Relationship of the Arabic version of the asthma control test with ventilatory function tests and levels of exhaled nitric oxide in adult asthmatics

To determine the relationship between the asthma control test [ACT] score using the Arabic version, fractional exhaled nitric oxide [FENO], and lung functions, and to derive the cutoff points for the ACT score with the American Thoracic Society recommended FENO standard levels of inflammation control. We recruited 59 adult asthmatics out of which 53 subjects completed the study between July 2011 and June 2012 at King Saud University, Riyadh, Saudi Arabia. The FENO levels were measured by NIOX MINO[R] [Aerocrine AB, Solna, Sweden], and ventilatory functions were recorded by standard techniques. The FENO values were significantly higher in patients with an ACT score <20 [65.5 +/- 35.4] compared with those patients with an ACT score >/= 20 [27.4 +/- 10.5, p<0.001]. Among the well-controlled group based on the ACT score criteria, 6 [25%] cases had high FENO levels, while among the poorly controlled group, 23 [79.3%] cases had high FENO levels [odds ratio: 11.5; p<0.0001; confidence interval: 3.16-41.72]. There was a significant negative correlation between FENO and ACT score [r=-0.581, p<0.0001]. At the international cutoff point of 20, the sensitivity was 95.2, and the specificity was 68.8. The receiver operating curve [ROC] showed that maximum sensitivity and specificity were observed at an ACT score cut off point of 19 [sensitivity: 90.5, and specificity: 81.2]. The FENO levels correlate negatively with ACT scores however, the relationship between FENO and lung function is not significant. A significant relationship between ACT score and FENO levels indicate that there is an ongoing inflammatory state in patients with poor asthma control

Abrupt withdrawal of inhaled corticosteroids does not result in spirometric deterioration in chronic obstructive pulmonary disease: effect of phenotyping?

Some studies show a decline of FEV [1] only one month after withdrawal of inhaled corticosteroids [ICS], while others show no decline. We speculate that the presence of an asthma phenotype in the Chronic Obstructive Pulmonary Disease [COPD] population, and that its exclusion may result in no spirometric deterioration. We performed a prospective clinical observation study on 32 patients who fulfilled the Global Initiative for Chronic Obstructive lung disease definition of COPD [Grade II-IV]. They were divided into two phenotypic groups. 1. Irreversible asthma [A and B] [n = 13]: A. Asthma: Bronchial biopsy shows diffuse thickening of basement membrane [>/= 6.6 microm]. B. Airflow limitation [AFL] likely to be asthma: KCO > 80% predicted if the patient refused biopsy. 2. COPD [A and B] [n = 19]: A. COPD: hypercapneic respiratory failure with raised bicarbonate, panlobular emphysema with multiple bullas, or bronchial biopsy showing squamous metaplasia and epithelial/subepithelial inflammation without thickening of the basement membrane. B. AFL likely to be COPD: KCO < 80% predicted. The asthma phenotype was significantly younger, had a strong association with hypertrophy of nasal turbinates, and registered a significant improvement of FEV [1] [350 ml] vs a decline of - 26.5 ml in the COPD phenotype following therapy with budesonide/formoterol for one year. Withdrawal of budesonide for 4 weeks in the COPD phenotype resulted in FEV [1] + 1.33% [SD +/- 5.71] and FVC + 1.24% [SD +/- 5.32]; a change of <12% in all patients. We recorded no spirometric deterioration after exclusion of the asthma phenotype from a COPD group

Saudi Guidelines for testing and treatment of latent tuberculosis infection. Joint statement of the Saudi thoracic society, the Saudi society of medical microbiology and infectious diseases, the Saudi association of public health, and the society of family and community medicine

Pulmonary tuberculosis is a common disease in Saudi Arabia. As most cases of tuberculosis are due to reactivation of latent infection, identification of individuals with latent tuberculosis infection [LTBI] who are at increased risk of progression to active disease, is a key element of tuberculosis control programs. Whereas general screening of individuals for LTBI is not cost-effective, targeted testing of individuals at high risk of disease progression is the right approach. Treatment of those patients with LTBI can diminish the risk of progression to active tuberculosis disease in the majority of treated patients. This statement is the first Saudi guideline for testing and treatment of LTBI and is a result of the cooperative efforts of four local Saudi scientific societies. This Guideline is intended to provide physicians and allied health workers in Saudi Arabia with the standard of care for testing and treatment of LTBI

Reference range values of fractional exhaled nitric oxide in healthy Arab adult males

