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Patients with diabetes have a higher risk of severe infection and mortality due to COVID-19. Considering the current limited effective pharmacological treatments, vaccination remains one of the most effective means to control the pandemic. The current study aimed to determine the prevalence of COVID-19 infection and the rate of COVID-19 vaccination coverage among patients with type 2 diabetes mellitus. The patients were identified from a diabetes hospital registry at Prince Sultan Military Medical City, Riyadh, Saudi Arabia in July 2021. The history of COVID-19 infection and the vaccination status were retrieved from the National Health Electronic Surveillance Network (HESN) program and the Seha platform, respectively. A total of 11,573 patients were included in this study (representing 99.5% of all patients in the registry). A total of 1981 patients (17.1%) had a history of confirmed COVID-19 infection. The rate of vaccination with a 1st dose was 84.8% (n = 9811), while the rate of full vaccination with the 2nd dose was 55.5% (n = 6422). The analysis showed that a higher proportion of male patients were fully vaccinated than female patients (61.0% versus 51.2%, p 80-year-old age group (p 80 (aOR (95% CI) = 3.081 (2.252–4.214), and prior history of COVID-19 infection (aOR (95% CI) = 2.501 (2.223–2.813)). In conclusion, a considerable proportion of patients with type 2 diabetes had confirmed COVID-19 infection. Continued targeted efforts are needed to accelerate vaccination coverage rates among patients with diabetes in general and the particular subgroups identified in this study.

Ayla M Tourkmani,1 Turki J Alharbi,1 Osama Abdelhay,2 Hesham I Alkhashan,1 Aljoharah H Alobaikan,1 Aboud F Alaboud,1 Ahmed Bakhiet,1 Hala Alqahtani,1 Saad M Albattal,1 Nawaf M Abanami1 1Family and Community Medicine Department, Prince Sultan Military Medical City, 2Research Unit, MSD, Riyadh, Saudi Arabia Aim: Despite the safety warnings issued for pioglitazone, its utilization continued in several countries. However, an individualized patient risk–benefit assessment has been advised before the use of pioglitazone. The objectives of the current study are to assess the adherence to pioglitazone safety monitoring and determine the reasons for pioglitazone discontinuation. Methods: Retrospective cohort study of patients with type 2 diabetes was carried out for patients who have been started on oral pioglitazone at the Al-Wazarat primary care center between ­January 2011 until the end of 2014. Adverse events and pioglitazone discontinuation were monitored during patient visits scheduled in 12-month period following the start of pioglitazone. The Chronic Disease Unit at the Al-Wazarat primary care center designed a monitoring data sheet. The safety-monitoring sheet included patients' demographics (age and gender), history of bladder cancer, current bladder cancer, and current bladder diseases. The patient's weight, edema status, liver function test (LFT), electrocardiogram (ECG), bone mass density (BMD), and hematuria were recorded at pioglitazone initiation and weeks 12, 24, and 48. Results: A total of 183 patients (78 males and 105 females) were included in the cohort. The side effect that was associated with highest monitoring adherence (two or more times during the study) was weight gain (94.5%), followed by LFTs (47.5%), edema (31.1%), bone mineral density (18.0%), and ECG (16.4%). Approximately 47.4% had one or more adverse events, with the most common side effect being weight gain (35.1%), followed by osteoporosis (10.5%), edema (8.8%), hypoglycemia (7.0%), elevated liver enzymes (3.5%), and osteopenia (3.5%). Approximately 63.9% discontinued pioglitazone, with the common reasons being shifting to insulin therapy (28.2%), weight gain (25.6%), loss to follow-up (15.4%), hypoglycemia (10.2%), and osteoporosis (8.4%). This reports an appropriate initiation of pioglitazone but suboptimal adherence to pioglitazone safety monitoring in a primary care setting. Keywords: hypoglycemia, primary care, adverse effects, diabetes care, follow-up

