Objectives:To examine the associations between sleep duration and a variety of demographic and clinical variables in a sample of Saudi adults.Methods:A cross-sectional study among 2,095 participants was conducted at King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia, between May and October 2014. A questionnaire was administered to collect data related to clinical health outcomes and demographic characteristics. Participants were asked to report their average sleep duration per night in hours.Results:One-third (33.8%) reported short sleep duration of less than 7 hours/night. Short sleep duration was more prevalent in females (37.3% versus 31.4%, p=0.004). The most common medical problems reported were obesity with body mass index of >30 Kg/m2 (39.1%), hypertension (33.9%), diabetes mellitus (20.8%), depression (4.3%), asthma (17.3%), COPD (6.6%), and hyperlipidemia (2.7%). Diabetes mellitus was associated with long sleep of more than 9 hours/night (25.4%, p=0.011) and hypertension (54.2%, p=0.001). The linear regression model tend to reduce their sleep duration by roughly 22 minutes in female gender, 66 minutes in participants with hyperlipidemia, and 70 minutes in participants with poor sleep quality.Conclusions:Short sleep duration per night was prevalent, it affects one in every 3 Saudi adults. Long sleep duration of more than 9 hours was associated with increased comorbid conditions.

Objective:To report on the clinical presentation, etiology, and laboratory features of acute and chronic atrial fibrillation (AF) in a tertiary hospital in Riyadh, Saudi Arabia.Materials and Methods:We retrospectively studied records of 720 patients with AF seen in outpatients and inpatients departments at King Abdulaziz Medical City, Riyadh, during the period of 1 January 2002 to 31 August 2008.Results:Documented acute and chronic AF was present in 157 (21.8%) and 563 (78.1%) patients, respectively. Palpitations, dizziness and syncope were the most frequent symptoms in acute AF, while dyspnea and palpitations were the most common symptoms in the chronic type. Acute respiratory problems and acute myocardial infarction were significantly more common in acute AF, while congestive heart failure and acute respiratory problems (chest infection, bronchial asthma, and pulmonary embolism) were significantly more common in chronic AF. The most common causes of both types of AF were diabetes mellitus (DM) in 68.8%, hypertension (HTN) in 59.3%, chronic lung diseases (bronchial asthma, chronic obstructive pulmonary disease and interstitial lung disease) in 31.8%, valvular heart disease in 23.6%, and ischemic heart disease (IHD) in 23.1%. In 9 (1.3%) patients, no cause was detected. The echocardiographic findings of left ventricular hypertrophy, valve lesions, and depressed left ventricular function were significantly more common in chronic AF (P<0.01).ConclusionsNowadays, DM, HTN, and IHD are becoming the most common predisposing factors for AF in the central region of Saudi Arabia and require prevention and control

