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OBJECTIVE: As of January 2020, there were 2,519 confirmed Middle East respiratory syndrome coronavirus (MERS-CoV) cases with 866 deaths across 27 countries. Most of these cases (2,121) were reported in Saudi Arabia. Since the initial identification of MERS, few studies have investigated the role of comorbidities that could potentially lead to mortality in cases of the infectious disease. This study aimed to examine the association between comorbidities and MERS mortality in Saudi Arabia. METHODS: This is a retrospective descriptive study. We retrieved the data published by the World Health Organization (WHO) between January 2017 and November 2019, and analysed the association between comorbidities and mortality. RESULTS: We found 572 MERS-CoV cases reported by WHO in Saudi Arabia during the defined period. Of these, 387 (68%) had a history of chronic illness. The overall mortality rate was found to be 25%. Diabetes mellitus was the most prevalent comorbidity-the mortality rate in the diabetics was 32% as opposed to 12% in the non-diabetics (p-value <0.01). Hypertension was second, with a mortality rate of 35%, as opposed to 15% in the non-hypertensive patients (p-value <0.001). The mortality rate in cases with cardiovascular disease was 39% as opposed to 21% in those without cardiovascular disease (p-value <0.05). CONCLUSION: Our study shows that MERS-CoV had a significant case fatality rate in patients with comorbidities. Thus, it will be beneficial if future clinical trials for MERS-CoV examine the impact of improved societal infection control measures such as social distancing and masks, in the context of the coronavirus disease 2019 pandemic, on the prevalence and incidence of MERS and its clinical outcomes.

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BACKGROUND: The relationship and interactions between physicians and the pharmaceutical industry can affect patient care. A physician's practice can be influenced by this relationship. It is believed that these interactions are common among doctors in Saudi Arabia. AIMS: This study was undertaken to assess the frequency of such relationships and physicians' attitudes and behaviours toward them. METHODS: This was a cross-sectional questionnaire survey completed by practicing physicians at four Saudi government and private tertiary care centres in Riyadh, Saudi Arabia. The questionnaire addressed the frequency of meetings with representatives of pharmaceutical companies (PRs) and of receiving gifts and considered the physicians' attitudes and behaviours towards PRs. RESULTS: A total of 300 completed questionnaires were obtained. Among the physicians surveyed, 223 (74.3%) met PRs one to three times per month. Up to 191 (64%) of physicians admitted receiving gifts. More than two thirds of physicians-192 (63%) have been invited to activities sponsored by pharmaceutical companies. Among the physicians, 239 (80%) agreed that PRs use promotional techniques in their approach and 251 (84%) of them stressed the need for expert physicians to attend presentations by PRs to correct the facts. CONCLUSION: The frequent meetings between physicians and PRs and the use of promotional techniques by PRs are concerning. Future studies should assess the impact of this involvement on medical practice and drugs prescription in Saudi Arabia.

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BACKGROUND AND AIMS: Perianal fistulizing Crohn's disease (PFCD) leads to significant disability. Data assessing healing of complex PFCD based on pelvic MRI using Parks' classification remains sparse. We aimed to assess the frequency of closure of fistula tract on MRI in patients treated with antitumor necrosis factor alpha antagonists and identify predictors of poor response. MATERIALS AND METHODS: We retrospectively identified patients registered in the Saudi Inflammatory Bowel Disease Information System registry, who were diagnosed as PFCD based on MRI and treated with infliximab or adalimumab. Fistulae were classified based on Parks' classification and response to treatment was determined as full, partial, or no response, after at least 12 months of treatment. RESULTS: Out of 960 patients, 61 had complex PFCD that required treatment with an anti-TNF agent. The median age was 27 years (range: 14-69 years) and the median duration of disease was 6.2 ± 5.8 years. A full response to treatment was achieved in 27 (44.4%), whereas 10 patients (16.3%) had partial response and 24 (39.3%) had no response. On univariable analysis, a statistically significant association was observed between poor fistula response and low BMI, rectal involvement, fistulae classification, and the presence of an abscess. According to multivariable regression, only low BMI predicted poor fistulae outcome (odds ratio = 1.37, 95% confidence interval: 0.69-0.98). CONCLUSION: Less than half of this cohort of patients with PFCD achieved complete radiological fistula healing with anti-TNF therapy. Low BMI appears to be the only predictor of poor outcome.

