OBJECTIVE: This prospective study was conducted to evaluate the value of sonographic B-lines (previously called "comet tail artifacts''), which are long, vertical, well-defined, hyperechoic, dynamic lines originating from the pleural line in assessment of interstitial lung diseases (ILD) and compare them with the findings of chest high-resolution computed tomography (HRCT) and pulmonary function tests (PFTs). MATERIALS AND METHODS: Sixty-one patients with ILD underwent transthoracic lung ultrasound for assessment of the presence of B-lines and the distance between them. These findings were compared with that of chest HRCT (ground glass, reticular, nodular or honey combing) and PFT as forced vital capacity (FVC), total lung capacity (TLC), diffusion capacity for carbon monoxide (DLCO) and partial arterial oxygen pressure (PaO2). RESULTS: All patients had diffuse bilateral B-lines. The distance between each of the two adjacent B lines correlated with the severity of the disease on chest HRCT where B3 (the distance was 3 mm) correlated with ground glass opacity and B7 (the distance was 7 mm) correlated with extensive fibrosis and honey combing. Also, the distance between B-lines inversely correlated with FVC (r = -0.848, P < 0.001), TLC (r = -0.664, P < 0.001), DLCO (r = -0.817, P < 0.001) and PaO2 (r = -0.902, P < 0.001). CONCLUSION: B-lines that are lung Ultrasound signs seem to be useful in the assessment of ILD.
Introduction: The differential diagnosis of sarcoidosis creates a challange due to tuberculosis also having lung and lymph node involvement. Because both diseases show granulomatous inflammation, it may not be possible to distinguish tuberculosis and sarcoidosis in pathological specimens. As a result of the complexity in the differential diagnosis of sarcoidosis and tuberculosis, new markers for differentiation are being investigated. Objective: The aim of our study is to investigate the value of neutrophil/lymphocyte ratio (NLR) as a possible marker in differentiating sarcoidosis and tuberculosis. Materials and Methods: In our study, 51 acid-fast bacilli (AFB) positive and/or culture-positive patients with pulmonary tuberculosis, 40 patients with biopsy-proven sarcoidosis and a control group consisting of 43 patients were included. In our study, information was collected retrospectively based on hospital records. Results: Leukocyte and neutrophil counts, NLR, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) were significantly higher, and albumin was significantly lower in the tuberculosis group compared with sarcoidosis (for all parameters P < 0.001). The most appropriate cut-off value of NLR to distinguish tuberculosis from sarcoidosis was determined as 2.55. For this cut-off value of NLR there was 79% sensitivity, 69% specificity, 73% positive predictive value (PPV), 75% negative predictive value (NPV), and area under the curve (AUC) was 0.788. For differentiation of sarcoidosis from tuberculosis, accuracy of the NLR test according to this cut-off value was found as 76%. Conclusion: NLR as a little known marker in respiratory medicine was found to be supportive in differentiation of tuberculosis and sarcoidosis. More studies on this issue is needed.
This is an updated guideline for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of SINA is to have guidelines that are up to date, simple to understand and easy to use by nonasthma specialists, including primary care and general practice physicians. SINA approach is mainly based on symptom control and assessment of risk as it is the ultimate goal of treatment. The new SINA guidelines include updates of acute and chronic asthma management, with more emphasis on the use of asthma control in the management of asthma in adults and children, inclusion of a new medication appendix, and keeping consistency on the management at different age groups. The section on asthma in children is rewritten and expanded where the approach is stratiied based on the age. The guidelines are constructed based on the available evidence, local literature, and the current situation in Saudi Arabia. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.
Obesity is becoming a major medical concern in several parts of the world, with huge economic impacts on health- care systems, resulting mainly from increased cardiovascular risks. At the same time, obesity leads to a number of sleep-disordered breathing patterns like obstructive sleep apnea and obesity hypoventilation syndrome (OHS), leading to increased morbidity and mortality with reduced quality of life. OHS is distinct from other sleep- related breathing disorders although overlap may exist. OHS patients may have obstructive sleep apnea/hypopnea with hypercapnia and sleep hypoventilation, or an isolated sleep hypoventilation. Despite its major impact on health, this disorder is under-recognized and under-diagnosed. Available management options include aggressive weight reduction, oxygen therapy and using positive airway pressure techniques. In this review, we will go over the epidemiology, pathophysiology, presentation and diagnosis and management of OHS.
