The Saudi Thoracic Society guidelines for influenza vaccinations.

Influenza viruses are responsible for the influenza outbreaks that lead to significant burden and cause significant morbidity and mortality worldwide. Based on the core proteins, influenza viruses are classified into three types, A, B, and C, of which only A and B cause significant human disease and so the vaccine is directed against these two subtypes only. The effectiveness of the vaccine depends on boosting the immune system against the serotypes included within it. As influenza viruses undergo periodic changes in their antigen, the vaccine is modified annually to ensure susceptibility. In contrast to other countries, Saudi Arabia faces a unique and challenging situation due to Hajj and Umrah seasons, when millions of people gather at the holy places in Mecca and Madinah, during which influenza outbreaks are commonly found. Such challenges making the adoption of strict vaccination strategy in Saudi Arabia is of great importance. All efforts were made to develop this guideline in an easy-to-read form, making it very handy and easy to use by health care workers. The guideline was designed to provide recommendations for problems frequently encountered in real life, with special consideration for special situations such as Hajj and Umrah seasons and pregnancy.

Intensive versus conventional insulin therapy: a randomized controlled trial in medical and surgical critically ill patients.

OBJECTIVE: The role of intensive insulin therapy in medical surgical intensive care patients remains unclear. The objective of this study was to examine the effect of intensive insulin therapy on mortality in medical surgical intensive care unit patients. DESIGN: Randomized controlled trial. SETTINGS: Tertiary care intensive care unit. PATIENTS: Medical surgical intensive care unit patients with admission blood glucose of > 6.1 mmol/L or 110 mg/dL. INTERVENTION: A total of 523 patients were randomly assigned to receive intensive insulin therapy (target blood glucose 4.4-6.1 mmol/L or 80-110 mg/dL) or conventional insulin therapy (target blood glucose 10-11.1 mmol/L or 180-200 mg/dL). MEASUREMENTS AND MAIN OUTCOMES: The primary end point was intensive care unit mortality. Secondary end points included hospital mortality, intensive care unit and hospital length of stay, mechanical ventilation duration, the need for renal replacement therapy and packed red blood cells transfusion, and the rates of intensive care unit acquired infections as well as the rate of hypoglycemia (defined as blood glucose < or = 2.2 mmol/L or 40 mg/dL). There was no significant difference in intensive care unit mortality between the intensive insulin therapy and conventional insulin therapy groups (13.5% vs. 17.1%, p = 0.30). After adjustment for baseline characteristics, intensive insulin therapy was not associated with mortality difference (adjusted hazard ratio 1.09, 95% confidence interval 0.70-1.72). Hypoglycemia occurred more frequently with intensive insulin therapy (28.6% vs. 3.1% of patients; p < 0.0001 or 6.8/100 treatment days vs. 0.4/100 treatment days; p < 0.0001). There was no difference between the intensive insulin therapy and conventional insulin therapy in any of the other secondary end points. CONCLUSIONS: Intensive insulin therapy was not associated with improved survival among medical surgical intensive care unit patients and was associated with increased occurrence of hypoglycemia. Based on these results, we do not advocate universal application of intensive insulin therapy in intensive care unit patients. TRIAL REGISTRATION: Current Controlled Trials registry (ISRCTN07413772) http://www.controlled-trials.com/ISRCTN07413772/07413772; 2005.

Perception of the role of inhaled corticosteroids and factors affecting compliance among asthmatic adult patients.

OBJECTIVE: To examine the patient characteristics linked with reduced adherence to inhaled corticosteroids (ICS) use. METHODS: A prospective study of adult asthmatic patients who were prescribed with ICS and are under regular follow-up at the pulmonary outpatient clinics between June 1st, and December 31st, 2001, at King Fahad National Guard Hospital in Riyadh. All patients underwent structured interviews with an investigator. RESULTS: Included in the study were 334 patients. Thirty eight percent (38%) of the patients reported irregular use of ICS. Factors associated with irregular ICS use were a negative perception of the role of ICS (p=0.03) and less than high school education (p=0.03). Almost 50% (169/334) of all patients had concerns regarding ICS safety resulting in reduced willingness to use them. These concerns were again significantly related to the level of education and the patient's attitude to ICS. Among the most common fears hindering regular ICS use were their potential to lead to addiction (60%) and worry from steroid side effects (41%). CONCLUSION: The result of this study raises the importance of patient's education and the importance of treatment of those involved in asthma care to educate the patient and discuss with them the role of asthma medications, particularly ICS, and to correct common fears and misconceptions.

Nosocomial infective endocarditis in critically ill patients: a report of three cases and review of the literature.

Nosocomial infective endocarditis (NIE) is a relatively uncommon but nevertheless a serious complication affecting critically ill hospitalized patients who are frequently exposed to life-saving invasive procedures. We report three cases of NIE in a tertiary-care hospital encountered during a period of two years. The first case developed in a 50% burn-injured patient; the second in a liver transplant recipient; and the third in a renal transplant recipient. All patients met indications for cardiac surgical intervention, however, the patient who had received a liver transplant (case 2) was considered a poor candidate and unfit for surgery; she subsequently died. The other two patients underwent open-heart surgery. The burns patient (case 1) survived; conversely, the renal transplant recipient (case 3) died postoperatively. We have reviewed the literature concerning NIE in critically ill patients and describe the epidemiology, microbiology and clinical features of this uncommon infection and comment on its diagnosis and management.

Diagnostic yield of closed pleural biopsy in exudative pleural effusion.

OBJECTIVE: Closed pleural biopsy is known to be diagnostic in approximately 75% of pleural effusion undiagnosed by thoracocentesis or pleural fluid evaluation. The purpose of this study was to determine the efficacy of closed pleural biopsy in a Saudi tertiary care teaching hospital. METHODS: We retrospectively reviewed the diagnostic utility of all closed pleural biopsies performed from January 1988 to December 1997 at the King Fahad National Guard Hospital, Riyadh, Kingdom of Saudi Arabia. RESULTS: One hundred and twenty-two pleural biopsies were performed in 116 patients using cope needle in 39, Abram's needle in 82, and Trucut needle in one patient. Twelve cases were excluded due to transudative effusion (N=6) and obtaining no pleural tissue (N=6). Specific diagnoses were obtained in 54 cases giving a diagnostic yield of 49.1%. Of these 10 revealed neoplasia, 35 tuberculosis, and 9 empyema. A non-specific diagnosis was obtained in 56 (50.9%) cases. CONCLUSION: By closed pleural biopsy 49.1% of undiagnosed exudative pleural effusions could be diagnosed. This shows that closed pleural biopsy is still of value as a diagnostic procedure, and should be carried out prior to invasive procedures such as thoracoscopy or open pleural biopsy.