Ayla M Tourkmani,1 Mohamed Azmi Hassali,2 Turki J Alharbi,1 Hesham I Alkhashan,1 Aljoharah H Alobikan,1 Ahmed H Bakhiet,1 Hala B Alqahtani,1 Alian A Alrasheedy,3 Ahmed D Alawwad,1 Adel M Mishriky,1 Hisham Aljadhey4 1Family and Community Medicine Department, Prince Sultan Military Medical City, Riyadh, Saudi Arabia; 2Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia; 3Department of Pharmacy Practice, Unaizah College of Pharmacy, Qassim University, Qassim Saudi Arabia; 4Medication Safety Research Chair, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia Background: Fasting during the month of Ramadan could lead to acute complications and increased hypoglycemic risk of patients with type 2 diabetes. Therefore, diabetes is one of the diseases that need careful observation and special considerations during Ramadan including patients' education and counseling. Objectives: To evaluate the impact of Ramadan focused education program on acute complications and biomedical parameters. Methods: A prospective nonrandomized interventional controlled design was run on three phases: before, during, and after Ramadan on 262 type 2 diabetes patients. The intervention group (n=140) received focused individualized diabetic education sessions and antidiabetic medications adjustment before and after Ramadan, while the control group (n=122) received standard diabetic care. A validated hypoglycemia questionnaire was used in both groups to assess the change of the risk. Patients were advised to adjust the dosage and timing of antidiabetic agents according to the recommendations for management of diabetes during Ramadan. Primary outcomes were postintervention change of hypoglycemia score and HbA1c over 6-month follow-up. Data were presented as mean ± standard deviation. HbA1c was expressed in percentage. Results: The hypoglycemic scores before, during, and after Ramadan were 14.21±8.50, 6.36±6.17, and 5.44±5.55 in the intervention group, respectively (P<0.001) and 14.01±5.10, 13.46±5.30, and 9.27±4.65 in the control group, respectively (P<0.001). HbA1c levels were 9.79±1.89, 8.26±1.54, and 8.52±1.61 before, during, and after Ramadan in the intervention group, respectively (P<0.001), and 10.04±1.47, 9.54±1.38, and 9.59±1.79 in the control group, respectively (P<0.001). Post-Ramadan reductions of HbA1c and hypoglycemic scores were significantly higher in the intervention group (-13.0% vs -4.5%, P=0.004 for HbA1c and -61.7% vs -33.8%, P<0.001 for hypoglycemic score). Low-density lipoprotein cholesterol improved in the intervention group from 2.41±0.91 mmol/L before Ramadan to 2.28±0.68 mmol/L after Ramadan (P<0.001). No statistically significant effects were observed on blood pressure or body weight in the intervention group. Also, no change was observed in the control group. Conclusion: Ramadan educational program had a positive impact with reduction of hypoglycemic risk, HbA1c, and low-density lipoprotein cholesterol. Therefore, it could be recommended for patients with increased risk of hypoglycemia during Ramadan fasting. Keywords: complications, diabetes, fasting, Saudi Arabia

The elderly population is increasing throughout the globe, resulting in higher healthcare costs. Potential inappropriate medication (PIM) prescriptions are a major health problem affecting the elderly persons. Due to limited studies in PIM use in primary care and home healthcare in Saudi Arabia, we aim to examine the extent of PIM prescription for and use by elderly patients. This study was carried out with 798 elderly patients, arbitrarily selected from Prince Sultan Medical Military City through the patient register. The mean age of the patients were in the range of 75.2 ± 5.5; 37.8% were males and 62.2% were females. The elderly patients are affected majorly with diabetes (73.9%), hypertension (83.2%) and lipid abnormalities (73.8%). The maximum patients involved in this study were affected with lower hemoglobin levels i.e. 99.2%. Renal impairment was found in 64% and iron supplements were the most commonly used in 23.1%, followed by analgesics and opioids (17%). The 52.5% of participants were using one or more PIMs. Kidney was the only functions and had influence on prescribed decisions. This study indicates PIM is a concern in elderly patients attending clinics and home residents and commonly prescribed ones are atypical antipsychotics, iron overdose, benzodiazepines and opioids. Prescription of drug–drug interactions, cascades and inappropriate drug doses results in preventable adverse effects.

The current study aims to assess the water quality of the Al-Diwaniyah River in the city of Al-Diwaniyah to drink in terms of chemical properties and heavy metals and their impact on the health of the local population. The results showed that most of the parameters in the river water are of low concentrations due to the limited human activities in polluting the river water. The study concluded that the water quality is suitable for drinking depending on major cations and anions in all seasons. The Heavy Metal Pollution Index (HPI) showed that the river water was clean and safe, except two slightly polluted samples. The study concluded that river water for drinking or various domestic uses does not pose any danger to human health if there are no other polluting factors.

