Shared clinical decision making: A Saudi Arabian perspective

Objectives:

To determine preferences of patients regarding their involvement in the clinical decision making process and the related factors in Saudi Arabia.

Methods:

This cross-sectional study was conducted in a major family practice center in King Abdulaziz Medical City, Riyadh, Saudi Arabia, between March and May 2012. Multivariate multinomial regression models were fitted to identify factors associated with patients preferences.

Results:

The study included 236 participants. The most preferred decision-making style was shared decision-making (57%), followed by paternalistic (28%), and informed consumerism (14%). The preference for shared clinical decision making was significantly higher among male patients and those with higher level of education, whereas paternalism was significantly higher among older patients and those with chronic health conditions, and consumerism was significantly higher in younger age groups. In multivariate multinomial regression analysis, compared with the shared group, the consumerism group were more likely to be female [adjusted odds ratio (AOR) =2.87, 95% confidence interval [CI] 1.31-6.27, p=0.008] and non-dyslipidemic (AOR=2.90, 95% CI: 1.03-8.09, p=0.04), and the paternalism group were more likely to be older (AOR=1.03, 95% CI: 1.01-1.05, p=0.04), and female (AOR=2.47, 95% CI: 1.32-4.06, p=0.008).

Conclusion:

Preferences of patients for involvement in the clinical decision-making varied considerably. In our setting, underlying factors that influence these preferences identified in this study should be considered and tailored individually to achieve optimal treatment outcomes.Patients and physicians assume different and varying roles in the medical consultation process. This could determine the extent of involvement of the patient and the physicians in the clinical decision making process and patient care management. In one extreme, the physician assumes the responsibility of the clinical decision with no or very little joint deliberation with the patient. This is known as the “paternalistic” approach.1,2 In the other extreme, the informed medical decision approach means that the clinical decision is made by patients and potential others, including family members, after obtaining all needed medical information that could enable the patient to make on appropriate decision. This is known as the “consumerism” approach to clinical decision-making.3,4 Shared decision making is probably at the center of this spectrum, in which patients and physicians exchange information, discuss the details of the medical problems, explore available treatment options, and conclude together an agreed treatment plan.5 The provision of health care that is consistent with the preferences of patients may improve the patients’ satisfaction and health outcomes.6,7 The practice of shared clinical decision-making was encouraged as it respects patients’ autonomy, values, and commitment to the agreed health plan and continuity of care.8 The relevant literature shows that most patients prefer to be offered information on their medical conditions, available options of treatment, and future plan of care.1,3,9 However, the extent of the involvement of patients in the process of decision making is variable and influenced by issues related to the patients status of their illnesses, and types of decisions under consideration.10,11 Patients of younger age, women, and with higher levels of education have been found to prefer an active role and to share this process. In addition, preferences of patients may change with time and different stages of the sickness.11,12 The complexity of this process is further compounded by the fact that patient views and attitudes towards involvement in medical decision making are influenced significantly by certain underlying cultural aspects. This necessitates a sensitive and individual approach for each patient.13 This study aims to explore preferences of patients from Saudi Arabia regarding their involvement in medical decision making, and to explore factors that may affect these preferences.     

Delayed inpatient diagnosis and isolation of active pulmonary tuberculosis patients,a large tertiary care academic hospital experience in Riyadh,Saudi Arabia: What are we missing?

Objectives:To identify pulmonary tuberculosis (PTB) delayed inpatient diagnosis duration and contributing factors in an academic center in Saudi Arabia (SA).Methods:Retrospective review of all culture-confirmed PTB cases between May 2015 and April 2019. The outcomes were the timing between admission and suspicion of PTB or isolation to either early group (within 24 hours of admission) and late group (24 hours after admission).Results:Forty-nine cases were included with a median age of 49 years; a third of them were above 65 years of age. Most patients were of Saudi nationality and male. Approximately 38% of the cases were in the delayed group, half of them were smear-positive, with an average delay of 5.5 days. This was significant with age above 65 years (odds ratio [OR]=8.93, 95% confidence interval [CI]=2.22-35.95) presence of non-respiratory symptoms (OR=5.6, 95% CI=1.56-19.98), malignancy (OR=13.38, 95% CI=1.46-122.71), chronic medical problems (OR=4.90, 95% CI=1.31-18.32), missed chest x-ray findings (OR= 48, 95% CI=8.63-266.88) or procalcitonin level above 0.5 ng/mL (OR=12, 95% CI=1.58-91.08).Conclusion:Physicians in SA need to have a low threshold for PTB consideration in elderly patients or those with a history of malignancy. A careful review of the initial chest x-ray might help to overcome missing cases of PTB.     

