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Abdulghfoor Abdurabuh,1 Mahar Diana Hamid,1,2 Che Rosmani Che Hassan,1 Mohammad I Fatani3 1Department of Chemical Engineering, Faculty of Engineering, Universiti Malaya, Kuala Lumpur, 50603, Malaysia; 2Sustainable Process Engineering Centre (SPEC), Department of Chemical Engineering, Faculty of Engineering, Universiti Malaya, Kuala Lumpur, 50603, Malaysia; 3Department of Dermatology, Hera General Hospital, Makkah, 24227, Saudi ArabiaCorrespondence: Mahar Diana Hamid, Sustainable Process Engineering Centre (SPEC), Department of Chemical Engineering, Faculty of Engineering, Universiti Malaya, Kuala Lumpur, 50603, Malaysia, Email mahar.diana@um.edu.myBackground: The impact of hospital accreditation on the organizational safety culture among healthcare workers, an essential indicator of patient safety, has yet to be directly quantified in Saudi Arabia’s healthcare system. This study aims to investigate this impact to sustain and maintain a positive safety culture in Saudi Arabia’s healthcare institutions.Methods: A cross-sectional assessment was conducted in five public hospitals in Makkah. Three hundred forty healthcare workers participated using a self-administered questionnaire. Data were analyzed using descriptive statistics, ANOVA, one-sample t-test, and multiple regression for a comprehensive understanding.Results and Discussion: Regression analysis revealed significant gender differences in patient safety ratings (B = 0.480, p < 0.001). Age positively influenced scores, with higher ages resulting in higher scores (B = 0.127, p = 0.041). The ratings were also associated with respondents’ nationality (B = 0.169, p < 0.001) and education levels (B = − 0.186, p < 0.001). Respondents rated disasters and training as the highest in patient safety culture, followed by facility safety and security, hazards and hazardous materials safety, utility and building safety, fire safety, and quality improvement. At the same time, leadership, commitment, and support received the lowest score.Conclusion: This study illustrates a strong connection between accreditation and improved patient safety, emphasizing the importance of quality improvement and leadership commitment. These insights can guide policymakers and healthcare executives in Saudi Arabia and similar countries toward developing a robust patient safety culture. It stresses the importance of considering human factors and organizational culture when developing patient safety models.Keywords: healthcare professionals, quality of healthcare, accreditation, facility management and safety, CBAHI

Mohammad I Fatani,1 Ibrahim Al-homood,2 Mohamed Bedaiwi,3 Sahar Al Natour,4 Alper Erdogan,5 Aya Alsharafi,5 Suzan M Attar6 1Department of Dermatology, Heraa Hospital, Mecca, Makkah, Kingdom of Saudi Arabia; 2Department of Rheumatology, King Fahad Medical City (KFMC), Riyadh, Riyadh Province, Kingdom of Saudi Arabia; 3Department of Rheumatology, King Saud University, Riyadh, Riyadh Province, Kingdom of Saudi Arabia; 4Department of Dermatology, Imam Abdulrahman Bin Faisal University, Dammam, Eastern Province, Kingdom of Saudi Arabia; 5Eli Lilly and Company, Riyadh, Riyadh Province, Kingdom of Saudi Arabia; 6Department of Internal Medicine, King Abdulaziz University, Jeddah, Makkah, Kingdom of Saudi ArabiaCorrespondence: Mohammad I Fatani, Department of Dermatology, Heraa Hospital, Al Madinah Al Munawarah Road, Mecca, Makkah, 24227, Kingdom of Saudi Arabia, Email m_fatani@yahoo.comPurpose: Psoriasis is a chronic, inflammatory, immune-mediated skin disease that has significant impact on a patient’s quality of life, yet it remains challenging for dermatologists to successfully identify and manage. Without effective screening, diagnosis and treatments, psoriasis can potentially progress to psoriatic arthritis. A descriptive, observational cross-sectional study of Saudi Arabian dermatologists and patients with psoriasis was conducted to explore dermatologist and patient perspectives of psoriasis, including diagnosis, management, disease course and unmet needs.Patients and Methods: This study involved a quantitative questionnaire administered to 31 dermatologists and 90 patients with psoriasis at eight medical centers and was analyzed using descriptive statistics.Results: Dermatologists and patients perceived that psoriasis treatment was initiated promptly and that follow-up visits were sufficient. Their perspectives differed in the time to diagnosis and patient reaction, symptom severity, input into treatment goals and educational needs. The dermatologists’ concerns about underdiagnosed psoriasis (13%) were primarily related to patient awareness (87%), physician awareness (58%), and the absence of a regular screening program (52%). Only 31% of patients with psoriasis were highly satisfied with their psoriasis treatment, with 78% experiencing unpleasant symptoms of pain or swelling in joints indicative of psoriatic arthritis. However, only 56% of these patients reported these symptoms to their physicians. When dermatologists were made aware of this difference, referrals to a rheumatologist increased.Conclusion: The study highlights the importance of strengthening psoriasis management by enhancing dermatologist referral and screening practices, adopting a multidisciplinary approach to care, and improving education and resources for physicians and patients. These results can help to inform the improvement of psoriasis screening, diagnosis and treatment strategies and ensure that expectations meet treatment outcomes. Further research exploring the dermatologist and patient perspectives of the disease pathway from psoriasis to psoriatic arthritis and tailor-made treatment approaches is recommended.Keywords: autoimmune disease, disease pathway, patient satisfaction, provider perspective

