Factors Influencing Treatment Success in Cholesteatoma Management: A Cross-Sectional Study.

Background/Objectives: Cholesteatoma presents significant management challenges in otolaryngology. This study aimed to delineate the influence of demographic and clinical characteristics, preoperative imaging, and surgical approaches on treatment success in cholesteatoma management. Methods: A cross-sectional analytical study was conducted at the Otolaryngology Department of the University Hospital from January 2021 to December 2022. It included 68 patients diagnosed with cholesteatoma, focusing on three objectives: assessing the impact of demographic and clinical characteristics on treatment outcomes, evaluating the predictive value of preoperative imaging findings, and analyzing the influence of surgical factors. Results: The study population predominantly consisted of male (56%) and Saudi (81%) patients, with an average age of 45 years. Logistic regression revealed that older age (OR: 1.05), male gender (OR: 0.63), and non-Saudi Arab ethnicity (OR: 2.14) significantly impacted treatment outcomes. Clinical characteristics such as severe disease severity (OR: 3.00) and longer symptom duration (OR: 0.96) also influenced treatment success. In preoperative imaging, labyrinthine fistula (Regression Coefficient: 0.63) and epidural extension (Coefficient: 0.55) emerged as key predictors. The surgical factors that significantly affected the outcomes included the extent of surgery (Complete Removal OR: 3.32) and the use of endoscopic approaches (OR: 1.42). Conclusions: This study highlights that patient demographics, clinical profiles, specific preoperative imaging features, and surgical strategies multifactorially determine cholesteatoma treatment success. These findings suggest the necessity for a tailored approach in cholesteatoma management, reinforcing the importance of individualized treatment plans based on comprehensive preoperative assessments.

Assessment of the risk of obstructive sleep apnoea among patients with type 2 diabetes and its associated factors using the STOP-BANG questionnaire: A cross-sectional study.

Objective: To assess the risk of obstructive sleep apnoea (OSA) and its associated risk factors among patients with type 2 diabetes in southern KSA. Methods: This was a cross-sectional study conducted at the Armed Forces Hospital in Jazan. The prevalence of OSA was assessed using a validated Arabic translation of the STOP-BANG screening questionnaire. The odds of a higher OSA risk were calculated via regression analysis, according to the measured clinical and demographic variables. Results: The total number of participants was 306, of which 213 (69.6%) were over the age of 50, 247 (80.7%) were married, and 161 (52.6%) were female. The overall median score of the OSA risk level assessed by the STOP-BANG items was three on a scale of 0-8, of which 193 (63.1%) of the participants in the sample were classified as being at high risk of developing OSA. Several statistically significant associations were identified, where odds ratios (ORs) with a higher OSA risk level were detected according to age, sex, marital status, waist and neck circumference, haemoglobin A1c (HbA1c) and body mass index levels, duration of diabetes, and comorbidity with hypertension (p < 0.05). Conclusion: The higher risk of OSA identified in our sample of diabetic patients can be related to a high prevalence of obesity, larger neck circumferences, hypertension, and other factors linked to the duration and treatment of diabetes. Additionally, the association between waist circumference, HbA1c, and duration since the diagnosis of diabetes suggests an interaction effect that requires further investigation.

Prevalence of alopecia and its contributing factors among primary healthcare attendees in the Jazan region, Saudi Arabia.

BACKGROUND: Alopecia is a common health condition that can be associated with social and psychological consequences. AIMS: This study aims to estimate the prevalence of hair loss and its associated risk factors among primary healthcare center (PHC) attendees in the Jazan region. METHODS: This investigation was a cross-sectional study conducted in the Jazan region of southwest Saudi Arabia. A total of 23 PHCs were randomly selected from five governorates in the region. Data were collected via interviewing PHCs attendees and were asked about their demographic characteristics, presence of hair loss, and among attendees who confirmed having hair loss, they were further asked about associated clinical features, healthcare-seeking behavior, and factors that might contribute to the development of their condition. RESULTS: A total of 729 participants consented to be involved in this study. The number of respondents who reported having hair loss was 483, representing 66.3% of the whole sample. Gender appears to have the highest level of variability, with the majority of participants reporting hair loss being female (P < 0.001). The most frequently reported type of hair loss was telogen effluvium, followed by androgenic alopecia. A total of 185 respondents reported taking medications to treat their hair loss, of whom 108 (58.3%) did not seek any medical advice to identify the cause of their condition. LIMITATIONS: The main weakness of this investigation is related to relying on a reported presence of hair loss without having it confirmed with a clinical diagnosis. CONCLUSION: A minority of participants who reported suffering from hair loss were further evaluated by healthcare professionals to learn the cause of their hair loss. This may indicate the presence of poor hair care and the probability of a higher risk of hair loss requiring the development of suitable preventive strategies.