OBJECTIVE: The objective of this retrospective study was to assess the efficacy of medical thoracoscopy in diagnosing of tuberculous pleurisy and characterize tuberculous pleurisy with medical thoracoscopy. METHODS: A total of 575 patients with tuberculous pleurisy who underwent medical thoracoscopy were included in the study. Demographic data, clinical manifestations, and routine and biochemical tests on pleural fluid, cultures of pleural fluid, sputum, and pleural biopsy for the detection of Mycobacterium tuberculosis and pathological findings were evaluated. RESULTS: Sputum, pleural fluid, and pleural biopsy cultures were positive for M. tuberculosis in 12.5%, 19.2%, and 41.9% of patients, respectively. Furthermore, there were significant differences in total positive tuberculosis (TB) tests in the pleural cavity according to patient's age (60 years old, 18.6%; and all groups vs. >60 years old, P60 years old (77.0% vs. 37.9%). The percentage of patients with high adenosine deaminase (ADA) levels in pleural fluid (>40 U/L), who were 60 years old, was 83.3% (15/18), 72.8% (193/265), 51.2% (88/172), and 34.7% (17/49), respectively (all groups vs. >60 years old, P < 0.001). CONCLUSION: Medical thoracoscopy is effective for diagnosing tuberculous pleurisy. Younger patients with tuberculous pleurisy have a higher number of positive TB tests in the pleural cavity, are more likely to have granuloma in pleural biopsy specimens, and have higher ADA levels in the pleural fluid.
BACKGROUND: Reports of thunderstorm asthma in the Middle East are few. This study is the first to report on cases of near-fatal and fatal thunderstorm asthma in Kuwait on December 1, 2016. METHODS: We conducted a chart review and interview with adult patients admitted to Mubarak Al-Kabir Hospital with near-fatal asthma, defined as an exacerbation requiring intubation and mechanical ventilation or hypercapnia with a PaCO2 >= 6 kPa. Information, including patient age, gender, occupation, asthma history, medication usage, and clinical outcome, was collected. For fatal asthma cases, patients' data were collected from the Forensic Department at the Kuwait Ministry of Interior. RESULTS: A total of 17 patients were admitted with near-fatal asthma. Fifteen patients (93.8%) had a prior history of asthma, with an average duration of 9 years. Five patients (33.3%) reported receiving a corticosteroid inhaler from their physician. Fifteen patients (93.8%) reported relying on a short-acting beta 2-agonist alone to manage their asthma. Eleven patients (68.8%) reported being outdoors during the storm. Eleven patients were diagnosed with fatal asthma. CONCLUSION: The study is the first to report on a thunderstorm-associated asthma epidemic in Kuwait and emphasizes the potential dangers associated with this entity.
NASAM (National Approach to Standardize and Improve Mechanical Ventilation) is a national collaborative quality improvement project in Saudi Arabia. It aims to improve the care of mechanically ventilated patients by implementing evidence-based practices with the goal of reducing the rate of ventilator-associated events and therefore reducing mortality, mechanical ventilation duration and intensive care unit (ICU) length of stay. The project plans to extend the implementation to a total of 100 ICUs in collaboration with multiple health systems across the country. As of March 22, 2019, a total of 78 ICUs have registered from 6 different health sectors, 48 hospitals, and 27 cities. The leadership support in all health sectors for NASAM speaks of the commitment to improve the care of mechanically ventilated patients across the kingdom.
Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNEC) is an abnormal proliferation of pulmonary neuroendocrine cells that occur without underlying etiology. Here, we report a unique case of 55-year-old female with unusual presentation of DIPNECH and thymoma and on the background history of Crohn's disease that might point toward an autoimmune phenomenon. To the best of our knowledge, there were no previous reports of DIPNECH with either thymoma or Crohn's disease. DIPNECH has premalignant potential and reported in association with carcinoid and non-small cell lung cancer: however, its autoimmune association never reported. The presence of multiple lung nodules along with evidence of small airway disease should alert the physician to include DIPNECH as part of the differential diagnosis given its malignant potential. The prognosis is variable and depends on the presence or absence of underlying malignancy as well as the severity of airflow obstruction.