Atopic dermatitis (AD) is a chronic inflammatory skin disease with an increasing prevalence regionally and globally. It is characterized by intense itching and recurrent eczematous lesions. With the increase in the availability of treatment options for healthcare practitioner and patients, new challenges arise for treatment selection and approach. The current consensus statement has been developed to provide up-to-date evidence and evidence-based recommendations to guide dermatologists and healthcare professionals managing patients with AD in Saudi Arabia. By an initiative from the Ministry of Health (MOH), a multidisciplinary work group of 11 experts was convened to review and discuss aspects of AD management. Four consensus meetings were held on January 14, February 4, February 25, and March 18 of 2021. All consensus content was voted on by the work group, including diagnostic criteria, AD severity assessment, comorbidities, and therapeutic options for AD. Special consideration for the pediatric population, as well as women during pregnancy and lactation, was also discussed. The present consensus document will be updated as needed to incorporate new data or therapeutic agents., (© 2022. The Author(s).)

A cutaneous horn is a rare clinical condition characterised by a conical projection of hyperkeratotic epidermis. Cutaneous horns most commonly arise from sun-exposed skin in elderly men, but may arise from any part of the body at any age in men and women. When a cutaneous horn forms, it is important to determine the underlying cause. Various skin diseases may present with cutaneous horns including viral warts, actinic keratosis, keratoacanthoma, seborrhoeic keratosis, pyogenic granuloma, discoid lupus erythematosus, verruca vulgaris, Bowen's disease, basal cell carcinoma and squamous cell carcinoma. The underlying pathology is benign in 61.1% of cases, premalignant in 23.2% of cases and malignant in 15.7% of cases. We report a patient with a cutaneous horn arising from an area of discoid lupus erythematosus on the scalp.

