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The Middle East respiratory syndrome (MERS) is a coronavirus (CoV)-mediated respiratory disease. Virus transmission occurs within health care settings, but cases also appear sporadically in the community. Camels are believed to be the source for community-acquired cases, but most patients do not have camel exposure. Here, we assessed whether camel workers (CWs) with high rates of exposure to camel nasal and oral secretions had evidence of MERS-CoV infection. The results indicate that a high percentage of CWs were positive for virus-specific immune responses but had no history of significant respiratory disease. Thus, a possible explanation for repeated MERS outbreaks is that CWs develop mild or subclinical disease. These CWs then transmit the virus to uninfected individuals, some of whom are highly susceptible, develop severe disease, and are detected as primary MERS cases in the community. Middle East respiratory syndrome (MERS), a highly lethal respiratory disease caused by a novel coronavirus (MERS-CoV), is an emerging disease with high potential for epidemic spread. It has been listed by the WHO and the Coalition for Epidemic Preparedness Innovations (CEPI) as an important target for vaccine development. While initially the majority of MERS cases were hospital acquired, continued emergence of MERS is attributed to community acquisition, with camels likely being the direct or indirect source. However, the majority of patients do not describe camel exposure, making the route of transmission unclear. Here, using sensitive immunological assays and a cohort of camel workers (CWs) with well-documented camel exposure, we show that approximately 50% of camel workers (CWs) in the Kingdom of Saudi Arabia (KSA) and 0% of controls were previously infected. We obtained blood samples from 30 camel herders, truck drivers, and handlers with well-documented camel exposure and from healthy donors, and measured MERS-CoV-specific enzyme-linked immunosorbent assay (ELISA), immunofluorescence assay (IFA), and neutralizing antibody titers, as well as T cell responses. Totals of 16/30 CWs and 0/30 healthy control donors were seropositive by MERS-CoV-specific ELISA and/or neutralizing antibody titer, and an additional four CWs were seronegative but contained virus-specific T cells in their blood. Although virus transmission from CWs has not been formally demonstrated, a possible explanation for repeated MERS outbreaks is that CWs develop mild disease and then transmit the virus to uninfected individuals. Infection of some of these individuals, such as those with comorbidities, results in severe disease and in the episodic appearance of patients with MERS. IMPORTANCE The Middle East respiratory syndrome (MERS) is a coronavirus (CoV)-mediated respiratory disease. Virus transmission occurs within health care settings, but cases also appear sporadically in the community. Camels are believed to be the source for community-acquired cases, but most patients do not have camel exposure. Here, we assessed whether camel workers (CWs) with high rates of exposure to camel nasal and oral secretions had evidence of MERS-CoV infection. The results indicate that a high percentage of CWs were positive for virus-specific immune responses but had no history of significant respiratory disease. Thus, a possible explanation for repeated MERS outbreaks is that CWs develop mild or subclinical disease. These CWs then transmit the virus to uninfected individuals, some of whom are highly susceptible, develop severe disease, and are detected as primary MERS cases in the community.

Middle East respiratory syndrome (MERS) remains of global public health concern. Dromedary camels are the source of zoonotic infection. Over 70% of MERS coronavirus (MERS-CoV)-infected dromedaries are found in Africa but no zoonotic disease has been reported in Africa. We aimed to understand whether individuals with exposure to dromedaries in Africa had been infected by MERS-CoV. Workers slaughtering dromedaries in an abattoir in Kano, Nigeria, were compared with abattoir workers without direct dromedary contact, non-abattoir workers from Kano, and controls from Guangzhou, China. Exposure to dromedaries was ascertained using a questionnaire. Serum and peripheral blood mononuclear cells (PBMCs) were tested for MERS-CoV specific neutralising antibody and T-cell responses. None of the participants from Nigeria or Guangdong were MERS-CoV seropositive. 18 (30%) of 61 abattoir workers with exposure to dromedaries, but none of 20 abattoir workers without exposure (p=0·0042), ten non-abattoir workers or 24 controls from Guangzhou (p=0·0002) had evidence of MERS-CoV-specific CD4+ or CD8+ T cells in PBMC. T-cell responses to other endemic human coronaviruses (229E, OC43, HKU-1, and NL-63) were observed in all groups with no association with dromedary exposure. Drinking both unpasteurised camel milk and camel urine was significantly and negatively associated with T-cell positivity (odds ratio 0·07, 95% CI 0·01–0·54). Zoonotic infection of dromedary-exposed individuals is taking place in Nigeria and suggests that the extent of MERS-CoV infections in Africa is underestimated. MERS-CoV could therefore adapt to human transmission in Africa rather than the Arabian Peninsula, where attention is currently focused. The National Science and Technology Major Project, National Institutes of Health.