BACKGROUND: Chronic obstructive pulmonary disease (COPD) patients are at an increased risk of postoperative pulmonary complications (PPCs). The purpose of this study is to evaluate the risks and benefits associated with preoperative steroids in COPD patients. METHODS: The National Surgical Quality Improved Program database was used to identify 92 COPD patients who underwent surgery at the American University of Beirut Medical Center between 2009 and 2013. COPD was diagnosed based on postbronchodilator forced expiratory volume in 1 s to forced vital capacity ratio <0.7 and a history of smoking. The exposure of interest was preoperative systemic corticosteroid therapy. The primary outcomes were PPCs and wound complications. Cardiac and urinary complications along with unplanned readmission or reoperation and death were also evaluated. RESULTS: Overall 42.4% of patients received preoperative systemic corticosteroids. Postoperative wound complications were significantly more frequent in COPD patients who received preoperative systemic corticosteroids compared to patients who did not (10.3% vs. none, respectively, P= 0.03). However, PPCs were not significantly different between patients who received preoperative systemic corticosteroids and patients who did not (17.9% vs. 13.2%, respectively, P = 0.53). There were no significant differences in the secondary outcomes. CONCLUSIONS: This study suggests that preoperative administration of systemic corticosteroids in stable COPD patients is associated with an increased risk of postoperative wound complications but may not reduce PPCs.
INTRODUCTION: E-cigarettes have emerged as the most commonly used tobacco or nicotine products among youth in the United States (US), and usage with other products (dual use) is not well understood. This study assessed dual use and identified associated factors of usage in school-going youth in the high tobacco burdened region of rural Appalachian Tennessee. METHODS: Two waves of data for the same cohort of students were collected in 2014 (Wave 1) and 2016 (Wave 2). Dual use of e-cigarettes with any other tobacco product was the dependent variable. The independent variables consisted of exposure to tobacco use at home, home smoking rules, smoking inside the vehicle, attitudes toward smoking, exposure to tobacco industry marketing/promotion, and peer/family pressure. Descriptive statistics and multivariate logistic regression analyses were conducted to determine the prevalence of dual use and delineate factors associated with usage. RESULTS: Dual use increased from 13.3% in Wave 1 to 18.6% in Wave 2. Results of logistic regression show that exposure to tobacco industry marketing/promotion was significantly associated with dual use in the two waves, odds ratio (OR) = 4.18 (confidence interval [CI] = 1.69-10.38) and OR = 4.43 (CI = 2.03-9.67), respectively. While allowing smoking inside the vehicles, sometimes, significantly increased dual use in Wave 1 (OR = 3.18 [CI = 1.19-8.48]), exposure to tobacco use at home (OR = 2.94 [1.24-6.97]), and peer/family pressure (OR = 2.92 [1.87-7.19]) increased usage in Wave 2 . CONCLUSION: The increasing trend in dual use of e-cigarettes and other tobacco products among youth in Appalachia Tennessee suggests a critical need for comprehensive tobacco control programs to avert exacerbating disparities in tobacco use and tobacco-related diseases in the US.
Low-dose hydrocortisone was found in one trial to reduce the risk of death in patients with septic shock and relative adrenal insufficiency without increasing adverse events. Respiratory The use of extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS) has been studied since 1979 with two earlier trials did not show significant improvement, but both trials suffered technical difficulties as the technology was fairly primitive then. , The POLAR trial was conducted in 14 institutes in 6 countries (Australia, France, Saudi Arabia, Qatar, Switzerland, and New Zealand) and included 510 patients who were randomized to hypothermia protocol with a target temperature of 35°C compared to normothermia protocol with a temperature target of 36.5°C–37.5°C. The proportion of patients with favorable neurological outcomes (Glasgow Outcome Score Extended: GOSE 5–8) at 6 months' following injurywas not statistically significant between the hypothermia group compared the normothermia group (relative risk, 0.99 [95% CI, 0.82–1.19]; P = 0.94). The study found no evidence that the use of haloperidol or ziprasidone had an effect on the number of days alive without delirium or coma during the 14-day intervention period among patients with acute respiratory illness or shock in the ICU (adjusted median number of days alive and without delirium or coma was 8.5 (95% CI 5.6–9.9) in the placebo group, 7.9 (95% CI 4.4–9.6) in the haloperidol group, 8.7 (95% CI 5.9–10.0) in the ziprasidone group (P value across trial groups = 0.26).