To determine the reference values of the fraction of exhaled nitric oxide [FENO] among healthy, non-smoking male adults and its correlation with age, height, weight, and body mass index [BMI]. This cross-sectional study was conducted at the Departments of Physiology and Medicine, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, from September 2007 to August 2008 on healthy non-atopic, non-smoking male Saudi subjects. The FENO was measured online using the single-breath technique according to recent guidelines of the American Thoracic Society [ATS]. We studied 121 subjects with a mean age of 31.00 +/- 12.24 years, BMI of 27.23 +/- 6.64, and FEV1/FVC 85% [81-92%]. The FENO ranged between 7.66 parts per billion [ppb] and 46.6 ppb [mean 22.79 +/- 8.13], with >84% of subjects recording levels <30 ppb and >95% with levels <40 ppb. The FENO negatively correlated with body weight [r=0.3888, p=0.001] and BMI [r=0.238, p=0.009]. No correlation was observed between FENO, FEV1/FVC ratio, age, and height. The reference values of FENO for non-smoking, non-atopic male Saudi adults fall between 7.66 and 46.6 ppb [mean 22.79 +/- 8.13], similar to other populations. The FENO negatively correlates with body weight and BMI

Exhaled nitric oxide in stable chronic obstructive pulmonary disease

The objective of the study was to test the hypothesis that fraction of exhaled nitric oxide [FENO] is elevated in nonsmoking subjects with stable chronic obstructive pulmonary disease [COPD] and compare it with the results in patients with asthma and a control population. Cross-sectional study. Pulmonology Clinic at a University Hospital. Twenty five control subjects, 25 steroid naive asthmatics and 14 COPD patients were studied. All the patients were nonsmokers and stable at the time of the study. All subjects completed a questionnaire and underwent spirometry. Exhaled nitric oxide was measured online by chemiluminescence, using single-breath technique. All the study subjects were males. Subjects with stable COPD had significantly higher values of FENO than controls [56.54 +/- 28.01 vs 22.00 +/- 6.69; P =0.0001] but lower than the subjects with asthma [56.54 +/- 28.01 vs 84.78 +/- 39.32 P = 0.0285].The FENO values in COPD subjects were inversely related to the FEV[1]/FVC ratio. There was a significant overlap between the FENO values in COPD and the control subjects. There is a significant elevation in FENO in patients with stable COPD, but the elevation is less than in asthmatic subjects. Its value in clinical practice may be limited by the significant overlap with control subjects

Exhaled nitric oxide in diagnosis and management of respiratory diseases

The analysis of biomarkers in exhaled breath constituents has recently become of great interest in the diagnosis, treatment and monitoring of many respiratory conditions. Of particular interest is the measurement of fractional exhaled nitric oxide [FENO] in breath. Its measurement is noninvasive, easy and reproducible. The technique has recently been standardized by both American Thoracic Society and European Respiratory Society. The availability of cheap, portable and reliable equipment has made the assay possible in clinics by general physicians and, in the near future, at home by patients. The concentration of exhaled nitric oxide is markedly elevated in bronchial asthma and is positively related to the degree of esinophilic inflammation. Its measurement can be used in the diagnosis of bronchial asthma and titration of dose of steroids as well as to identify steroid responsive patients in chronic obstructive pulmonary disease. In primary ciliary dyskinesia, nasal NO is diagnostically low and of considerable value in diagnosis. Among lung transplant recipients, FENO can be of great value in the early detection of infection, bronchioloitis obliterans syndrome and rejection. This review discusses the biology, factors affecting measurement, and clinical application of FENO in the diagnosis and management of respiratory diseases

H1N1 influenza A. Preliminary evaluation in hospitalized patients in a secondary care facility in Saudi Arabia

To assess the epidemiologic and clinical manifestations of the first wave of H1N1 influenza A patients. This study is a retrospective chart review of all patients admitted in King Saud Medical Complex, Riyadh, Kingdom of Saudi Arabia, from 22nd May to 31st August 2009, with a proven diagnosis of H1N1 influenza A. Only patients with a positive nasopharyngeal swab were included, and excluded when the swab was negative. Charts were then analyzed for epidemiological and clinical data. A total of 153 patients with proven H1N1 infection were admitted, with a predominance of male patients [108 [71%]]. Most patients were Saudis [111 [73%]], with 83 males [75%], and 28 females [25%]. The mean age was 25 years [standard deviation; 9.45 years], and median age was 24 years. The most common symptoms in order of frequency were; fever [143 patients], cough [126 patients], sore throat [70 patients], headache [18 patients], shortness of breath [17 patients], myalgia [11 patients], diarrhea [9 patients], and vomiting [7 patients]. Average duration of symptoms before admission was 3.55 days, and the average time of hospitalization was 4.8 days. Full recovery was obtained in 150 patients. Death occurred in 3 patients. True to its designation as a pandemic, H1N1 influenza A, has reached Saudi Arabia and poses a risk to the young population without immunity, and those with co-morbid disease, particularly of the lungs [bronchial asthma], and the pregnant. Despite its virulence in infecting people, deaths are far less than anticipated for such a novel virus. Social distancing can be recommended. However, further observation has to continue to substantiate these tentative preliminary findings

Management of acute myocardial infraction: do we follow guidelines applied in practice?