Objective: To reduce ventilator associated pneumonia (VAP) incidence rate, lessen the cost of care, and correlate VAP bundles compliance with VAP incidence rate., Methods: This study was a prospective longitudinal study conducted on adult intensive care unit (ICU) patients at Hera General Hospital, Makkah, Kingdom of Saudi Arabia from January to December 2010. The following Institute for Healthcare Improvement VAP prevention bundle was applied: head-of-bed elevation; daily sedation-vacation along with a readiness-to-wean assessment; peptic ulcer disease (PUD) prophylaxis; and deep venous thrombosis (DVT) prophylaxis., Results: Among a total of 2747 patients, the bundle compliance rate in January 2010 was 30%, and reached to 100% in December 2010, while the overall rate was 78.9%. The individual bundle compliance rates were as follows: head-of-bed elevation - 99.9%; daily sedation vacation - 88.9%; PUD prophylaxis - 94.9%; and DVT prophylaxis - 85.7%. At the beginning, VAP rate was 2.5/1000 ventilator days, and reduced to 0.54 in the next month. The overall VAP incidence rate in 2010 was found to be 1.98 with a reduction of 1.41 by comparing with the same data of year 2009 collected retrospectively. The total reduction cost in one year was $154,930. A significant correlation was found between the VAP rate and its bundle compliance (p=0.001). Most frequent pathogens found were Pseudomonas aeruginosa (30.8% of all isolates) followed by Acinetobacter baumannii (27.7%), and methicillin-resistant Staphylococcus aureus (15.4%)., Conclusion: Application of VAP prevention bundle reduced the VAP incidence rate and lowered the cost of care.

Objective: To motivate healthcare professionals, with a focus on improving hand hygiene compliance., Methods: An observational, prospective, longitudinal study was conducted on the evaluation of hand hygiene compliance at Hera General Hospital, Makkah, Kingdom of Saudi Arabia from May 2009 to May 2010. Four components to improve hand hygiene compliance were implied; daily audit, monthly staff education; quarterly workshops of hand hygiene, and education material distribution. The compliance rate was calculated by its adherence with number of opportunities., Results: Of total 163 healthcare professionals were surveyed for hand hygiene compliance; 57 (35%) were doctors, 92 (56.4%) nurses, and 14 (8.6%) patient care technicians. The overall compliance rate was 50.3%, and its distribution among staff was as follows; doctors 49.1%, nurses 52.2%, and technicians 42.8%. The highest compliance rate among doctors and nurses was found in surgical units. A low compliance in high intensity patient care area was observed such as in the emergency room and out patient department. The patient care technicians showed highly variable results, as their compliance rate was 100% in medical units while 0% in various other clinical areas., Conclusion: The overall hand hygiene compliance rate of healthcare professionals reached 50% after a long education campaign, and was highest among the nurses. Further study is needed to explore the reasons for non-compliance.

An unusual case of malaria presented with gastroenteritis and bloody diarrhoea in a 46-year-old male. The patient was a non-Saudi resident of Makkah, Saudi Arabia. Fever was not the presenting complaint, and the patient had not experienced any chills or sweating. He gave history of recent travel to Pakistan. Initial laboratory investigations showed anemia, thrombocytopenia, normal liver function, and negative blood film for malaria. His widal, Brucella, and dengue serology was negative. Endoscopic examination showed gastroenteritis. On the fifth day of admission, a sexual form of Plasmodium falciparum on peripheral smear was reported by chance. Malaria was misdiagnosed because of initial negative blood film which may have been due to false microscopy or a long period between exposures and positive blood film. We concluded that a repeat blood film for malaria at 12- to 24-hour intervals for 48 to 72 hours is cost effective when a patient has recently travelled to an endemic area.

The majority of patients with primary mediastinal lymphoma are symptomatic at the time of diagnosis and commonly have fever, weight loss and/or night sweats. Symptoms due to compression of adjacent mediastinal structures are infrequent, but may include pain, dyspnoea, stridor, or superior vena cava syndrome. Local infiltration into the chest wall, pleura and pericardium is not uncommon.In the present report, two interesting cases of chest wall swellings that in fact were extensions of primary mediastinal lymphoma are given. Histopathology of the tumour was large B cell lymphoma (CD20+). The first case was in a 23-year-old woman, with dramatic onset but a good outcome. The second was in a 34-year-old Pakistani woman, with insidious onset and poor outcome due to extent and invasion by the tumour. Interesting CT images are presented showing chest wall and left supraclavicular swelling.