Primary health care physicians' knowledge and adherence regarding hypertension management guidelines in southwest of Saudi Arabia.

To measure Primary Health Care physicians' knowledge of and adherence to the Saudi Hypertension Management Guidelines (SHMGs) in Southwest of Saudi Arabia.This study was a cross-sectional investigation where data was collected via a self-administered questionnaire. The demographics of the physicians, data related to the source of the guidelines for hypertension management, knowledge about the SHMGs and physicians' adherence to the SHMG were collected. Student's t test was used to assess the presence of any statistical difference between the level of knowledge and adherence according to the study's measured variables.A total of 316 physicians participated in this investigation, representing 65% of all the PHC physicians in the Jazan region. The number of correct answers measuring knowledge about various topics varied between 18% and 94% with a mean overall score of 7.9/16. The number of reported practices adherent to the guidelines varied between 2% and 97%, and the mean overall score was 7.2/11. Receiving hypertension management guidelines from the Directory of Health was statistically associated with a higher level of knowledge (P value < .05). Undergoing clinical training for hypertension management and seeing fewer numbers of patients on a daily basis was associated with a statistically higher level of adherence to the guidelines (P value < .05).Improper distribution of guidelines, lack of continuous clinical training, negative attitude of physicians toward guidelines and large number of patients seen by physicians are likely to hinder translating guidelines to actual clinical practice.

Advances in respiratory monitoring during mechanical ventilation.

This review provides an update on the various techniques that are available to monitor patients during mechanical ventilation with an emphasis on clinical observations and applications in critically ill patients.

Reliability of pulse oximetry in titrating supplemental oxygen therapy in ventilator-dependent patients.

Pulse oximetry is widely used in the critical care setting, but few studies have examined its usefulness in clinical decision making. One area where pulse oximetry might be useful is in the titration of fractional inspired O2 concentration (FIO2) in ventilator-dependent patients. Unfortunately, documented guidelines for this use do not exist, and in a survey of directors of intensive care units, we found that they employed a wide range of target O2 saturation (SpO2) values. Consequently, we undertook a study to determine if SpO2 could be reliably substituted for measurements of arterial O2 tension (PaO2) when adjusting FIO2 in ventilator-dependent patients. We examined a number of SpO2 target values in 54 critically ill patients aiming for a PaO2 of greater than or equal to 60 mm Hg, while minimizing the risk of O2 toxicity. In white patients, we found that a SpO2 target of 92 percent was reliable in predicting a satisfactory level of oxygenation. However, in black patients, such a SpO2 reading was commonly associated with significant hypoxemia (PaO2 as low as 49 mm Hg), and a higher SpO2 target, 95 percent, was required. In addition, inaccurate oximetry readings (ie, greater than 4 percent difference between SpO2 and direct SaO2 measurements) were more common in black (27 percent) than in white patients (11 percent, p less than 0.05). In conclusion, a SpO2 target of 92 percent was reliable when titrating supplemental O2 in white patients receiving mechanical ventilation; however, in black patients, such a SpO2 reading was commonly associated with significant hypoxemia, and a higher SpO2 target, 95 percent, was required to ensure a satisfactory level of oxygenation.

Experimental polyacrylamide-induced acute injury in rat lung.

We recently reported the first case of accidental aspiration of polyacrylamide occurring in a 26-year-old man. The patient developed severe airway obstruction and parenchymal lung damage and died. Autopsy revealed numerous polyacrylamide particles in his lungs, as well as extensive bronchiolar and alveolar damage. Gas chromatographic and mass spectrometric assessment of the lung tissue failed to reveal polyacrylamide activity, although assessment of the suspending solvent of the polyacrylamide showed a pattern characteristic of an aliphatic hydrocarbon mixture with a prominent dodecane peak. This experimental study was performed to determine the nature and extent of damage to rat bronchial and alveolar epithelia following endotracheal instillation of polyacrylamide, hydrocarbon mixture (petroleum distillate), dodecane (C12H26), or normal saline. The rat lungs were examined grossly and microscopically 10 min and 24, 72, and 96 h after endotracheal instillation, following inflation and fixation with 10 percent buffered formaldehyde. Gross examination revealed congested, mottled visceral pleural surfaces in the rats treated with polyacrylamide and dodecane. There were no pleural exudates or effusions. Microscopically, vascular engorgement, bronchiolitis, and focal pneumonia were observed. Vascular engorgement was most pronounced at 72 to 96 h in rat lungs treated with polyacrylamide and dodecane and was moderate at 24 h in rats treated with petroleum distillate. Focal organizing pneumonia was marked at 96 h in rats treated with petroleum distillate, at 72 h in those treated with polyacrylamide, and at 24 h in those treated with dodecane. The saline-treated control animals showed no change. Our findings suggest that polyacrylamide, dodecane, and petroleum distillate are strong irritants to the airways. However, a direct obstructive/mechanical effect of the polyacrylamide upon the airway has not been excluded. Airway exposure to polyacrylamide may result in lung injury secondary to the polyacrylamide itself, its suspending agents, or both.