Tuberculosis of the breast is an uncommon disease even in countries where the incidence of pulmonary and extrapulmonary tuberculosis is high. Clinical presentation is usually of a solitary, ill-defined, unilateral hard lump situated in the upper outer quadrant of the breast. This disease can present a diagnostic problem on radiological and microbiological investigations, and thus a high index of suspicion is needed. Incorporating a highly sensitive technique like polymerase chain reaction (PCR) may be helpful in establishing the usefulness of such technology and can aid in conforming the diagnosis early. The disease is curable with antitubercular drugs, and surgery is rarely required.

BackgroundRecurrent urinary tract infection (UTI) occurs in sizable percentages of patients after a single episode and is a frequent cause of primary healthcare visits and hospital admissions, accounting for up to one quarter of emergency department visits. We aim to describe the pattern of continuous antibiotic prophylaxis prescription for recurrent urinary tract infections, in what group of adult patients they are prescribed and their efficacy.MethodsA retrospective chart review of all adult patients diagnosed with single and recurrent symptomatic urinary tract infection in the period of January 2016 to December 2018.ResultsA total of 250 patients with a single UTI episode and 227 patients with recurrent UTI episodes were included. Risk factors for recurrent UTI included diabetes mellitus, chronic renal disease, and use of immunosuppressive drugs, renal transplant, any form of urinary tract catheterization, immobilization and neurogenic bladder. E. coli infections were the most prevalent organism in patients with UTI episodes. Prophylactic antibiotics were given to 55% of patients with UTIs, Nitrofurantoin, Bactrim or amoxicillin clavulanic acid. Post renal transplant is the most frequent reason to prophylaxis antibiotics (44%). Bactrim was more prescribed in younger patients (P < 0.001), in post-renal transplantation (P < 0.001) and after urological procedures (P < 0.001), while Nitrofurantoin was more prescribed in immobilized patients (P = 0.002) and in patients with neurogenic bladder (P < 0.001). Patients who received continuous prophylactic antibiotics experienced significantly less episodes of urinary tract infections (P < 0.001), emergency room visits and hospital admissions due to urinary tract infections (P < 0.001).ConclusionDespite being effective in reducing recurrent urinary tract infection rate, emergency room visits and hospital admissions due to UTI, continuous antibiotic prophylaxis was only used in 55% of patients with recurrent infections. Trimethoprim/sulfamethoxazole was the most frequently used prophylactic antibiotic. Urology and gynecological referral were infrequently requested as part of the evaluation process for patients with recurrent UTI. There was a lack of use of other interventions such as topical estrogen in postmenopausal women and documentation of education on non-pharmacological methods to decrease urinary tract infections.

Understanding the immune response to Middle East respiratory syndrome coronavirus (MERS-CoV) is crucial for disease prevention and vaccine development. We studied the antibody responses in 48 human MERS-CoV infection survivors who had variable disease severity in Saudi Arabia. MERS-CoV-specific neutralizing antibodies were detected for 6 years postinfection.

[Please see PDF for full article text] Objectives: To investigate the risk factors associated with single and multiple hospital readmissions within 30 days of discharge. Methods: A retrospective study carried out during 2019 at King Abdulaziz Medical City in Riyadh, Saudi Arabia. Using simple random sampling with an estimated prevalence of readmission rates between 10-20%, the calculated sample size was 200 patients. Patients were classified into 2 categories: patients with single or multiple readmissions. For comparison of categorical variables, the Chi-square test and Fishers exact test were employed as relevant. Means comparisons were carried out using independent samples t-test. Multivariate logistic regression analysis was implemented to identify factors associated with multiple readmissions. Results: The rate of readmission in hospital patients was 10.18%. A significant burden of comorbidities was observed with diabetes, hypertension, and heart failure being the most prevalent diseases. Multiple readmissions were observed in 18% of the total readmissions, predominantly for conditions related to the initial hospitalization. Age (odds ratio [OR]=1.057, 95% confidence interval [CI]: [1.005-1.108]; p=0.030), ejection fraction (OR=0.925; 95% CI: [0.873-0.980]; p=0.008), depression (OR=1.396; 95% CI: [0.3072-26.957]; p=0.049), and previous stroke (OR=0.236, 95% CI: [0.062-0.903]; p=0.035) were identified as independent predictors of multiple readmissions. Conclusion: We found a high burden of comorbidities among patients requiring multiple readmissions. Older age, heart failure and ejection fraction, stroke, and depression were identified as risk factors for multiple readmissions. With interventions tailored to at-risk populations, we hypothesize that better utilization of available resources is achievable to reduce readmissions. Keywords: hospital readmission, acute disease, internal medicine, Saudi Arabia