Presentation of primary antiphospholipid syndrome (APS) is usually untrustworthy and unusual presentations are difficult to diagnose on the basis of clinical features alone. This is true especially in young and elderly patients. Cerebral venous thrombosis (CVT) is less frequent than arterial thrombosis in APS. CVT has a wide spectrum of signs and symptoms, which may evolve suddenly or over weeks. It mimics many neurological conditions such as meningitis, encephalopathy, benign intracranial hypertension and stroke. Headache is the most frequent symptom in patients with CVT, and is present in about 80% of cases. The most common pattern of presentation is with a benign intracranial hypertension-like syndrome. Sixth cranial nerve palsy usually manifests as a false localising sign. Patients may have recurrent seizures. Cranial nerve syndromes are seen with venous sinus thrombosis. We present a case of APS with lower cranial nerve palsy, aseptic meningitis and hydrocephalus initially treated as tuberculous meningitis.

Delirium is a cognitive disorder. DSM-IV criteria for delirium must include both acute onset and fluctuating symptoms; disturbance of consciousness (including inattention); at least one of the following: disorganised thinking, disorientation, memory impairment or perceptual disturbance; and evidence of a putative causal medical condition. Traditionally, the course has been described as transient in which recovery is likely to be complete if the underlying aetiological factor is promptly corrected or is self-limited. The most common precipitating causes in elderly include sepsis, dehydration and drugs. Work-up for delirium is limited to septic screening, baseline investigations and imaging. Patients with delirium without focal signs and with either evidence for a medical aetiology of delirium or pre-diagnosed dementia are at a very low risk of having focal lesions in their contrast-enhanced CT or MRI. We are presenting an interesting case of delirium with urosepsis whose imaging revealed milliary brain tuberculomas on contrast-enhanced MRI.

Toxic epidermal necrolysis (TEN) is a rare but life threatening skin disease that is most commonly drug induced. The exact pathogenesis of TEN is still unknown and many drugs, including prednisolone, cyclosporin and intravenous immunoglobulin (IVIG), have been used in an attempt to halt the disease process. The use of IVIG in particular is controversial. Recently, the US Food and Drug Administration (FDA) has made a labelling change to the drug information for carbamazepine. Owing to recent data implicating the HLA allele B*1502 as a marker for carbamazepine induced Stevens-Johnson syndrome and TEN in Han Chinese, the FDA recommends genotyping all Asians for the allele. We present an interesting case of carbamazepine induced TEN which was confused with oral thrush, had no skin lesions on presentation, and had an excellent response to a 5 day course of methylprednisolone and high dose IVIG in combination.

Congenital chloride diarrhoea (CCD) is a serious inherited defect of intestinal electrolyte absorption transmitted in an autosomal recessive way. The molecular pathology involves an epithelial Cl(-)/HCO(3)(-) exchanger protein, encoded by the solute carrier family 26 member 3 gene (SLC26A3) and known DRA (down regulated in adenomas) in the distal ileum and colon. Polyhydramnios, premature birth, ileus without meconium passage, hypochloremia, and hyponatremia are typical features of CCD in the neonate followed by chronic metabolic alkalosis, hypokalemia, hypochloremia, retarded growth and renal impairment in older children and adults if the disease is not adequately treated. Antenatal diagnosis if made on the basis of findings on ultrasonography-a non-invasive diagnostic test-can help in early management of the disorder immediately after birth and, thus, prevent the sequelae. We present an interesting case of CCD diagnosed antenatally and found to have congenital cataract, which is a unique occurrence not reported in literature so far.

The most common cause of upper gastrointestinal bleeding in patients with systemic rheumatic diseases is non-steroidal drug use; this is the case with COX-2 inhibitors, especially when used concomitantly with corticosteroids. Bleeding from varices is unusual in the absence of liver disease. We present an interesting case of a patient with systemic lupus erythematosus, rheumatoid arthritis and polymyositis overlap syndrome with recurrent upper gastrointestinal bleeds from isolated fundal gastric varices and a normal liver.

