivery OR 2.26, CI 1.65-3.11.

CONCLUSION

Maternal obesity and GDM were independently associated with adverse pregnancy outcomes. The combination of both conditions further increase the risk.

Awareness of an obstetric population about environmental tobacco smoking

BACKGROUND AND OBJECTIVES

The reported rate of women's smoking is typically low. However, many pregnant women are exposed to environmental tobacco smoke (ETS), which could affect their own health and the health of their growing fetus. The aim of this study was to estimate the magnitude of the problem of exposure to ETS and assess the awareness of postpartum women to ETS and its possible effects.

DESIGNS AND SETTINGS

This was a cross-sectional study conducted on 1182 postpartum women at a university hospital in Riyadh, Saudi Arabia, between 1(st) January and 30(th) June, 2012.

MATERIALS AND METHODS

A structured questionnaire was used for data collection. Factors associated with the level of understanding of the possible effects of ETS exposure were analyzed.

RESULTS

The majority of the participating women knew that exposure to ETS had adverse effects on maternal and fetal health (>80%), but their knowledge of the specific effects on fetal health was limited. The level of mothers' education was found to be associated with better knowledge of effects on mother and fetal health (P < 0.01).

CONCLUSION

This study revealed that pregnant women in our sample had limited knowledge of the specific effects of ETS on fetal health. This shortcoming in knowledge needs to be addressed by improving health.

Effects of secondhand smoke on the birth weight of term infants and the demographic profile of Saudi exposed women

BACKGROUND

Maternal exposure to tobacco smoke during pregnancy is associated with detrimental effects on the mother and the fetus including; impaired fetal growth, low birth weight and preterm delivery. In utero exposure to tobacco is implicated in the etiology of many adults' diseases including obesity, diabetes and hypertension.The objectives of this study were to evaluate the effects of Secondhand Tobacco Smoke (SHS) exposure on newborns' anthropometric measurements and to compare the demographic profile of the women exposed to SHS to those who were not.

METHOD

This is a retrospective cohort study investigating the effects of SHS during pregnancy on newborns' anthropometry. Women who self-reported SHS exposure were compared with those not exposed. The primary outcomes were birth weight, newborn length and head circumference. Univariate analysis and multivariate regression analysis were performed. Adjusted differences with 95% confidence intervals were calculated.

RESULTS

Mothers exposed to SHS constituted 31% of the cohort. The mean birth weight of infants of exposed mothers was significantly lower by 35 g, 95% CI: 2-68 g, (P = 0.037) and the mean length was shorter by 0.261 cm, 95% CI 0.058-0.464 cm, (P = 0.012) compared to the infants of unexposed mothers. Women exposed to SHS, were younger, of lower parity and more likely to be illiterate than those who were not exposed in addition, exposed women were less likely to be primiparous.

CONCLUSION

The prevalence of exposure of Saudi pregnant women to SHS is high at 31% and it is associated with reduced birth weight, and shorter length of the newborn.

Pre-pregnancy care for women with pre-gestational diabetes mellitus: a systematic review and meta-analysis

BACKGROUND

Pre-gestational diabetes mellitus is associated with increased risk for maternal and fetal adverse outcomes. This systematic review was carried out to evaluate the effectiveness and safety of pre-pregnancy care in improving the rate of congenital malformations and perinatal mortality for women with pre-gestational diabetes mellitus.

METHODS

We searched the following databases, MEDLINE, EMBASE, WEB OF SCIENCE, Cochrane Library, including the CENTRAL register of controlled trials and CINHAL up to December 2011, without language restriction, for any pre-pregnancy care aiming at health promotion, glycemic control and screening and treatment of diabetes complications in women with type I or type II diabetes mellitus. Study design were trials (randomized and non-randomized), cohort and case-control studies.

RESULTS

Of the 2452 title scanned 54 full papers were retrieved of those 21 studies were included in this review. Twelve cohort studies at low and medium risk of bias, with 3088 women, were included in the meta-analysis. Meta-analysis suggested that pre-pregnancy care is effective in reducing congenital malformation, Risk Ratio (RR) 0.25 (95% CI 0.16-0.37), number needed to treat (NNT) 19 (95% CI 14-24), and perinatal mortality RR 0.34 (95% CI 0.15-0.75), NNT = 46 (95% CI 28-115). Pre-pregnancy care lowers glycosylated hemoglobin A1c (HbA1c) in the first trimester of pregnancy by an average of 1.92% (95% CI -2.05 to -1.79). However women who received pre-pregnancy care were at increased risk of hypoglycemia during the first trimester of pregnancy RR 1.51 (95% CI 1.15-1.99).