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AIMS: We hypothesized that if we control for food composition, caloric intake, light exposure, sleep schedule, and exercise, intermittent fasting would not influence the circadian pattern of melatonin. Therefore, we designed this study to assess the effect of intermittent fasting on the circadian pattern of melatonin. METHODS: Eight healthy volunteers with a mean age of 26.6 ± 4.9 years and body mass index of 23.7 ± 3.5 kg/m2 reported to the Sleep Disorders Center (the laboratory) on four occasions: (1) adaptation, (2) 4 weeks before Ramadan while performing Islamic intermittent fasting for 1 week (fasting outside Ramadan [FOR]), (3) 1 week before Ramadan (nonfasting baseline [BL]), and (4) during the 2nd week of Ramadan while fasting (Ramadan). The plasma levels of melatonin were measured using enzyme-linked immunoassays at 22:00, 02:00, 04:00, 06:00, and 11:00 h. The light exposure, meal composition, energy expenditure, and sleep schedules remained the same while the participants stayed at the laboratory. RESULTS: The melatonin levels followed the same circadian pattern during the three monitoring periods (BL, FOR, and Ramadan). The peak melatonin level was at 02:00 h and the trough level was at 11:00 h in all studied periods. Lower melatonin levels at 22:00 h were found during fasting compared to BL. Cosinor analysis revealed no significant changes in the acrophase of melatonin levels. CONCLUSIONS: In this preliminary report, under controlled conditions of light exposure, meal composition, energy expenditure, and sleep-wake schedules, intermittent fasting has no significant influence on the circadian pattern of melatonin.

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The role of gender and menopause in obstructive sleep apnoea is well known; however, no study has reported the impact of gender on the clinical presentation and the nocturnal respiratory events in patients with obesity hypoventilation syndrome. Therefore, this study prospectively evaluated differences in the clinical characteristics of women and men with obesity hypoventilation syndrome in a large cohort of patients with obstructive sleep apnoea. During the study period, a total of 1973 patients were referred to the sleep clinic with clinical suspicion of obstructive sleep apnoea. All patients underwent overnight polysomnography, during which time spirometry, arterial blood samples and thyroid tests were routinely obtained. Among 1973 consecutive patients, 1693 (617 women) were diagnosed with obstructive sleep apnoea, among whom 144 suffered from obesity hypoventilation syndrome (96 women). The prevalence of obesity hypoventilation syndrome among women and men was 15.6% and 4.5%, respectively (P < 0.001). Women with obesity hypoventilation syndrome were significantly older than men with obesity hypoventilation syndrome (61.5 ± 11.9 years versus 49.1 ± 12.5 years, P < 0.001). Although there were no significant differences between genders regarding symptoms, body mass index, spirometric data or daytime PaCO2 , women with obesity hypoventilation syndrome suffered significantly more from hypertension, diabetes and hypothyroidism. The prevalence of obesity hypoventilation syndrome was higher in post-menopausal (21%) compared with pre-menopausal (5.3%) women (P < 0001). HCO3 and duration of SpO2 <90% were the only independent predictors of obesity hypoventilation syndrome. In conclusion, this study reported that among subjects referred to the sleep disorders clinic for evaluation of obstructive sleep apnoea, obesity hypoventilation syndrome is more prevalent in women than men, and that women with obesity hypoventilation syndrome suffer from significantly more co-morbidities. Post-menopausal women with obstructive sleep apnoea have the highest prevalence of obesity hypoventilation syndrome.

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Leprosy is a chronic disease caused by Mycobacterium leprae. Although the occurrence of leprosy has declined in Saudi Arabia, it has not yet been eradicated. To our knowledge, this descriptive retrospective study is the first to assess the clinical presentation of leprosy at the time of diagnosis in Saudi Arabia. All study subjects were leprosy patients admitted to Ibn Sina hospital, the only referral hospital for leprosy in Saudi Arabia, between January 2000 and May 2012. A total of 164 subjects, the majority of whom (65%) were between 21 and 50 years of age, were included, and the male-to-female ratio was 2.8:1. Of these 164 patients, 63% were Saudis, and 77% of all admitted patients were from the western region. Lepromatous leprosy was observed most frequently (33%), and 31% of cases had a positive history of close contact with leprosy. At the time of diagnosis, 84% of all subjects presented with skin manifestation. The prevalence of neurological deficit at the time of diagnosis was 87%. Erythema nodosum leprosum (E.N.L.) developed in only 10% of all subjects. Further studies are needed to determine the clinical characteristics pertaining to each type of leprosy in the region, and training courses in caring for and diagnosing patients with leprosy should be organized for health workers.

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PURPOSE: To compare the apnea-hypopnea indices (AHIs) derived using three hypopnea definitions published by the American Academy of Sleep Medicine (AASM) and to determine the impact of the new modifications of the definition on AHIs and the diagnosis of obstructive sleep apnea (OSA). METHODS: The study comprised 100 consecutive patients who were investigated for OSA using overnight diagnostic polysomnography (PSG). The hypopneas were scored in three passes by two certified sleep technologists; in the first pass, the hypopneas were scored using the 2007 AASM "Alternative" (H Alt) criteria. In the second pass, the hypopneas were scored using the 2007 AASM "Recommended" (H Rec) criteria. In the third pass, the hypopneas were scored according to the new AASM "2012" (H 2012) criteria. Agreement analysis of the results obtained using the three scoring criteria was performed using the Bland-Altman plot methodology. RESULTS: The studied group had a mean age of 45.5±12.6 years and a body mass index of 30.2±5.8 kg/m2. Using the H 2012, H Rec and H Alt criteria, the AHIs were 37.9±27.6, 14.8±22.4 and 29.6±27.0/h, respectively (p<0.05). The Bland-Altman analysis of the AHI demonstrated that more events were nearly always detected using the H 2012 definition. CONCLUSION: A significant difference in detecting hypopnea events exists among the H 2012, H Rec and H Alt definitions. The 2007 AASM "Recommended" definition tended to result in lower AHI than the other two definitions.