We report a case of pneumonia due to multi-drug resistant Ewingella americana in a young patient admitted in the Intensive Care Unit of Hera General Hospital, Makkah, Saudi Arabia with severe head injury in a road traffic accident. He was an Indonesian pilgrim who had traveled to the Kingdom of Saudi Arabia to perform Hajj in December 2007. Ewingella americana was identified to be the pathogen of pneumonia with clinical signs and symptoms along with positive radiological findings.

Objective: To develop better understanding of Medication Errors (MEs) in the health care sector, and to improve the error prevention services in the hospital., Methods: We conducted a retrospective study at the Hera General Hospital, Makkah, Saudi Arabia. The medical records were reviewed for adult hospitalized patients from June 1, 2000 to June 30, 2002. Patients demographic data, types, and causes of MEs, were recorded. The contributing factors, frequency and patient's outcome were also analyzed., Results: A total of 2627 patient files were analyzed, 3963 errors were studied as follows: 1559 files contain one error, 800 files with 2 errors, and 268 with >3 errors. The most common type of error found was wrong strength (concentration) in 914 patients (34.79%), 807 patients (30.7%) had wrong route of administration, and 788 (30%) had wrong dosage form. On the other hand, the most common cause identified for MEs, was human factor, which accounted in 1223 patients (46.49%). Miscommunication was the most common second cause in 920 patients (35.02%), and the third common cause was name confusion [484, (18.43%)]. Medication Errors were classified from a regulatory prospective into actual in 735 patient files (28%), potential in 1866 (71%) and serious in 26 (0.98%)., Conclusion: The study showed that wrong strength was the most common ME found and human factors were the most common cause contributing MEs. Therefore, focusing on these factors will definitely minimize MEs in hospitalized patients.

Objective: To determine the prevalence of Helicobacter pylori (H. pylori) infection among patients presenting with peptic ulcer disease (PUD) and to establish the relationship between H. pylori infection and its diverse pathology. Secondly, we aimed to examine the effect of age, gender, and geographical distribution on the prevalence of the disease., Methods: The study included patients with PUD who underwent upper gastrointestinal endoscopy at Hera General Hospital, Makkah, Kingdom of Saudi Arabia between January 2003 and February 2004. We tested the biopsies for the detection of H. pylori by Campylobacter like organism (CLOTM) test, histopathology, immunoglobulin G (IgG) antibodies, culture, and antimicrobial susceptibility testing., Results: The overall prevalence rate of H. pylori infection among 132 patients with PUD was 63%, while it was high among females (70%) as compared with males (58%). The H. pylori were mainly found in chronic active gastritis (89%) and severe active gastritis (96%). Helicobacter pylori were documented by CLOTM test in 73 (55.3%) cases, histopathology in 69 (52.3%) cases, microbiological culture in 59 (44.7%) cases, and IgG antibodies in 61 (46.2%) cases. The highest resistance (31%) was found in metronidazole, while lowest the (3%) in tetracycline and erythromycin., Conclusion: The highest prevalence of H. pylori was found in the younger age group with female preponderance. The leading causes of multifocal pathology were chronic and severe active gastritis secondary to H. pylori infection.

Objective: To describe the epidemiological, clinical and laboratory features of meningococcal disease and explore the factors responsible for its morbidity and mortality among the pilgrims during Hajj 2000., Setting: This study was conducted at King Faisal Hospital, Makkah, Saudi Arabia., Method: Any patient suspected of meningococcal disease during the period of pilgrimage presenting with fever, head ache, signs of meningeal irritation and turbid CSF, confirmed on gram stain smears. Latex agglutination test and culture was included in this study. Their clinical features, management and outcome was recorded and analysed., Results: Of 105 confirmed cases of meningococcal disease, 64% had predominantly meningitis, 36% meningococcaemia and meningitis. Meningococcal rash was found in 2% and co-morbidity in 18% of cases. Antibiotics used empirically were benzylpenicillin or ceftriaxone along or in combination. Overall case fatility rate was 34%. Delay in diagnosis, delay of antibiotic administration, older patients and patients with serious concurrent medical problems, were the factors leading to higher than expected mortality rate. Maximum number of patients were Pakistanis (18%) followed by Indians (15%) and Indonesians (12%). Overall serogrouping was as follows: group A (44), W135 (19), B (1) and untypable (1). Serogroup W135 appeared more invasive and more fatal., Conclusion: Quadrivalent vaccine ACYW135 is recommended for pilgrims to enter Saudi Arabia and for mass vaccination in local population.