Aspiration injury due to polyacrylamide.

Acute lung injury secondary to aspiration of polyacrylamide, a synthetic polymer used widely in industry, has not been previously described in man or animal. We report the case of a 26-year-old man who aspirated polyacrylamide gel while cleaning it out of a tank truck. Subsequently, severe airway obstruction and lung parenchymal damage developed, and the patient died. At autopsy, numerous polyacrylamide particles were found in the lungs, along with extensive bronchiolar and alveolar damage.

Comparative cost-effectiveness analysis of theophylline and ipratropium bromide in chronic obstructive pulmonary disease. A three-center study.

The charts of 311 patients receiving theophylline (T) and 289 patients receiving ipratropium bromide (IB) for COPD were reviewed to determine the total costs and cost-effectiveness of these 2 agents in 3 different health-care settings. A direct cost-accounting method assessed cost, and a Markov decision-analysis model calculated cost-effectiveness. Costs to treat toxic effects were greater for T versus IB. The types and incidences of toxic effects, by drug, were similar among the three centers. Overall costs for T were $121.40 per patient per therapy-month versus $84.56 per patient per therapy-month for IB, as determined by the cost-accounting method. The marginal cost was $366 for T over IB when extrapolated over 1 year using the Markov model. The Markov model also predicted that patients receiving IB had a greater number of complication-free therapy-months (measurement of effectiveness) than patients receiving T. We conclude that treatment with IB was less costly and more cost-effective than T.

Sparfloxacin vs ofloxacin in the treatment of acute bacterial exacerbations of chronic bronchitis: a multicenter, double-blind, randomized, comparative study. Sparfloxacin Multicenter ABECB Study Group.

STUDY OBJECTIVE: Comparison of efficacy and safety of sparfloxacin vs ofloxacin for treatment of acute bacterial exacerbations of chronic bronchitis (ABECB). DESIGN: Multicenter, double-blind, randomized study. SETTING: Sixty-eight private offices and outpatient clinics in the United States and Canada. PATIENTS: Seven hundred ninety-eight adults with ABECB, as confirmed by the acute onset of new (or worsened from the immediate premorbid state) cough and sputum production. INTERVENTIONS: Randomization 1:1 to sparfloxacin, 400 mg on day 1, then 200 mg once daily, or ofloxacin, 400 mg twice daily, with matching comparator placebos, given concurrently for 10 consecutive days. RESULTS: The primary efficacy parameter was overall response in the bacteriologically evaluable population. Overall success rates in this population were 85.3% and 89.3% for sparfloxacin and ofloxacin, respectively. The two-sided 95% confidence interval was -9.9, 1.9, indicating that sparfloxacin was statistically equivalent to ofloxacin. The all-treated population analysis was similar to that in the evaluable population. Bacterial eradication rates were similar in both treatment groups for Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Chlamydia pneumoniae, Haemophilus parainfluenzae, Klebsiella pneumoniae, Enterobacter cloacae, and Staphylococcus aureus. The frequency of adverse events overall was comparable in the two treatment groups. The sparfloxacin group had a lower frequency of digestive and nervous system adverse events, but a higher frequency of photosensitivity reactions than the ofloxacin group. CONCLUSIONS: Once-daily oral treatment with 200 mg sparfloxacin (after initial 400 mg dose) is as effective as twice-daily treatment with 400 mg ofloxacin in patients with ABECB.

Response time, autonomic mediation, and reversibility of hyperoxic bradycardia in conscious dogs.

Normobaric hyperoxia decreases heart rate (HR) in humans and animals. This study explored the mechanisms of hyperoxic bradycardia by examining its response time, autonomic neural mediation, and reversibility in conscious dogs. Five trained mongrel dogs breathed from a mask as the inspired gas was alternated between air and O2 for multiple cycles, and continuous time series records of HR and oxyhemoglobin saturation were recorded on a digital computer and analyzed by the technique of ensemble averaging. Hyperoxia decreased HR by 9% (P < 0.001), but only gradually, requiring 5 min to reach steady state. This delay was much longer than the time required for hyperoxic respiratory depression (10-20 s), a response known to be mediated by chemoreceptor reflexes. The bradycardia was sustained for > or = 30 min. On return to normoxia, HR gradually returned toward, but failed to reach, the baseline HR, suggesting incomplete reversibility of the response. However, in control experiments without hyperoxic challenge, HR showed a slow continuous downward trend that was sufficient to account for the apparent incomplete reversibility of hyperoxic bradycardia. Hyperoxic bradycardia was unaffected by beta-adrenergic blockade but was completely prevented by muscarinic cholinergic blockade. We conclude that 1) hyperoxia-induced bradycardia in conscious dogs is mediated by efferents of the vagus nerve; 2) its afferent pathway remains unknown, but its long response time suggests mechanisms other than chemoreceptor reflexes or other known neural reflexes; and 3) it is completely reversible.