Acute myocardial infarction [MI] is a major health problem with a substantial fatality and morbidity. The management of patients with acute MI has been addressed in major trials to improve the survival and enhance the quality of life of the patients. Numerous guidelines have been established for the management of such patients. The objective of this study is to determine whether the current practice in managing patients admitted with acute MI in a major community hospital in Riyadh is evidence based compliant. The data were collected from patients admitted to the Coronary Care Unit [CCU], Riyadh Medical Complex [RMC], Riyadh, Kingdom of Saudi Arabia, a 1500 bed community hospital, with a diagnosis of acute MI over one-year period [April 1999 to April 2000]. The administration of different therapeutic modalities upon admission as well as discharge medications was obtained. Patients outcome [all cause mortality] post treatment were collected. The data was analyzed and compared with the current guidelines. A total of 335 patients, 315 males [94%], were admitted to the CCU of RMC with a diagnosis of acute MI. Two hundred and seventy-one patients [80.9%] received thrombolytic therapy. Discharge medications were beta-blocker in 255 [76.1%], angiotensin converting enzyme inhibitors in 206 [61.5%], nitrates in 281 [83.9%], hypolipidemic agents in 15 patients [4.5%], and aspirin in all patients. The outcome of these patients obtained either alive or dead was 313 [93.4%] and 22 [6.6%] [p<0.00001]. The patients with acute MI received management compliant with evidence-based practice. However, more awareness to the use of angiotensin converting enzyme inhibitors as well as hypolipidemic agents is needed to provide maximum benefit to these patients. Moreover, national guidelines for the management of acute MI are needed for improvement of quality of care

Clinical spectrum of Swyer-James-Macleod syndrome in adults

The aim of this study is to describe the clinical and imaging features of Swyer-James-Macleod syndrome [SJMS] in 9 adults. We reviewed the charts of 9 patients diagnosed with SJMS at the King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia over a 10 year period. The patients mean age was 38.1 years; males were more affected than females [7:2]. Seven of the patients had symptoms referable to the chest and a similar number had compatible abnormalities on physical examination. The left lung was involved in all cases. Bronchiectasis was present in 7 [77.8%]. Eight patients who underwent pulmonary function tests had combined defects. Two patients demonstrated significant reversibility. All patients had a stable course over at least before a 3 year follow-up period. Swyer-James-Macleod syndrome has a diverse manifestations in adults and can mimic other pulmonary disorders, which may lead to incorrect diagnosis and inappropriate therapy. The course is generally a stable one

Door to needle time in administering thrombolytic therapy for acute myocrdial infarction

Thrombolytic therapy is a standard treatment for patients presenting with acute myocardial infarction [MI]. Early administration of these agents is crucial for the outcome of management. This audit was conducted to evaluate the time between arrival to emergency department [ED] and the administration of thrombolysis [door to needle time]. Data was collected from patients admitted to the Coronary Care Unit of Riyadh Medical Complex [RMC], Riyadh, Kingdom of Saudi Arabia, a 1500-bed community hospital, with a diagnosis of acute MI and received thrombolytic therapy over a one-year period [April 1999 to April 2000]. The time between arrival to the ED to the time of administration of thrombolytic therapy was obtained as well as the time of onset of chest pain up to presentation to the hospital, and the outcome [all cause mortality] post treatment. A total of 271 patients [256 males] admitted to RMC with a diagnosis of acute MI received thrombolytic therapy over a one-year duration. The median door to needle time was 95 minutes. The median time of onset of chest pain to arrival to ED was 5 hours [300 minutes]. The outcome of these patients obtained either alive was 260 [96%] or dead was 11 [4%] [P < 0.00001]. The door to needle time was relatively similar to other centers. The delay in administering thrombolytic therapy should be reduced to a target of <70 minutes from onset of symptoms. Delay in presentation to the hospital was more important and factors contributing to this delay should be looked for and corrected. Another audit is needed to evaluate the implementation of these recommendations

Asymptomatic full term pregnant patient with a grossly abnormal chest radiograph [clinical quiz]

An asymptomatic full term pregnant lady with a grossly abnormal chest radiograph is presented as a clinical quiz. The diagnosis is discussed and the topic reviewed in detail

Predicting nodal malignancy from clinical data

A large variety of disorders can lead to lymphadenopathy. It is important and beneficial to patient management to rapidly differentiate between benign and malignant causes. The objective of the study is to identify factors predicting nodal malignancy from readily available clinical data. A retrospective study was carried out on patients admitted to Riyadh Medical Complex, Riyadh, Kingdom of Saudi Arabia between April 1996 and March 2000 with lymphadenopathy, who underwent lymph node biopsy. Univariate analysis suggests 6 variables [age, sex, the presence of other physical signs, abnormal complete blood count, abnormal liver function test and negative Mantoux test] to have independent association with nodal malignancy. The multivariate logistic regression model revealed patients aged more than 40 years, males, generalized lymphadenopathy, presence of other physical signs, abnormal liver function tests and negative Mantoux test to be statistically significantly associated with nodal malignancy [p>0.05]. The present logistic model can be useful in predicting nodal malignancy using routinely collected clinical data