Respiratory disorders in the Middle East: a review.

The spectrum of pulmonary pathology in the Middle East is as versatile as its civilizations and cultures. In this review, we outline the key challenges confronting pulmonologists in the Middle East. We shed light on the diverse conditions commonly encountered in the region, from the centuries-old illnesses of tuberculosis, to contemporary problems such as lung complications from chemical warfare. We specifically highlighted unique aspects related to respiratory illnesses in the Middle East, for example, climate factors in the desert region, cultural habits, for example, water-pipe smoking and disorders unique to the region, such as Behçet's disease. Pulmonologists are also faced with the consequences of modernization, including large immigrant population and associated social and health issues, rising incidence of obesity and sleep apnoea, and drug-resistant tuberculosis. Tackling these health issues will require an integrated approach involving public health, primary care as well as specialist pulmonology input, taking into consideration the unique cultural and environmental factors to ensure effective management and compliance to medical care.

Increased Risk of Spontaneous Bacterial Peritonitis in Cirrhotic Patients Using Proton Pump Inhibitors.

BACKGROUND: The association between bacterial infections and proton pump inhibitors (PPIs) has recently been studied with debatable results. AIM: The aim of this study was to investigate the relationship between PPIs and the development of spontaneous bacterial peritonitis (SBP) or other bacterial infections in cirrhotic patients. MATERIALS AND METHODS: Consecutive cirrhotic patients hospitalized from 2007 through 2012 to Hamad General Hospital-, Doha, Qatar, were enrolled and classified as PPI users or non-users according to PPI consumption in the 90 days prior to hospitalization. Cirrhosis was clinically diagnosed by a combination of physical, biochemical, radiological, and endoscopic findings, or by liver biopsy. RESULTS: A total of 333 patients were included in this study, of whom 171 (51.4%) used PPIs and 162 (48.6%) did not use PPIs. PPI users were significantly older in age (p = 0.001). There was no statistical difference between the 2 groups in sex distribution and etiology of cirrhosis (p > 0.05 for both parameters). PPI users had a significantly higher incidence of overall bacterial infection (38%) than non-PPI users (13.6%), p = 0.0001. Statistical significance is observed specifically for SBP and chest infection (p = 0.0006 and p = 0.01, respectively). In multivariate analysis, older age (> 60 years; OR = 1.246, 95% CI 1.021-08.486; p = 0.02), and PPI use (OR = 2.149, 95% CI 1.124-06.188; p = 0.01) were independent predicting factors for SBP and overall bacterial infection. CONCLUSION: The present study shows that PPI use, as well as older age (> 60 years), was an independent predicting factor for the development of overall infection and SBP in hospitalized cirrhotic patients. Unless it is indicated, PPI therapy should be avoided in this group of patients, particularly in those older than 60 years of age.

INTRODUÇÃO: A associação entre infeções bacterianas e os Inibidores da bomba de protões (IBPs) tem vindo a ser estudada com resultados discutíveis. OBJETIVO: O objetivo deste estudo foi investigar a relação entre IBPs e o desenvolvimento de peritonite bacteriana espontânea (PBE) ou outras infeções bacterianas em doentes cirróticos. MATERIAL E MÉTODOS: Doentes consecutivos com cirrose hospitalizados entre 2007 e 2012 no Hamad General Hospital- Qatar foram selecionados e classificados como utilizadores ou não utilizadores de IBPs de acordo com o seu consumo nos 90 dias prévios ao internamento. A cirrose foi clinicamente diagnosticada por uma combinação de achados no exame físico, no estudo bioquímico, radiológico e endoscópico; ou por biopsia hepática. RESULTADOS: Um total de 333 doentes foi incluído neste estudo, 171 (51.4%) medicados com IBPs e 162 não (48.6%). Os utilizadores de IBPs eram significativamente mais velhos (p = 0.001). Não se observaram diferenças estatísticas entre os dois grupos no que se refere ao sexo ou etiologia da cirrose (p > 0.05 para os dois parâmetros). A incidência global de infeções bacterianas foi significativamente superior nos utilizadores de IBPs (38%) do que nos não utilizadores (13.6%), p = 0.0001. O significado estatístico desta diferença foi observado especificamente para a PBE e para as infeções pulmonares (p = 0.0006 e p = 0.01, respetivamente). Na análise multivariada, a idade superior a 60 anos (OR = 1.246, 95% CI 1.021−08.486; p = 0.02), e a utilização de IBPs (OR = 2.149, 95% CI 1.124−06.188; p = 0.01) foram fatores preditivos independentes para PBE e para infeção bacteriana no global. CONCLUSÃO: Este estudo mostra que a utilização de IBPs, assim como a idade superior a 60 anos, são fatores preditivos independentes para o desenvolvimento de infeções bacterianas no global e para PBE nos doentes cirróticos hospitalizados. A não ser que esteja especificamente indicado a utilização de IBPs deve ser evitada neste grupo de doentes, particularmente naqueles com idade superior a 60 anos.