CONTEXT: Asthma control is suboptimal in the Middle East and North Africa (MENA). AIMS: The aim of this study is to assess the level of asthma control in Saudi patients as per the Global Initiative for Asthma 2012 classification and explore its potential predictive factors. SETTINGS AND DESIGN: Epidemiological Study on the Management of Asthma in Asthmatic Middle East Adult Population (ESMAA) is a multicentric, descriptive, epidemiological study assessing asthma management in the MENA region. In this article, we report the results of patients from Saudi Arabia included in the ESMAA study. METHODS: Adult patients diagnosed with asthma at least 1 year before study entry were considered for inclusion. Asthma control level and its predictive factors were explored. Treatment adherence and quality of life (QoL) were assessed by MMAS-4(C) and Short Form 8 Health Survey QoL questionnaires, respectively. STATISTICAL ANALYSIS USED: Descriptive statistics were done considering two-sided 95% confidence intervals. Logistic regression was used to explore the potential predictive factors of asthma control. All statistical tests were two-sided, and P < 0.05 was considered statistically significant. RESULTS: Data of 1009 patients from Saudi Arabia were analyzed. Less than one-third of patients (30.1%) were found to have controlled asthma with significantly higher QoL. High level of asthma control was reported among male patients and those with high educational level, while age, body mass index, and adherence to treatment were found to have no effect on asthma control. CONCLUSIONS: Asthma control remains suboptimal among Saudi population. This needs huge efforts to achieve acceptable levels of control and better QoL for asthma patients. Further studies are still needed in Saudi Arabia and the Middle East region.
CONTEXT AND AIM: The skeleton is a frequent site for metastasis in patients with breast, lung, and prostate cancer. Bone metastasis compromises skeletal integrity leading to skeletal-related events (SREs). This study aims at estimating the prevalence of bone metastasis in lung cancer and describing types of bone involvement, management, outcomes, and overall survival. METHODS: We retrospectively reviewed the charts of 259 patients with nonsmall cell lung cancer who consulted the Department of Medical Oncology at our institution between January 2002 and December 2012. We documented their lung cancer characteristics, presence of skeletal metastases, management types, outcome parameters, and survival status. RESULTS: A total of 116 patients (58.6%) were diagnosed with bone metastasis. The most common site of metastasis was the spine. The most common SREs were bone pain (44%) and need for radiotherapy (25.9%). Patients with adenocarcinoma (P = 0.002) and concomitant liver metastasis (P = 0.013) tended to have more incidence of bone metastasis. Survival rates were (36%) at 1 year, and (3%) at 5 years. Metastasis to the bone did not impact patients' survival. Patients tended to have worse survival in the presence of concomitant bone and liver metastases (P = 0.012), older age (P = 0.024), lower limb metastasis (P = 0.014), hypercalcemia (P = 0.001), and not receiving calcium therapy (P = 0.011). CONCLUSION: Metastatic bone disease is considered a huge burden on patients, clinicians, and the society. The majority of bone metastasis patients will experience SREs. Most SREs predict poor prognosis. Supportive therapy to overcome the reasons for poor prognosis may improve patients' survival and quality of life.
