COPD care in Saudi Arabia: physicians' awareness and knowledge of guidelines and barriers to implementation.

OBJECTIVE: To assess Saudi physicians' awareness and knowledge about chronic obstructive pulmonary disease (COPD) guideline recommendations. METHODS: Cross-sectional study including physicians involved in COPD care in five hospitals in the Eastern Province of Saudi Arabia. The level of physicians' knowledge was considered as satisfactory (score > 80%), fair (score 50-80%) or poor (<50% of total score). RESULTS: Among the 44 physicians included in the study, the mean ± standard deviation knowledge score was 29.5 ± 4.2 out of 45 points (65.5%). Most physicians appeared to be unaware of any COPD guidelines (n = 27, 61.4%), and reported not adhering to guidelines (n = 28, 63.6%). CONCLUSION: Saudi physicians' knowledge about Global Initiative for Chronic Obstructive Lung Disease guidelines was assessed as fair. It is therefore highly recommended to increase physicians' awareness and knowledge about COPD-related guidelines.

The Saudi Thoracic Society pneumococcal vaccination guidelines-2016.

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.

The Saudi clinical practice guideline for the diagnosis of the first deep venous thrombosis of the lower extremity

The diagnosis of deep venous thrombosis (DVT) may be challenging due to the inaccuracy of clinical assessment and diversity of diagnostic tests. On one hand, missed diagnosis may result in life-threatening conditions. On the other hand, unnecessary treatment may lead to serious complications. As a result of an initiative of the Ministry of Health of the Kingdom of Saudi Arabia (KSA), an expert panel led by the Saudi Association for Venous Thrombo-Embolism (SAVTE; a subsidiary of the Saudi Thoracic Society) with the methodological support of the McMaster University Working Group, produced this clinical practice guideline to assist healthcare providers in evidence-based clinical decision-making for the diagnosis of a suspected first DVT of the lower extremity. Twenty-four questions were identified and corresponding recommendations were made following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. These recommendations included assessing the clinical probability of DVT using Wells criteria before requesting any test and undergoing a sequential diagnostic evaluation, mainly using highly sensitive D-dimer by enzyme-linked immunosorbent assay (ELISA) and compression ultrasound. Although venography is the reference standard test for the diagnosis of DVT, its use was not recommended.(AU)

Prevalence of rhinitis symptoms among 16 to 18 years old adolescents in Saudi Arabia.

OBJECTIVE: The present study was designed to estimate the prevalence of rhinitis symptoms among secondary school students in Saudi Arabia METHODS: A cross-sectional study was conducted among children from secondary schools in the city of Riyadh. The study utilised the International Study of Asthma and Allergies in Children (ISAAC) questionnaire. RESULTS: Among the 3073 students (1504 boys and 1569 girls), the prevalence of life-time rhinitis, rhinitis in the past 12 months, and hay fever were 43.8%, 38.6% and 21.3%, respectively. There was a significant difference between boys and girls in the prevalence of life-time rhinitis (41% versus 46.5%, p = 0.02) and the prevalence of rhinitis in the past 12 months (35.1% versus 41.9%, p = 0.001). There was no significant difference between boys and girls in the prevalence of hay fever (22.5% versus 20.2%, p = 0.144). The prevalence of asthma symptoms among students with life-time rhinitis and hay fever were 35.4% and 39.9%, respectively. Asthma symptoms were strongly linked with life-time rhinitis (Odds Ratio [OR] = 2.5, p < 0.001) and hay fever (OR = 2.4, p value < 0.001). CONCLUSIONS: The prevalence of rhinitis symptoms is high among 16 to 18 years old adolescents in Saudi Arabia, and symptoms are more common in girls compared to boys. Rhinitis symptoms are also associated with a high frequency of asthma symptoms.

Impact of a pulmonary rehabilitation programme on respiratory parameters and health care utilization in patients with chronic lung diseases other than COPD.

Pulmonary rehabilitation is a tool that is receiving more acceptance in chronic lung diseases. A retrospective study was made in Riyadh, Saudi Arabia, on the impact of pulmonary rehabilitation on respiratory parameters and health care utilization in a group of outpatients with chronic lung diseases other than chronic obstructive pulmonary disease. A group of 51 patients diagnosed with interstitial lung diseases, bronchiectasis, asthma and scoliosis were studied. Initial number of emergency department visits and hospital admissions and use of prednisone and antibiotics were significantly associated with adherence to the pulmonary rehabilitation programme. There was a significant improvement in functional exercise capacity as manifested on the 6-minute walking distance and distance on treadmill, bicycle and arm ergometer and significantly better utilization of health care resources (fewer emergency department and outpatient department visits) over the 12 months after completion of the programme.

Innovations in medical internship: benchmarking and application within the King Saud bin Abdulaziz University for Health Sciences.