AbstractBackgroundRisk of bias (RoB) tools are critical in systematic reviews and affect subsequent decision‐making. RoB tools should have adequate interrater reliability and interconsensus agreement. We present an approach of post hoc evaluation of RoB tools using duplicated studies that overlap systematic reviews.MethodsUsing a back‐citation approach, we identified systematic reviews that used the Risk Of Bias In Nonrandomized Studies‐of Interventions (ROBINS‐I) tool and retrieved all the included primary studies. We selected studies that were appraised by more than one systematic review and calculated observed agreement and unweighted kappa comparing the different systematic reviews' assessments.ResultsWe identified 903 systematic reviews that used the tool with 51,676 cited references, from which we eventually analyzed 171 duplicated studies assessed using ROBINS‐I by different systematic reviewers. The observed agreement on ROBINS‐I domains ranged from 54.9% (missing data domain) to 70.3% (deviations from intended interventions domain), and was 63.0% for overall RoB assessment of the study. Kappa coefficient ranged from 0.131 (measurement of outcome domain) to 0.396 (domains of confounding and deviations from intended interventions), and was 0.404 for overall RoB assessment of the study.ConclusionA post hoc evaluation of RoB tools is feasible by focusing on duplicated studies that overlap systematic review. ROBINS‐I assessments demonstrated considerable variation in interconsensus agreement among various systematic reviewes that assessed the same study and outcome, suggesting the need for more intensive upfront work to calibrate systematic reviewers on how to identify context‐specific information and agree on how to judge it.

Background:The impact of public health policy to reduce the spread of COVID-19 on access to surgical care is poorly defined. We aim to quantify the surgical backlog during the COVID-19 pandemic in the Brazilian public health system and determine the relationship between state-level policy response and the degree of state-level delays in public surgical care. Methods:Monthly estimates of surgical procedures performed per state from January 2016 to December 2020 were obtained from Brazil's Unified Health System Informatics Department. Forecasting models using historical surgical volume data before March 2020 (first reported COVID-19 case) were constructed to predict expected monthly operations from March through December 2020. Total, emergency, and elective surgical monthly backlogs were calculated by comparing reported volume to forecasted volume. Linear mixed effects models were used to model the relationship between public surgical delivery and two measures of health policy response: the COVID-19 Stringency Index (SI) and the Containment & Health Index (CHI) by state.Findings:Between March and December 2020, the total surgical backlog included 1,119,433 (95% Confidence Interval 762,663–1,523,995) total operations, 161,321 (95%CI 37,468–395,478) emergent operations, and 928,758 (95%CI 675,202–1,208,769) elective operations. Increased SI and CHI scores were associated with reductions in emergent surgical delays but increases in elective surgical backlogs. The maximum government stringency (score = 100) reduced emergency delays to nearly zero but tripled the elective surgical backlog. Interpretation:Strong health policy efforts to contain COVID-19 ensure minimal reductions in delivery of emergent surgery, but dramatically increase elective backlogs. Additional coordinated government efforts will be necessary to specifically address the increased elective backlogs that accompany stringent responses.

Mujeres indígenas, territorialidad y biodiversidad en el contexto latinoamericano, se articula en torno a cinco ejes temáticos: participación política y ambiental, reconfiguraciones territoriales, conocimientos tradicionales y biodiversidad, alternativas desde lo local, y políticas globales y sus efectos locales. Estos temas se desarrollan a lo largo de 28 textos, desde la perspectiva indígena y no indígena, los cuales presentan las voces, demandas, situaciones y propuestas de las mujeres de 19 pueblos indígenas habitantes de 11 países latinoamericanos. De igual manera, se presentan diversos análisis sobre las políticas globales y nacionales (biodiversidad, objetivos del milenio, desarrollos, entre otros) y sus efectos en relación con las propuestas y las prácticas de las mujeres indígenas. En síntesis, este libro agrupa una serie de artículos que quieren aportar a la discusión contemporánea sobre las problemáticas de las mujeres indígenas en Latinoamérica.