Simvastatin-induced rhabdomyolysis and acute renal injury.

Simvastatin is one of the most commonly prescribed CoA reductase inhibitors. The safety profile of this drug has been widely discussed in the medical and consumer advocacy communities. Like other statins, simvastatin can cause a serious and potentially life-threatening complication: rhabdomyolysis. We describe a case of simvastatin-induced rhabdomyolysis complicated by acute renal failure requiring urgent hemodialysis. The relative safety of simvastatin compared to other HMG-CoA reductase inhibitors and the conditions that can potentiate its toxicity are discussed. The clinical features of rhabdomyolysis, and subsequent acute renal failure, and their treatment modalities are presented.

Elusive Cardiac Angiosarcoma in a Young Pregnant Female: Rare Presentation With Fatal Outcome.

Heart tumors are rare occurrences. They can present diagnostic challenges and severe complications especially in pregnant women. We report a rare case of angiosarcoma (AS) cordis of the right atrium in a young healthy pregnant female. Her diagnosis remained elusive for some time until development of advanced disease symptomatology. The diagnosis was unfortunately clinched when her tumor grew to be detected by imaging modalities. An emergency cesarean section was performed delivering a healthy baby. The patient was aggressively treated with chemotherapy to no avail. She passed away 2 months after her diagnosis was established. Only few cases of the occurrence of aggressive cardiac AS and human pregnancy are documented. The course of this disastrous combination is usually marked by severe complications, difficult therapeutic options and ultimately fast demise. Physicians need to be more aware of such diagnosis and diligently try to diagnose it as early as possible.

A case of successful remission of extensive primary gastric diffuse large B cell lymphoma: radiologic, endoscopic and pathologic evidence.

Though rare amongst stomach neoplasms, primary gastric diffuse large B cell lymphoma is one of the commonest extranodal non-Hodgkin lymphomas. If left untreated, it can have a devastating progression and life-threatening consequences. We present the case of a successfully treated large antral ulcer confirmed to be large B cell lymphoma as evidenced by radiologic, endoscopic and histopathologic findings. A brief discussion about the types of gastric lymphoma, their Helicobacter pylori relation and therapeutic modalities follows.

Tuberculous peritonitis associated with peritoneal dialysis.

Even though rare, tuberculous peritonitis (TBP) in patients on continuous ambulatory peritoneal dialysis (CAPD) is a perilous condition. Physicians worry about continuing treatment of their patients, whether to continue this modality of dialysis or switch to hemodialysis. A retrospective cohort study of 89 patients undergoing CAPD over a 12-year period was carried out for any episode of peritonitis with the objectives to find out the incidence of TBP in these patients, evaluation of patients' 3-year survival, possibility of retention of Tenckhoff catheter, and modality of dialysis post-infection. One hundred and three episodes of peritonitis occurred in our patients. Most of them were bacterial and occasionally fungal. We identified four cases of TBP, with one patient having concurrent bacterial infection in the peritoneal fluid. The clinical presentation was insidious with cloudy fluid in all cases. The diagnosis was established by the polymerase chain reaction (PCR) technique in one case, by positive peritoneal fluid culture for Mycobacterium tuberculosis in two cases, and clinically in the fourth one that responded well to anti-tuberculous therapy. All four patients survived their mycobacterial infection. Removal of catheter was necessary in all four patients and all were converted to hemodialysis. Three patients remained on hemodialysis thereafter, and one patient had to be re-implanted with a new catheter and was restarted on CAPD. TBP in patients undergoing CAPD in Jeddah remains a real concern, especially with the evidence of high prevalence of tuberculosis and with the emergence of drug-resistant tuberculosis. We recommend early initiation of anti-tuberculous therapy and removal of the Tenckhoff catheter for better survival. Most of these patients probably will require conversion to hemodialysis, but in a selected few CAPD can be restarted.

Eosinophilic pneumonia: experience at two tertiary care referral hospitals in Saudi Arabia.