CONCLUSION

Pre-pregnancy care for women with pre-gestational type 1 or type 2 diabetes mellitus is effective in improving rates of congenital malformations, perinatal mortality and in reducing maternal HbA1C in the first trimester of pregnancy. Pre-pregnancy care might cause maternal hypoglycemia in the first trimester of pregnancy.

Reasons behind non-adherence of healthcare practitioners to pediatric asthma guidelines in an emergency department in Saudi Arabia

BACKGROUND

The prevalence of childhood bronchial asthma in Saudi Arabia has increased in less than a decade from 8% to 23%. Innovations in the management of asthma led to the development of evidence based clinical practice guidelines and protocols to improve the patients' outcomes. The objectives of this study are to examine the compliance of the healthcare providers in the Pediatrics Emergency Department, in King Khalid University Hospital, with the recommendations of the Pediatrics Asthma Management Protocol (PAMP), and to explore the reasons behind non-adherence.

METHODS

This study is designed in 2 parts, a patients' chart review and a focus group interview. The medical records of all the children who presented to the Pediatric Emergency Department (PED) and were diagnosed as asthmatic, during the period from the 1st of January 2009 to the 31st of March 2009, were reviewed to investigate the compliance of healthcare providers (physicians and nurses) with 8 recommendations of the PAMP which are considered to be frequently encountered evidence-practice gaps, and these are 1) documentation of asthma severity grading by the treating physician and nurse 2) limiting the prescription of Ipratropium for children with severe asthma 3) administration of Salbutamol through an inhaler and a spacer 4) documentation of parental education 5) prescription of systemic corticosteroids to all cases of acute asthma 6) limiting chest x-ray requisition for children with suspected chest infection 7) management of all cases of asthma as outpatients, unless diagnosed as severe or life threatening asthma 8) limiting prescription of antibiotics to children with chest infection. The second part of this study is a focus group interview designed to elicit the reasons behind non-adherence to the recommendations detected by the chart review. Two separate focus group interviews were conducted for 10 physicians and 10 nurses. The focus group interviews were tape-recorded and transcribed verbatim. Theory-based content analysis was used to analyze interviews into themes and sub-themes.

RESULTS AND DISCUSSION

A total of 657 charts were reviewed. The percentage of adherence by the healthcare providers to the 8 previously mentioned recommendations was established. There was non-adherence to the first 5 of the 8 aforementioned recommendations. Analysis of the focus group interview revealed 3 main themes as reasons behind non-compliance to the 5 recommendations mentioned above and those are 1) factors related to the organization, 2) factors related to the asthma management protocol 3) factors related to healthcare providers.

CONCLUSION

The organizational barriers and the lack of an implementation strategy for the protocol, in addition to the attitude and beliefs of the healthcare providers, are the main factors behind non-compliance to the PAMP recommendations.

Factors associated with successful induction of labor

OBJECTIVE

To evaluate the prevalence, indications, and factors associated with successful induction of labor (IOL), and maternal and neonatal outcomes.

METHODS

All women booked for IOL at King Khalid University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia from April 2010 to March 2011 were included. The characteristics of women who had successful IOL were compared to those who delivered by cesarean section (CS). A multivariable logistic regression analysis was performed to evaluate the factors associated with successful IOL.

RESULTS

During the study period, 564 women had IOL. The prevalence rate of IOL was 16%. Vaginal delivery was achieved in 472 (84%) women. The most common indications for IOL were post-term pregnancy in 174 (31%), and diabetes mellitus in 131 (23.2%) of the participants. Maternal characteristics associated with risk of CS were nulliparity (odds ratio: 1.58; 95% confidence interval: 1.09-2.320; p=0.01), and high maternal body mass index (p=0.01). Neonates of women with successful IOL had significantly higher APGAR scores (p=0.04), and more frequent pH more than or equal to 7.1 at delivery (p=0.02). There was no difference in the rate of post-partum hemorrhage, CS, or ruptured uterus between the women who had IOL, and those who went into spontaneous labor.

CONCLUSION

Nulliparity and maternal weight are the main determinants of the outcome of IOL. Case selection for IOL is vital for achieving outcomes similar to spontaneous labor.

Progestogen for treating threatened miscarriage

BACKGROUND

Miscarriage is a common complication encountered during pregnancy. The role of progesterone in preparing the uterus for the implantation of the embryo and its role in maintaining the pregnancy have been known for a long time. Inadequate secretion of progesterone in early pregnancy has been linked to the aetiology of miscarriage and progesterone supplementation has been used as a treatment for threatened miscarriage to prevent spontaneous pregnancy loss.