Hemophagocytic lymphohistiocytosis (HLH) is a rare syndrome that can present with variable clinical and laboratory manifestations, and some distinct features are seen in adults. Type B lactic acidosis, which occurs in the absence of tissue hypoxia, has been reported in a few adult patients with HLH. We report a case of HLH presenting with type B lactic acidosis, with a literature review of this association. A 48-year-old Saudi woman with a past medical history of hypertension, dyslipidemia, and morbid obesity, presented with a 1-month history of intermittent high-grade fever up to 39°C daily. The patient was admitted for further evaluation of fever and was in our hospital for 70 days. Initial laboratory investigations revealed normocytic hypochromic anemia (102 g/L [normal 120-160]), lactic acidosis (2.36 mmol/L [0.5-2.2]), mild transaminitis, and elevated levels of lactate dehydrogenase (1761 U/L [125-220]), erythrocyte sedimentation rate (95 mm/hr [0-20]), and ferritin (1090.5 μg/L [4.6-204.0]). Further investigations failed to reveal any autoimmune or rheumatologic disease and extensive septic workup was negative. Lymphocyte subset by flow cytometry showed a low percentage of absolute natural killer cells (5% [10-20%]). Abdominal CT revealed splenomegaly with a span of 16.5 cm. Positron emission tomography-CT scan showed diffuse prominence of splenic activity, with a standardized uptake value of 4.5, and bone marrow activity throughout the axial skeleton. Liver biopsy and bone marrow aspiration were unremarkable. A month after admission, her anemia worsened with the hemoglobin level gradually dropping to 63 g/L prompting multiple transfusions. Lactic acid levels remained persistently elevated throughout this period [Figure 1]. A trial of intravenous steroids and immunoglobulins failed to decrease the lactic acid level [Figure 1; A to B]. The hospital course was complicated by Acinetobacter baumannii pneumonia requiring antibiotics [Figure 1; C to E]. Two months after the initial presentation, she developed pancytopenia, and repeated bone marrow aspiration and biopsy showed hemophagocytosis. Repeated ferritin level was more than 40,000 μg/L with hypertriglyceridemia (2.92 mmol/L [<1.7]), and hypofibrinogenemia (0.9 g/L [1.5-4.1]). HLH-94 protocol with etoposide (150 mg/m2twice weekly) and dexamethasone (10 mg/m2) was commenced; however, the patient continued to deteriorate prompting elective intubation. She then developed acute acalculous cholecystitis and brain CT revealed a large central pontine hypodensity. Nine days after initiation, the patient was switched from the HLH-94 protocol to alemtuzumab, however, the patient arrested and passed away. To our knowledge, this is the first report of HLH presenting with persistent lactic acidosis lasting several weeks. Although no cause was found, this patient likely had HLH that was not detected early. We searched the PubMed and EMBASE databases for English-language reports describing adult patients (>18 years) with HLH and lactic acidosis. Patients with type A lactic acidosis, associated with tissue hypoxia, were excluded. Five case reports describing patients with variable underlying diagnosis causing HLH and type B lactic acidosis were identified (Table I). Lactic acidosis started before HLH was diagnosed in all patients except one, in whom lactic acidosis developed two days after diagnosis. All patients had neither sepsis nor hypotension at the time of lactic acidosis. The mechanism of type B lactic acidosis in HLH is poorly understood and is likely multifactorial. As HLH in adults is more likely to be secondary to malignancies, Warburg effect, a high rate of glycolysis exhibited by tumor cells, has been proposed as the cause in these cases. Alternatively, acute cytokine hyperactivation in inflammatory states can enhance lactate dehydrogenase activity leading to excess lactic acid production. Inflammation, infection, or tumor cells can also induce stress and accelerate aerobic glycolysis-which does not depend on hypoxia-resulting in excess lactate production. Finally, acute hepatic dysfunction, a common finding in adult-onset HLH, can impair lactate clearance and further elevate levels. This report suggests that type B lactic acidosis may be a manifestation of HLH. Analyses of large HLH registries can better clarify the diagnostic and prognostic value of type B lactic acidosis in adult-onset HLH. Disclosures No relevant conflicts of interest to declare.

Background:Medical grand rounds (MGRs) are considered key educational tools in most academic medical institutions. In this multi-center cross-sectional survey, we tried to determine the current attitudes of local medical practitioners to MGRs, as well as perceived barriers.Methodology:A total of 120 physicians from the National Guard Hospital, King Fahad Medical City, King Khalid University Hospital and King Faisal Specialist Hospital participated in the survey. The questionnaire consisted of statements on attitudes and perceived barriers against participating in MGRs, as well as participants’ levels of agreement.Results:Most participants attend MGRs regularly (94.2%), claiming that it is mandatory (88%). Participants also agreed that MGRs were important tools for continuing medical education (89.2%) and that they provided an opportunity to both present materials and interact with their colleagues in other divisions (86.7% and 81.6%, respectively). The vast majority of respondents agreed that “topic review/update” and “inviting guest speakers” were the two most preferred suggestions for improving MGRs (94.2% and 92.5%, respectively). Major barriers included constraints of time (43.3%) and topics that were not patient-related (40.8%).Conclusion:MGRs in the major Tertiary Hospitals in Riyadh are well attended, and the majority of the local practitioners believe in the positive effect of MGRs in delivering quality and up to date medical knowledge. Time and physician-specific issues were identified as major barriers that needed to be addressed in order to maximize participation of medical staff.