Introduction: Readmission to the hospital after an acute COVID‐19 infection varies in the literature in terms of rate, causes, and outcomes. The 30‐day readmission rate ranges from 4% to as high as 11.3%. The causes of readmission after a COVID‐19 admission are diverse and include persistent respiratory symptoms, hypoxia, secondary bacterial infection, and thromboembolic disease. This study aims to describe the causes of hospital readmission within 30 days of discharge following an acute COVID‐19 infection. Methods: This retrospective cohort study was conducted at a tertiary care center in Riyadh, Saudi Arabia, between March 2020 and February 2022 and included all adult patients who were readmitted to the hospital within 30 days after a primary hospital admission due to COVID‐19 infection. Results: A total of 3517 patients were hospitalized with acute COVID‐19 infection during the study period, and 200 patients were rehospitalized within 30 days postdischarge, resulting in a readmission rate of 5.7%. The mean age of the readmitted patients was 66.35 ± 19.5 years, and 105 (52.5%) were male. Hypertension and diabetes mellitus were the most common comorbidities. Chronic respiratory disease was present in 44 patients (22%) prior to their acute COVID‐19 infection. The mean time to readmission was 7.86 ± 5.8 days. Persistent COVID‐19 pneumonia was the most common cause of readmission, diagnosed in 105 patients (52.5%), followed by renal impairment in 29 patients (14.5%). Urinary tract infections were the leading infectious cause of readmission, occurring in 23 patients (11.5%), while secondary bacterial pneumonia was rare. Shortness of breath and cough were the most common symptoms at the second presentation. Respiratory therapeutic interventions were required for 120 patients (60%), and 45 patients required intensive care unit (ICU) admission. Compared to the index admission, a higher proportion of patients required ICU admission and mechanical ventilation. After the index admission, most patients were still symptomatic at discharge (moderate to critical National Early Warning Scores (NEWS)). Conclusion: The readmission rate after acute COVID‐19 infection was 5.7%, aligning with rates reported internationally. The most frequent causes of readmission were persistent COVID‐19 pneumonia, renal impairment, and urinary tract infections, while secondary bacterial pneumonia at readmission was rare. Readmission was associated with increased rates of ICU admission and the need for mechanical ventilation. The use of NEWS at discharge may serve as a useful criterion for determining readiness for discharge. Future follow‐up of this cohort of patients will determine chronic long‐term respiratory complications.

Background. Candida has emerged as one of the most important pathogens that cause bloodstream infection (BSI).Understanding the current Candida BSI trends, the dominant species causing disease and the mortality associated with this infection are crucial to optimize therapeutic and prophylaxis measures. Objectives. To study the epidemiology and to evaluate the risk factors, prognostic factors, and mortality associated with candidemia and to compare these findings with previously published studies from Saudi Arabia. Design. A retrospective medical record review. Setting. Tertiary hospital in Riyadh. Patients and Methods. The analysis included all cases of Candida blood stream infection who are >18 years old over the period from 2013 to 2018. Continuous variables were compared using the parametric T-test while categorical variables were compared using the Chi-squared test. Main Outcome Measure. Incidence, resistance, and hospital outcomes in Candida blood stream infection. Sample Size. 324 patients. Results. Three hundred and twenty-four episodes of Candida blood stream infections were identified. Median age of patients was 49.7 SD ± 28.1 years, and 53% of patients were males. More than half of the patients had an underlying disease involving the abdomen or laparotomy, 78% had an indwelling intravenous catheter, and 62% had suffered a bacterial infection within 2 weeks prior to candidemia. Candida albicans represents 33% of all isolates with decreasing trend overtime. There was an increase in the number of nonalbicans Candida overtime with Candida tropicalis in the lead (20%). Use of broad spectrum antibiotics (82%), prior ICU admission (60%) and use of central venous catheters (58%) were the most prevalent predisposing factors of candidemia. Azole resistance was variable overtime. Resistance to caspofungin remained very low (1.9%). Fourteen days crude mortality was 37% for ICU patients and 26.7% in non-ICU patients, while hospital crude mortality was 64.4% and 46.7%, respectively. Conclusion. There is an increasing trend of nonalbicans Candida blood stream infection. Fluconazole resistance remained low to C. albicans. Most isolates remain susceptible to caspofungin, voriconazole, and amphotericin B. Candida bloodstream infection is associated with high 14-day hospital mortality.

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 greater than 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.