OBJECTIVES

To determine the efficacy and the safety of progestogens in the treatment of threatened miscarriage.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2011) and bibliographies of all located articles for any additional studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compare progestogen with placebo, no treatment or any other treatment given in an effort to treat threatened miscarriage.

DATA COLLECTION AND ANALYSIS

At least two authors assessed the trials for inclusion in the review, assessed trial quality and extracted the data. Data were checked for accuracy.

MAIN RESULTS

We included four studies (421 participants) in the meta-analysis. In three studies all the participants met the inclusion criteria and in the fourth study, we included only the subgroup of participants who met the inclusion criteria in the meta-analysis. There was evidence of a reduction in the rate of spontaneous miscarriage with the use of progestogens compared to placebo or no treatment (risk ratio (RR) 0.53; 95% confidence interval (CI) 0.35 to 0.79). There was no increase in the rate of antepartum haemorrhage (RR 0.76; 95% CI 0.30 to 1.94), or pregnancy-induced hypertension (RR 1.00; 95% CI 0.54 to 1.88) for the mother. The rate of congenital abnormalities was no different between the newborns of the mothers who received progestogens and those who did not (RR 0.70; 95% CI 0.10 to 4.82).

AUTHORS' CONCLUSIONS

The data from this review suggest that the use of progestogens is effective in the treatment of threatened miscarriage with no evidence of increased rates of pregnancy-induced hypertension or antepartum haemorrhage as harmful effects to the mother, nor increased occurrence of congenital abnormalities on the newborn. However, the analysis was limited by the small number and the poor methodological quality of eligible studies (four studies) and the small number of the participants (421), which limit the power of the meta-analysis and hence of this conclusion.

Innovative teaching methods for capacity building in knowledge translation

BACKGROUND

In some current healthcare settings, there is a noticeable absence of national institutions committed to the synthesis and use of evidence in healthcare decision- and policy-making. This absence creates a need to broaden the responsibilities of healthcare providers to include knowledge brokering and advocacy in order to optimize knowledge translation to other stakeholders, especially policy-makers. However, this process requires practitioners and researchers to acquire certain types of knowledge and skills. This article introduces two innovative methods for capacity building in knowledge translation (KT).

METHODS

During a workshop aimed at preparing 21 trainers in evidence-based medicine, two innovative methods were used: (1) debate and (2) a knowledge translation project (KTP). The main objective of the debates approach was to strengthen participants' critical thinking abilities by requiring them to search for and appraise evidence and defend their arguments. The KTP was used to introduce participants to the essential steps of knowledge translation and to suggest an extended role for healthcare practitioners, i.e., using evidence to manage not only individual patients but also to a community of patients. Participants' performances were assessed according to a pre-designed scheme. At the end of the workshop, participants' opinions and experiences with the innovative teaching methods were evaluated based on their answers to a questionnaire and the results of small-group discussions.

RESULTS

The participants performed well in both the debate and KTP methods. During post-workshop group discussions, they indicated that the debate approach had added a new dimension to their evidence-based medicine skills by adding purpose and motivation. However, they felt that their performances would have been better if they had been offered practical demonstrations of how to conduct the debate. The participants indicated that the KTP enhanced their understanding of the relationships between evidence and implementation, and motivated them to investigate public health problems in addition to individual patient problems. However, some participants maintained that these issues fell outside the scope of their role as doctors.

CONCLUSION

Debates and evidence implementation through KTP are generally well accepted by healthcare practitioners as methods by which they can improve their skills in KT.

Attitude and practice of the health care professionals towards the clinical practice guidelines in King Khalid University Hospital in Saudi Arabia

RATIONALE, AIMS AND OBJECTIVES

To explore the opinion and practice of the health care providers in King Khalid University Hospital (KKUH) towards clinical practice guidelines (CPGs).

METHODS

A cross-sectional self-reported anonymous survey was distributed to 2225 health care professionals working in KKUH clinical departments.

RESULTS

The response rate was 56.5%. The respondents had a positive attitude towards CPGs; 90% thought that CPG unify patients' care and 96% agreed that CPGs improve the quality of services provided. The respondents' practice in using CPGs concurred with their attitude and opinion. A total of 86.3% agreed that CPGs changed the way they manage their patients and 71.8% agreed with the statement that they have already used CPGs in the management of the patients. Compared to nurses, physicians were significantly less likely to use CPGs in practice (P < 0.05); moreover, the practice of using guidelines differs significantly according to the years of experience, with 71% of respondents with experience of 15 years or more using CPGs in the management of their patients, compared to 60% among respondents with less years of experience (P < 0.05).

CONCLUSION

The health care providers at KKUH have positive practice and attitude towards CPGs in general, which could positively influence the future introduction and implementation of evidence-based CPGs.