Prevalence of cerebral venous thrombosis with the use of oral contraceptive pills during the Holy month of Ramadan

Objectives:To identify the epidemiologic profile of cerebral vein thrombosis (CVT) among fasting women using oral contraceptive pills (OCPs) during the holy month of Ramadan.Methods:This retrospective study was conducted on all patients diagnosed with CVT and using OCPs from records at a tertiary care hospital in Riyadh, Saudi Arabia during 2016-2017. The study participants were categorized into 2 groups (an intermittently fasting group during the holy month of Ramadan and a non-fasting group).Results:Out of 108 female patients with CVT, 36.1% were secondary to OCP, of whom 41% participants were fasting. The most affected site was the transverse sinus. Holocephalic headache was more common amongst fasting group (68.8%) compared to non-fasting group (30.4%) (p=0.025). Dehydration (p=0.003) amongst the fasting group and protein S deficiency (p=0.027) in the non-fasting group were identified as the 2 prominent risk factors. Unfractionated heparin was the most common anticoagulant therapies used during the initiation phase for non-fasting (36.4%) and fasting groups (50%).Conclusion:All women who are using OCP should undergo formal written risk assessments for factors of CVT. Our study suggests that the negative effects of OCPs use might outweigh its benefits; thus, it should be prescribed with caution, more so in fasting patients.     

Case fatality of bleeding and recurrent venous thromboembolism during,initial therapy with direct oral anticoagulants: A systematic review

Introduction

The frequency and case fatality of venous thromboembolism (VTE) and major bleeding during the initial 3 months of therapy in those treated for symptomatic VTE with either direct oral anticoagulants (DOACs) or vitamin K antagonists (VKA) are important clinically relevant outcomes. We sought to measure it during the initial months of anticoagulation for symptomatic VTE.

Material and Methods

We searched MEDLINE, EMBASE, and CENTRAL to identify studies that enrolled patients with acute symptomatic VTE treated with DOACs or VKA and reported data on bleeding, VTE recurrence and death. Studies were evaluated according to a priori inclusion criteria and critically appraised using established internal validity criteria. Single-proportion random-effects models were used to pool estimates.

Results

Of the 2453 citations retrieved, 5 RCTs that enrolled 24,507 patients were included. The rate of major bleeding was 1.8 (95% CI: 1.3-2.5) and 3.1 (95% CI: 2.4-3.9) per 100 patient-years in DOAC and VKA arms, respectively. The rate of VTE recurrence was 3.7 (95% CI: 2.7-4.7) and 4.1 (95% CI: 3.0-5.4) per 100 patient-years of DOAC and VKA, respectively. The case fatality rate of bleeding was significantly higher in the VKA arms 10.4% (95% CI: 6.6-15.4) compared to DOACs 6.1% (95% CI: 2.7-11.7; p value for difference = 0.029) with no statistical difference between the case fatalities for recurrent VTE. The rate of death from either definite major bleeding or definite recurrent VTE was 0.27 (95% CI: 0.16-0.40) and 0.46 (95% CI: 0.32-0.63) per 100 patient-years for DOACs and VKAs respectively, resulting in a number needed to treat of 875 for DOACs to prevent one death.

Conclusion

DOACs are attractive alternatives to VKAs for initial treatment of symptomatic VTE, with lower frequency and case fatality for major bleeding. However, the incremental safety benefit of DOACs over VKAs is small, with large numbers needed to treat.     

The society for cardiovascular angiography and interventions structural heart disease early career task force survey results: Endorsed by the society for cardiovascular angiography and interventions

Over the last decade, structural heart disease interventions have emerged as a new field in interventional cardiology. Currently, the Accreditation Council for Graduate Medical Education accredited interventional cardiology fellowship programs in the United States provide high‐quality and well established training curriculum in coronary and peripheral interventions, but training in structural interventions remains in its infancy. The current survey seeks to collect relevant information and assess the opinion of interventional cardiology program directors in ACGME‐accredited institutions that are actively involved in structural interventional training. Our study describes the actual number of structural procedures performed by interventional cardiology fellows in ACGME‐accredited programs, the form of the structural training today and the suggestions from program directors who are actively trying to integrate structural training in the interventional cardiology fellowship programs. © 2012 Wiley Periodicals, Inc.     