INTRODUCTION: While the medical internship (MI) has evolved in some countries into competency-based training with innovative tools for assessment and feedback, the traditional MI is still the norm in many countries. AIM: To describe recent advances in the MI in several countries, to discuss the current MI situation in Saudi Arabia as an example of a country that applies a traditional MI, and to present a Framework for Medical Interns' Competencies (FMIC) implemented within the King Saud bin Abdulaziz University for Health Sciences (KSAU-HS). METHODS: Common electronic databases were searched for the years 1990 to 2008 under keywords related to medical internship education. Information on curricula designed for medical interns or junior doctors in selected countries was obtained by searching relevant websites. At the KSAU-HS, the FMIC was created by first building the case for the urgent need for revising the MI and adapting international approaches to the KSA's needs, followed by dialogue among faculty and leaders, planning, coordination and execution of the framework. RESULTS: Two trends were identified in the recent evolution of the MI. In North America, the first postgraduate year now serves the traditional purpose of the MI. Australia and the United Kingdom have embedded the MI within junior doctor training. These innovative curricula have in common a focus on the domains of medical knowledge, clinical practice, professionalism and communication skills. The FMIC applies innovative principles during the MI years customized to the local medical education setting. CONCLUSION: The evolution in medical education and healthcare systems worldwide has necessitated innovations in the MI. The FMIC is a model whereby innovative curriculum was introduced to enhance the outcomes of the MI in a country that has applied a traditional MI.

Pulmonary changes in liver transplant candidates with hepatitis C cirrhosis.

OBJECTIVE: Several studies have shown that pulmonary abnormalities are common in patients with end-stage liver disease. However, most of these studies were conducted on patients with heterogeneous etiologies. Therefore, we studied these changes in a homogenous group of hepatitis C cirrhotic patients who were potential candidates for liver transplantation. METHODS: The charts of 81 patients from King Fahad National Guard Hospital, Riyadh, Kingdom of Saudi Arabia with hepatitis C cirrhosis who were evaluated for liver transplantation were reviewed. The following data was retrieved: echocardiography with micro-bubble study, arterial blood gases, and pulmonary function tests of 81 candidates and reviewed over 3 years from 1994 to 1997. RESULTS: The mean age was 53 (+/-9) years with male to female ratio of 1.4:1. Echocardiographic micro-bubble study, revealed 4 of 62 (7%) had an intrapulmonary shunt. Arterial blood gases results were pH of 7.44 (+/-0.4), partial arterial tension of carbon dioxide of 33 mm Hg (+/-4), partial arterial tension of oxygen of 84 mm Hg (+/-12), and alveolar-arterial gradient of 30 mm Hg (+/-10). Eleven percent had obstructive airway disease, 17% had restrictive lung impairment, and 43% had reduced diffusion capacity. Seventy five percent of patients with reduced diffusion capacity had normal lung volumes. Various pulmonary function test abnormalities did not lead to significant differences in arterial blood gases. CONCLUSION: Pulmonary changes were frequent in liver transplant candidates with hepatitis C virus cirrhosis with reduced diffusion capacity being the most. Apart from the effect of hepatopulmonary syndrome on arterial oxygenation, other pulmonary abnormalities were not significantly different.

Complications of carbon monoxide poisoning.

OBJECTIVE: Acute carbon monoxide poisoning is a common problem that occurs during winter and leads to serious complications. METHODS: We retrospectively studied 24 consecutive cases admitted with the aim of finding the causes and outcome of acute carbon monoxide poisoning. RESULTS: The source of poisoning was charcoal in 71% of patients, motor gasoline in 21%, and other causes in 8%. Immediate complications included altered consciousness level in 54% of patients, metabolic acidosis in 46%, pneumonia in 42%, cardiac arrhythmia in 29% and rhabdomyolysis in 25%. Late neurological complications occurred in 17% of patients. All the patients received 100% oxygen. Eleven patients (46%) required mechanical ventilation. Ultimately, 19 patients (79%) recovered completely, 4 (17%) had neurological or cardiac disorders, and 1 (4%) died. CONCLUSION: Immediate and late complications are common in carbon monoxide poisoning cases admitted to the hospital especially when they arrive late. Time lapse between exposure and presentation may have a role in predicting the outcome.

The significance of the persistent presence of acid-fast bacilli in sputum smears in pulmonary tuberculosis.

STUDY OBJECTIVES: Identification of acid-fast bacilli (AFB) in the sputum smear at the completion of tuberculosis therapy is in some settings considered evidence of treatment failure. However, some patients with pulmonary tuberculosis (TB) will have positive smear results with negative sputum culture results at the end of therapy. The objectives of this study were to estimate the prevalence of persisting positive sputum smear results in patients with TB and to identify characteristics that distinguish patients with persistently positive sputum smear results who also had negative sputum culture results from patients identified as treatment failures. DESIGN: A population-based, historical cohort study with nested case control study. SETTING: British Columbia Division of Tuberculosis Control central case registry. PATIENTS: All 428 patients with culture-proven pulmonary TB in British Columbia over 7 years with sputum that was positive for AFB. METHODS: Review of laboratory data of all 428 patients, as well as clinical data of a subset of 30 patients with persistently positive smear results beyond 20 weeks. RESULTS: Sputum smears were positive for AFB in 205 patients (48%) at 4 weeks, in 30 patients (7%) at 20 weeks, and in 12 patients (3%) at 36 weeks. Of the patients with smear results that were persistently positive at 20 weeks, 23 (77%) had negative sputum culture results and 7 (23%) had positive sputum culture results (ie, they were treatment failures). Patients identified as treatment failures had more localized disease as shown on chest radiographs, had less radiographic improvement at follow-up, had a higher prevalence of drug resistance, and were less compliant with medications than patients with persistently positive smear results and negative culture results. No subject with a negative culture result relapsed over the 6- to 48-month observation period. CONCLUSION: Sputum that is persistently positive for AFB in patients in developed countries is more likely to be associated with negative culture results than with treatment failure.