Progestogen for treating threatened miscarriage

BACKGROUND

Miscarriage is a common complication encountered during pregnancy. The role of progesterone in preparing the uterus for the implantation of the embryo and its role in maintaining the pregnancy have been known for a long time. Inadequate secretion of progesterone in early pregnancy has been linked to the aetiology of miscarriage and progesterone supplementation has been used as a treatment for threatened miscarriage to prevent spontaneous pregnancy loss.

OBJECTIVES

To determine the efficacy and the safety of progestogens in the treatment of threatened miscarriage.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2009) and bibliographies of all located articles for any unidentified articles.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials that compare progestogen with placebo, no treatment or any other treatment given in an effort to treat threatened miscarriage.

DATA COLLECTION AND ANALYSIS

At least two authors assessed the trials for inclusion in the review and extracted the data.

MAIN RESULTS

Two studies (84 participants) were included in the meta-analysis. In one study, all the participants met the inclusion criteria and in the other study, only the subgroup of participants who met the inclusion criteria was included in the meta-analysis. There was no evidence of effectiveness with the use vaginal progesterone compared to placebo in reducing the risk of miscarriage (risk ratio 0.47; 95% confidence interval 0.17 to 1.30).

AUTHORS' CONCLUSIONS

Based on scarce data from two methodologically poor trials, there is no evidence to support the routine use of progestogens for the treatment of threatened miscarriage. Information about potential harms to the mother or child, or both, with the use of progestogens is lacking. Further, larger, randomized controlled trials on the effect of progestogens on the treatment of threatened miscarriage, which investigate potential harms as well as benefits, are needed.

The effectiveness of Hibiscus sabdariffa in the treatment of hypertension: a systematic review

INTRODUCTION

Hypertension is a common global health problem with significant mortality and morbidity. Hibiscus sabdariffa is a plant known in many countries and is consumed as hot and cold drinks In addition to its use in folk medicine; it has been suggested as treatment for many conditions including hypertension.

OBJECTIVES

The objectives of this review were to examine the evidence of effectiveness and safety of hibiscus in the treatment of hypertension.

METHODS

We searched several medical databases (MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and the specialized register of the Cochrane Hypertension Group and the general engine Google) to January 2009. We included randomized controlled trials that had examined Hibiscus's effectiveness and safety in the treatment of primary hypertension in adults. Two authors independently selected the trials for the review, extracted the data, and critically appraised the included studies.

RESULTS

Four trials, with a total of 390 patients, met our inclusion criteria. Two studies compared Hibiscus sabdariffa to black tea; one study compared it to captopril and one to lisinopril. The studies found that Hibiscus had greater blood pressure reduction than tea but less than the ACE-inhibitors. However, all studies, except one, were short term and of poor quality with a Jadad scoring of <3 and did not meet international standards.

CONCLUSION

The four randomized controlled studies identified in this review do not provide reliable evidence to support recommending Hibiscus sabdariffa for the treatment of primary hypertension in adults.

Progestogen for treating threatened miscarriage

BACKGROUND

Miscarriage is a common complication encountered during pregnancy. The role of progesterone in preparing the uterus for the implantation of the embryo and its role in maintaining the pregnancy have been known for a long time. Inadequate secretion of progesterone in early pregnancy has been linked to the aetiology of miscarriage and progesterone supplementation has been used as a treatment for threatened miscarriage to prevent spontaneous pregnancy loss.

OBJECTIVES

To determine the efficacy and the safety of progestogens in the treatment of threatened miscarriage.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 1), MEDLINE (January 1966 to April 2006), EMBASE (1980 to April 2006) and CINAHL (1982 to April 2006). We scanned bibliographies of all located articles for any unidentified articles.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials that compare progestogen with placebo, no treatment or any other treatment given in an effort to treat threatened miscarriage.

DATA COLLECTION AND ANALYSIS

At least two authors assessed the trials for inclusion in the review and extracted the data.

MAIN RESULTS

Two studies (84 participants) were included in the meta-analysis. In one study, all the participants met the inclusion criteria and in the other study, only the subgroup of participants who met the inclusion criteria was included in the meta-analysis. There was no evidence of effectiveness with the use vaginal progesterone compared to placebo in reducing the risk of miscarriage (relative risk 0.47; 95% confidence interval (CI) 0.17 to 1.30).

AUTHORS' CONCLUSIONS

Based on scarce data from two methodologically poor trials, there is no evidence to support the routine use of progestogens for the treatment of threatened miscarriage. Information about potential harms to the mother or child, or both, with the use of progestogens is lacking. Further, larger, randomized controlled trials on the effect of progestogens on the treatment of threatened miscarriage, which investigate potential harms as well as benefits, are needed.