Acquired reactive perforating collagenosis is a rare skin disorder associated with several systemic diseases, particularly diabetes and chronic renal failure. A 52-year-old Saudi female patient with a known case of diabetes mellitus type II, chronic renal impairment, hypertension, peripheral vascular disease, congestive heart failure, stroke and left hemiplegia presented with multiple pruritic skin eruption on the trunk and extremities. We believe that this is the first case of acquired reactive perforating collagenosis in association with sick euthyroid syndrome to be reported.

Objective: Bacterial skin infections have been considered as a possible health problem of the Hajj pilgrims. Significant increase in the rate of resistance to commonly used antibiotics against gram positive organisms has been observed. The present study was planned to obtain the microbiological profile of bacterial skin infections and their susceptibility to antimicrobials., Methods: Pyodermas were investigated clinically and bacteriologically by a prospective study conducted on patients attending the dermatology clinic at the King Faisal Hospital, Makkah, Kingdom of Saudi Arabia during 2 Hajj periods (2000 - 2001)., Results: Of a total of 80 pyoderma patients, 52.5% were primary and 47.5% secondary. The leading cause of primary pyoderma was found to be impetigo in 28.8% cases, and of secondary pyoderma was infected eczema in 18.8% cases. Positive cultures were found in 87.5% cases. The organisms responsible for primary pyoderma were: Staphylococcus aureus (65.6%), Streptococcus pyogenes (28.1%) or both (6.4%) while in secondary pydermas were: Staphylococcus aureus (44.7%), Streptococcus pyogenes (15.8%), or both (18.4%), and gram negative bacilli (21.1%). The resistant pattern of antimicrobials against Staphylococcus aureus was as follows: penicillin 80.85%, tetracycline 10.6%, gentamicin 6.4%, erythromycin 4.3% and cotrimoxazole [corrected] 4.3%. Oxacillin and cephalothin were found least resistant (2.1%)., Conclusion: Pyoderma appeared as one of the common health hazard of our Hajj pilgrims. Penicillin and tetracycline are found ineffective in treating skin infections caused by Staphylococcus aureus while oxacillin is recommended as first line of treatment.

Objective: To determine the percentage occurrence, demographic and clinical features of psoriasis in adult patients at King Fahd Hospital of the University, Al-Khobar, Kingdom of Saudi Arabia., Methods: The medical records of all the adult patients with psoriasis were analyzed from January 1991 to December 1994 at the dermatology clinic, King Fahd Hospital of the University, Al-Khobar, Kingdom of Saudi Arabia., Results: A total of 263 adult psoriatic patients were studied with the percentage occurrence of 5.3%. There was a male preponderance with sex ratio of 1.4:1. The mean age of onset in males was 26.9 years while in females it was 22.3 years. Fifty-three percent of psoriatic cases developed before the age of 30 years. Family history of psoriasis was recorded in 8.4% of the cases. Itching was the only symptom reported by patients in 43% of cases. The sites of involvement were as follows: lower extremity 44.9%, scalp 41.8%, nail 26.6% and palmoplanter 12.6%. Plaque psoriasis was the most common clinical type (87.1%), followed by erythrodermic (4.2%), pustular (3%), guttate (1.9%), flexural, (2.3%) and follicular (0.4%)., Conclusion: The present study represents the apparent magnitude of psoriasis in the eastern province of Saudi Arabia, which may reflect that the disease is common in our area as elsewhere. The clinical features of psoriasis in our patients were similar to those reported from other parts of the world.