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BACKGROUND: Limited information is available regarding sleep medicine education worldwide. Nevertheless, medical education has been blamed for the under-recognition of sleep disorders among physicians. This study was designed to assess the knowledge of Saudi undergraduate medical students about sleep and sleep disorders and the prevalence of education on sleep medicine in medical schools as well as to identify the obstacles to providing such education. METHODS: We surveyed medical schools that were established more than 10 years ago, asking fourth- and fifth-year medical students (men and women) to participate. Seven medical schools were selected. To assess knowledge on sleep and sleep disorders, we used the Assessment of Sleep Knowledge in Medical Education (ASKME) Survey, which is a validated 30-item questionnaire. The participants were separated into two groups: those who scored ≥60% and those who scored <60%. To assess the number of teaching hours dedicated to sleep medicine in the undergraduate curricula, the organizers of the major courses on sleep disorders were contacted to obtain the curricula for those courses and to determine the obstacles to education. RESULTS: A total of 348 students completed the survey (54.9% male). Among the participants, 27.7% had a specific interest in sleep medicine. More than 80% of the study sample had rated their knowledge in sleep medicine as below average. Only 4.6% of the respondents correctly answered ≥60% of the questions. There was no difference in the scores of the respondents with regard to university, gender, grade-point average (GPA) or student academic levels. Only five universities provided data on sleep medicine education. The time spent teaching sleep medicine in the surveyed medical schools ranged from 0-8 hours with a mean of 2.6 ±2.6 hours. Identified obstacles included the following: (1) sleep medicine has a lower priority in the curriculum (53%) and (2) time constraints do not allow the incorporation of sleep medicine topics in the curriculum (47%). CONCLUSIONS: Medical students in the surveyed institutions possess poor knowledge regarding sleep medicine, which reflects the weak level of education in this field of medicine. To improve the recognition of sleep disorders among practicing physicians, medical schools must provide adequate sleep medicine education.

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OBJECTIVES: Studies have suggested that ethnicity and environment may influence thyroid disease. We aim in this study to determine the prevalence of thyroid disease among Saudi (Arab) patients with laboratory-diagnosed obstructive sleep apnea (OSA) and the characteristics and predictors of thyroid disease associated with OSA. METHODS: Serum thyroid-stimulating hormone (TSH) and free-thyroxine (FT4) levels were measured in all patients referred to the sleep disorders center for an overnight sleep study. The levels were measured within 4 weeks of the sleep study. Type I attended polysomnography (PSG) was performed for all patients. RESULTS: During the study period, 271 patients with OSA and a mean age of 48.7 ± 14.1 yr, a body mass index (BMI) of 37.7 ± 9.6 kg/m(2) and an AHI of 55.2 ± 37/hr as well as 76 non-OSA patients with a mean age of 40.8 ± 14.9 yr, a BMI of 33.7 ± 8.9 kg/m(2) and an AHI of 3.8 ± 3.1/hr underwent thyroid function tests. In the OSA patients, the prevalence of newly diagnosed clinical hypothyroidism was 0.4%, and the prevalence of newly diagnosed subclinical hypothyroidism was 11.1%. In the non-OSA patients, the prevalence of newly diagnosed clinical hypothyroidism was 1.4%, and the prevalence of newly diagnosed subclinical hypothyroidism was 4%. There were no cases of clinical or subclinical hyperthyroidism in the studied group. Female gender was the only predictor of clinical hypothyroidism. CONCLUSION: In the OSA patients, the prevalence of newly diagnosed clinical hypothyroidism was low; however, subclinical hypothyroidism was common among patients with OSA.

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We hypothesize that factors other than a sudden shift in eating habits contribute to delay of circadian rhythms during Ramadan. We assessed circadian changes during a baseline period (BL, 1 week before Ramadan), the first week (R1), and the second week (R2), of Ramadan, in six healthy Muslim young adults using portable armband physiological and activity sensor devices. All participants lived in an unconstrained environment and showed delayed sleep phase syndrome, so that they normally slept during the day and ate at night. During Ramadan, there was a further delay in the acrophase of skin temperature during Ramadan, indicating a shift in the circadian pattern of body temperature. Additionally, there was a delay in the peak of energy expenditure during R1 and R2. These results support our hypothesis that in addition to sudden shift in meal times, other factors may affect the sleep pattern and circadian rhythms during Ramadan.

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