Cobalt–carbon/silica nanocomposites prepared by pyrolysis of a cobalt 2,2′-bipyridine terephthalate complex for remediation of cationic dyes

Recently, carbon nanostructures have attracted interest because of their unique properties and interesting applications. Here, CoC@SiO₂-850 (3) and CoC@SiO₂-600 (4) cobalt–carbon/silica nanocomposites were prepared by solid-state pyrolysis of anthracene with Co(tph)(2,2′-bipy)·4H₂O (1) complex in the presence of silica at 850 and 600 °C, respectively, where 2,2′-bipy is 2,2′-bipyridine and tph is the terephthalate dianion. Moreover, Co(μ-tph)(2,2′-bipy) (2) was isolated and its X-ray structure indicated that cobalt(ii) has a distorted trigonal prismatic coordination geometry. 2 is a metal–organic framework consisting of one-dimensional zigzag chains within a porous grid network. 3 and 4 consist of cobalt(0)/cobalt oxide nanoparticles with a graphitic shell and carbon nanotubes embedded in the silica matrix. They were characterized by scanning electron microscopy (SEM), transmission electron microscopy (TEM), powder X-ray diffraction (XRD), Brunauer–Emmett–Teller (BET), Raman spectroscopy, and X-ray photoelectron spectroscopy (XPS). XPS revealed that the nanocomposites are functionalized with oxygen-containing groups, such as carboxylic acid groups. In addition, the presence of metallic cobalt nanoparticles embedded in graphitized carbon was verified by XRD and TEM. The efficiency of 3 for adsorption of crystal violet (CV) dye was investigated by batch and column experiments. At 25 °C, the Langmuir adsorption capacity of 3 for CV was 214.2 mg g⁻¹ and the fixed-bed column capacity was 36.3 mg g⁻¹. The adsorption data were well fitted by the Freundlich isotherm and pseudo-second-order kinetic model. The adsorption process was spontaneous and endothermic.

A cobalt–carbon@silica nanocomposite was synthesized from a cobalt 2,2′-bipyridine terephthalate complex and its adsorption behavior towards crystal violet dye was tested using batch and column techniques.     

Gender Differences in the Heritability of Musculoskeletal and Body Composition Parameters in Mother-Daughter and Mother-Son Pairs

Bone mass and body composition traits are genetically programmed, but the timing and gender and site specificities of their heritability are unclear. Mother-child correlations of bone mineral density (BMD) and bone mineral content, lean mass, and fat mass were studied in 169 premenopausal mothers and their 239 children. Heritability estimates of lean mass, fat mass, BMD, and area were derived for each gender and pubertal stage. There were significant correlations for most densitometry-derived variables at the spine, hip, femoral neck (FN), and total body (r = 0.192–0.388) in mother-postmenarcheal daughter pairs, for bone areas at all sites in early puberty (r = 0.229–0.508) and for volumetric-derived density at FN and spine (r = 0.238–0.368) in mother-son pairs. Fat mass correlations were significant in both genders after puberty (r = 0.299–0.324) and lean mass in postmenarcheal girls only (r = 0.299). Heritability estimates varied between 21% and 37% for mother-daughter and 18% and 35% for mother-son pairs for density-derived variables and between 26% and 40% for body composition variables. Maternal inheritance of bone traits is expressed in early-pubertal boys for several skeletal site traits but consistently involves most site traits in girls and boys by late puberty. Body composition inheritance is more variable.     

Sex-specific differences in presentations and determinants of outcomes after endovascular thrombectomy for large vessel occlusion stroke

Journal of Neurology - Sex-specific differences in ischemic stroke outcomes are prevalent. We sought to investigate sex differences in the determinants of reperfusion and functional outcomes after...     

Quality of life and stability of tooth color change at three months after dental bleaching

Purpose

Intracoronary bleaching is a minimally invasive, alternative treatment that addresses aesthetic concerns related to non-vital teeth discoloration. However, to the best of our knowledge, no studies have assessed the psychosocial impacts of such procedures on patients’ aesthetic perceptions. The aim of this study was to evaluate aesthetic perceptions and the psychosocial impact of patients up to 3 months after their teeth had been bleached with hydrogen peroxide (35%) and carbamide peroxide (37%) using the walking bleach technique.

Methods

The patients were randomly divided into two groups according to the bleaching agent used: G1?=?hydrogen peroxide 35% (n?=?25) and G2?=?carbamide peroxide 37% (n?=?25). Non-vital bleaching was performed in four sessions. Color was objectively (ΔE) and subjectively (ΔSGU) evaluated. Aesthetic perception and psychosocial factors were evaluated before, 1 week and 1 month after the bleaching using the Oral Health Impact Profile (OHIP) and Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ) questionnaires.

Results

The color change (ΔE) values at 1 month were G1?=?16.80?±?6.07 and G2?=?14.09?±?4.83. These values remained stable until the third month after treatment (p?>?0.05). There was a decrease in the values of OHIP-aesthetics and PIDAQ after treatment versus baseline (p?<?0.05). This status was maintained through the third month after treatment.

Conclusions

Both agents were highly effective and had a positive impact on the aesthetic perception and psychosocial impact of patients, values that also remained stable over time. Non-vital bleaching yields positive and stable impacts on aesthetic perception and psychosocial factors. ClinicalTrials.gov identifier NCT02718183.