Streptococcus pneumoniae (pneumococcus) is the leading cause of morbidity and mortality worldwide. Saudi Arabia is a host to millions of pilgrims who travel annually from all over the world for Umrah and the Hajj pilgrimages and are at risk of developing pneumococcal pneumonia or invasive pneumococcal disease (IPD). There is also the risk of transmission of S. pneumoniae including antibiotic resistant strains between pilgrims and their potential global spread upon their return. The country also has unique challenges posed by susceptible population to IPD due to people with hemoglobinopathies, younger age groups with chronic conditions, and growing problem of antibiotic resistance. Since the epidemiology of pneumococcal disease is constantly changing, with an increase in nonvaccine pneumococcal serotypes, vaccination policies on the effectiveness and usefulness of vaccines require regular revision. As part of the Saudi Thoracic Society (STS) commitment to promote the best practices in the field of respiratory diseases, we conducted a review of S. pneumoniae infections and the best evidence base available in the literature. The aim of the present study is to develop the STS pneumococcal vaccination guidelines for healthcare workers in Saudi Arabia. We recommend vaccination against pneumococcal infections for all children 5 years old, adults >= 50 years old, and people >= 6 years old with certain risk factors. These recommendations are based on the presence of a large number of comorbidities in Saudi Arabia population 50 years of age, many of whom have risk factors for contracting pneumococcal infections. A section for pneumococcal vaccination before the Umrah and Hajj pilgrimages is included as well.
Although accurate identification of Mycobacterium tuberculosis is the gold standard for tuberculosis (TB) diagnosis, there have been several reports of false-positive results. After identifying a sudden increase in extensively drug-resistant TB, false-positive mycobacterial culture tests were suspected, and we contacted the supranational reference center for molecular typing. In silico genotyping tests showed that isolates from all five patients had an identical genotype pattern, and all harbored the same Beijing strain based on sequence-based phylogenic analysis and drug-resistant single nucleotide polymorphisms (SNPs) analysis. We also used whole genome sequencing (WGS) to compare the SNPs of all isolates with a reference genome, and all were identical. We adapted WGS to efficiently detect false-positive MTB culture tests.
Idiopathic Pleuro-Parenchymal Fibroelsatosis (PPFE) is a rare, progressive and recently recognized subtype of idiopathic interstitial lung disease with no recorded successful treatment other than lung transplant. We report a case of idiopathic pleuroparenchymal fibroelastosis from the Middle East, managed successfully by bilateral lung transplant performed on a 26 year old Saudi male.
BACKGROUND: Many individuals complain of disturbed sleep during the wintertime when their air conditioner (AC) is off. Therefore, we conducted this study to objectively assess the impact of AC sound on sleep latency, sleep duration, and sleep efficiency. METHODS: An experimental study was conducted on 48 healthy young adults, in their homes, to assess the effect of a standardized AC white noise, on sleep latency, duration, and efficiency, while simultaneously monitoring light intensity and room temperature. The study was conducted during the winter months. Sleep quality was objectively assessed using sleep actigraphy. Participants were monitored for two nights, during which two different, randomized sets of conditions were used: During one of the nights, the adults were exposed to 43 dB AC white noise; during the other night, adults were not exposed to the AC white noise. RESULTS: Actigraphy results showed that the mean sleep duration during the AC sound nights (ASNs) was 466.8 +/- 60.8 min, compared to 478.8 +/- 55.4 min during the non-AC sound nights (NASNs) (P = 0.6). Sleep-onset latency was 10.8 +/- 15.2 min and 15.1 +/- 18.2 min during the ASNs and the NASNs, respectively (P = 0.8). Moreover, there was no difference in sleep efficiency, 81% +/- 7.8% vs. 78.8% +/- 15.4% in the ASNs and NASNs, respectively (P = 0.9). CONCLUSION: AC sound had no significant positive effect on sleep duration, latency, and efficiency.
Pharmacotherapy is an important part of asthma management, and we know that low-dose inhaled corticosteroids (ICS) are effective in reducing morbidity and mortality from asthma in a wide variety of settings. [...]as a community, we must do better implementing the guidelines that we have. [...]the SINA guidelines Group is to be congratulated on this update, which is thorough, scholarly, and wide ranging.
This is the fourth version of the updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma ( SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up to date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is now more aligned for different age groups. The guidelines have focused more on personalized approaches reflecting better understanding of disease heterogeneity with integration of recommendations related to biologic agents, evidence-based updates on treatment, and role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and current situation at national and regional levels. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.