BACKGROUND AND OBJECTIVES: Eosinophilic lung diseases are a diverse group of disorders characterized by pulmonary opacities associated with tissue or peripheral eosinophilia. DESIGN AND SETTING: A retrospective study conducted at two tertiary care hospitals from January 1999 to December 2009. METHODS: All cases with the diagnosis of pulmonary eosinophilia were reviewed over a period of 10 years. Data on demographic, clinical, and radiologic characteristics were collected. RESULTS: Thirty-five patients with a mean age of 33.9 (16.2) years, of which 20 (57.1%) were male and meeting the criteria of eosinophilic lung disease were identified. Cough and dyspnea were the most frequent symptoms at presentation in 29 (82.9%) and 27 (77.1%) patients, respectively. Reticulonodular and airspace patterns were the most common radiographic findings in 17 (48.6%) and 15 (42.9%) patients, respectively. Peripheral eosinophilia was present in 33 (94.3%) patients. Twenty-four patients (68.6%) were labeled as having idiopathic pulmonary infiltrate with eosinophilia. Complete remission was achieved in 13 (54.2%) of 24 patients, while 10 (41.7%) patients relapsed within a few months of discontinuation of therapy. Specific therapy for a specific disease was administered in 8 patients: 2 patients for pulmonary tuberculosis, 2 for Churg-Strauss syndrome, 1 for lymphoma, 1 for schistosomiasis, 1 for acute eosinophilic pneumonia, and 1 for Wegener granuloma; 3 patients were treated as allergic bronchopulmonary aspergillosis. CONCLUSIONS: Pulmonary eosinophilia remains rare but challenging, and it can have the same diverse clinical and radiographic presentations seen with other common pulmonary conditions. Clinicians should be alert to these syndromes and must think of them in any lung disease differential diagnoses.

Ethical concerns in early 21(st) century organ transplantation.

Medical ethics is an indispensible and challenging aspect of clinical practice. This is particularly prominent in the field of organ transplantation. In this paper, initially, a clinical case with brain death that ended up as an organ donor will be presented. Following the presentation, important moral challenges which initially formed medical ethics and some highlights of it in organ transplantation will be discussed in detail. The impact of complex modern influential factors that might interfere with the practice of medical ethics in this field such as patients' vulnerability, financial temptations, and legal regulations will be also dealt with. Finally, we shall propose practical guidelines aiming at improving the practice of medical ethics in the emerging issue of organ transplantation.

Nocardiosis in a tertiary care hospital in saudi arabia.

BACKGROUND: Nocardiosis is an uncommon bacterial infection that is caused by aerobic actinomycetes of the genus Nocardia. This pathogen has emerged as an important cause of mortality and morbidity among both immunocompetent and (more commonly) immunocompromised hosts. The prevalence of nocardiosis is unknown in Saudi Arabia. Only sporadic cases of cutaneous nocardiosis have been reported. In this study, we performed a 10-year retrospective review of all cases of nocardiosis identified at the King Fahad National Guard Hospital in Riyadh. Clinical presentation, risk factors, site of disease involvement, radiological features, and outcomes of 30 patients with pulmonary and disseminated nocardiosis are presented. MATERIALS AND METHODS: A retrospective chart review of all cases of nocardiosis over the last ten years. RESULTS: Thirty cases of nocardiosis were identified. The disease was more common in males. Fever and cough was the most common presentation. Most of the patients had an underlying pulmonary disease. Consolidation was the most prevalent radiological feature. Pleural effusion was common. Unfortunately, none of the isolates were sub-speciated. Cure was possible in 40% of the cases. Ten percent of patients died, while follow-up on the rest of the patients was lost. CONCLUSION: Nocardiosis is not uncommon in Saudi Arabia. Cases are not restricted to the classical immunocompromised host. A database is urgently needed to better evaluate the prevalence of the illness among the Saudi population.

Inpatients' care experience and satisfaction study.

OBJECTIVE AND BACKGROUND: Measures to promote patient satisfaction are important components of the assessment of outcome and strategies for the delivery of health care. In this article, we assess satisfaction among inpatients and the impact of demographics on satisfaction levels. MATERIALS AND METHODS: This cross-sectional survey adapted from previously used survey tools and validated in our patient group included questions on demographics, communication skills, hospital environment, and the patients' overall evaluation of the hospital. Inpatients from acute wards of five different specialties who stayed for at least 2 days were enrolled. RESULTS: There were 988 respondents with a mean age of 39.1 years (25.9%) and the mean length of stay (LOS) of 10.0 days (24.1%). Illiteracy rate was 42.4%, and 43.1% were male. The overall satisfaction scores-out of five-were 4.3 (0.6%) for communication with nurses, 4.4 (0.4%) for communication with doctors, and 4.1 (0.3%) for hospital environment; 98.9% of the patients would recommend the hospital to their family and friends. The lowest score was for the "room environment" (3.99, 0.8%) and the highest for overall services of the hospital (4.7, 0.5%). Satisfaction levels drop significantly with LOS of more than 4 days (P < 0.006). The satisfaction was higher in females than males across all the three domains of care assessed (P < 0.005). The highest satisfaction seen in the obstetrics service could be explained by the nature of the condition normally seen in this department and the normally good outcome. There was higher satisfaction in the medical than surgical services but this reached a significant level for the overall center score domain only (4.1, 0.3% versus 4.0, 0.3%; P < 0.0001). CONCLUSION: The factors with positive impact on satisfaction were the female gender and shorter LOS. There was higher satisfaction in the medical than surgical services for all three domains reaching significant levels for center score only.

Revisiting Methicillin-Resistant Staphylococcus aureus Infections.

Within less than 50 years, methicillin-resistant Staphylococcus aureus (MRSA) made a tremendous impact worldwide. It is not limited to medical facilities and healthcare institutions anymore. Indeed since two decades, cases of MRSA infections arising from the community among apparently healthy individuals are increasing. In this paper, I will present a case of community-associated MRSA sepsis followed by a comprehensive review about the history, pathogenesis, epidemiology, clinical presentations, diagnostic modalities, therapeutic options, contributing factors, growing cost and other pertinent elements of this newly evolving epidemic of MRSA infections.

Increased risk of hypertension, proteinuria and preeclampsia in pregnant Saudi females with IgA nephropathy.

BACKGROUND: IgA nephropathy is fairly prevalent in Saudi Arabia. In this paper we examine the natural history of pregnancies and their impact on renal function in Saudi females affected by this condition. METHODS: We followed a series of 12 patients, documented to have IgA nephritis by kidney biopsy, during their gestation. We monitored their blood pressure, serum creatinine, creatinine clearance, 24-hour protein before conception and at the third trimester of pregnancy. We also documented any maternal or fetal complications. RESULTS: All patients had well-controlled blood pressure, normal renal function, and proteinuria of less than one gram per day prior to conception. During pregnancy, all patients (100%) developed hypertension-requiring treatment and three of them (25%) developed preeclampsia. One patient (8.3%) had hemolysis, elevated liver enzymes, and, low platelets syndrome. All patients had worsening of their proteinuria during pregnancy from 535.2 (101.4) to 2179.2 (636.6) mg/24 h (p < 0.01) with a decrease in creatinine clearance from 88.6 (7.6) mls/min to 77.4 (5.9) mls/min (p < 0.05). No fetal complications were observed. CONCLUSION: We conclude that pregnancies in patients, even with mild IgA nephritis, require close observation as there is an increased incidence of worsening hypertension and preeclampsia.

Global hospital bed utilization crisis. A different approach.

OBJECTIVE: To test the effect of improved physician availability on hospital bed utilization. METHODS: A prospective cohort study was conducted from 1st January 2009 to 31st March 2009 in the Division of Internal Medicine (DIM), King Abdul-Aziz Medical City (KAMC), Riyadh, Kingdom of Saudi Arabia. Two clinical teaching units (CTU) were compared head-to-head. Each CTU has 3 consultants. The CTU-control provides standard care, while the CTU-intervention was designed to provide better physician-consultant availability. Three outcomes were evaluated: patient outsourcing to another hospital, patient discharge during weekends, and overall admissions. Statistical analysis was carried out by electronic statistics calculator from the Center for Evidence-Based Medicine. RESULTS: Three hundred and thirty-four patients were evaluated for admission at the Emergency Room by both CTU's. One hundred and eighty-three patients were seen by the CTU-control, 6 patients were outsourced, and 177 were admitted. One hundred fifty-one patients were seen by the CTU-intervention: 39 of them were outsourced, and 112 were admitted. Forty-eight weekend patient discharges occurred during this period of time: 21 by CTU-control, and 27 by CTU-intervention. Analysis for odds ratio in both the rate of outsourcing, and weekend discharges, showed statistical significance in favor of the intervention group. CONCLUSION: The continuous availability of a physician-consultant for patient admission evaluation, outsourcing, or discharge during regular weekdays and weekends at DIM, KAMC proved to have a positive impact on bed utilization.

Diffuse alveolar haemorrhage secondary to warfarin therapy for atrial fibrillation: a case report and literature review.

Alveolar haemorrhage is a rare and serious medical emergency with many causes. Diffuse alveolar haemorrhage due to warfarin therapy has been rarely reported in the literature. In this paper, we describe the case of 62-year-old woman with a history of chronic atrial fibrillation treated with warfarin, who was admitted to our institution with haemoptysis and dyspnoea. Alveolar haemorrhage was suspected clinically and subsequently confirmed by bronchoscopy. The patient required aggressive treatment with fresh frozen plasma, vitamin K and mechanical ventilation with a successful outcome. We emphasise the need for early diagnosis and fast therapeutic intervention, especially with over-anticoagulation (INR >9), in patients with this rare and potentially lethal condition.

The rise of an opportunistic infection called "Invasive Zygomycosis".

Invasive zygomycosis is a devastating fungal infection seen mostly in immune-compromised patients. We present a case of a 48-year old diabetic man, with aplastic anemia, who developed severe pulmonary mucormycosis that led to his rapid demise despite early diagnosis and treatment with liposomal amphotericin B. We also conducted an extensive review of the pathogenesis of invasive zygomycosis, its history, predisposing factors, clinical aspects, diagnostic modalities, treatment options, morbidity and mortality.