Monitoring during mechanical ventilation.

Approximately half of the patients admitted to an ICU are admitted for the purposes of monitoring rather than interventional therapy. In the last decade, significant technologic advances have enhanced monitoring capacities, and the understanding of the pathophysiology of respiratory failure has improved pari passu, allowing clinicians to employ monitors in a more intelligent manner. This article deals with new developments in arterial blood gas monitoring, pulse oximetry, capnometry, and monitoring of neuromuscular function and pulmonary mechanics, emphasizing issues most relevant to mechanical ventilation.

Pulse oximetry.

Pulse oximetry is one of the most commonly employed monitoring modalities in the critical care setting. This review describes the latest technological advances in the field of pulse oximetry. Accuracy of pulse oximeters and their limitations are critically examined. Finally, the existing data regarding the clinical applications and cost-effectiveness of pulse oximeters are discussed.

Monitoring patient mechanics during mechanical ventilation.

This article provides a review of respiratory mechanics that can be monitored in ventilator-dependent patients during passive and spontaneous breathing. Special focus is placed on resistance, compliance, and work of breathing. A description of methods and techniques, and a summary of clinical observations and applications in critically-ill patients are also included.

Using physiologic end points to assess innovations in mechanical ventilation.

It is our view that new ventilatory methods should be withheld from clinical practice until there has been adequate evaluation of their effect on physiologic variables and the link to long-term outcomes has been established. In the past, premature and over-enthusiastic acceptance of ventilatory strategies may have resulted in patient discomfort and even harm, and this can be minimized by a more careful evaluation of the physiologic effects of such innovations before their acceptance into clinical practice.

Hypercapnic respiratory failure during weaning: neuromuscular capacity versus muscle loads.

Patients who fail a weaning trial develop hypercapnia as a result of alveolar hypoventilation, which, in turn, is caused by an imbalance between the respiratory muscle load and capacity. In some patients, especially those with obstructive lung diseases, respiratory muscle performance is impaired as a result of dynamic hyperinflation and paradoxical motion of the rib cage and abdomen. Worsening of pulmonary mechanics causes further embarrassment of the respiratory muscles and can lead to marked alterations of oxygen use by the peripheral tissues. The development of rapid shallow breathing together with worsening of pulmonary mechanics results in inefficient clearance of COcf152cf1 during a failed weaning attempt.

The use of mechanical ventilation via a nasal mask in myotonic dystrophy.

A 36-year-old woman with myotonic dystrophy presented with generalized weakness and daytime somnolence. Arterial blood gas analysis revealed significant hypoxemia and hypercapnia, and a polysomnogram revealed additional oxygen desaturation during sleep. For nocturnal ventilatory assistance, the patient received positive-pressure ventilation via a nasal mask. This mode of ventilation produced marked improvement in the patient's nocturnal hypoxemia.

The effect of hyperinflation on rib cage-abdominal motion.

Abnormalities of rib cage-abdominal motion are common in patients with chronic obstructive pulmonary disease (COPD), but the basis of the abnormal motion has not been completely determined. Although airway obstruction has been shown to be a major factor in causing abnormal chest wall motion, the effect of hyperinflation (which has numerous adverse effects on respiratory muscle function) has not been systematically examined. We induced graded levels of hyperinflation in six healthy volunteers using continuous positive airway pressure (CPAP) levels of 10, 20, and 30 cm H2O. Chest wall motion was measured by a calibrated inductive plethysmograph. Rib cage-abdominal asynchrony and paradox were quantitated by the Konno-Mead method of analysis. CPAP levels of 10, 20, and 20 cm H2O produced increases in end-expiratory lung volume of 0.98 +/- 0.14 (SE), 1.90 +/- 0.31, and 2.42 +/- 0.37 L, respectively (p < 0.0001). This corresponded to an increase in the ratio of functional residual capacity to predicted total lung capacity from 0.38 +/- 0.08 at baseline to 0.74 +/- 0.14 at 30 cm H2O CPAP-comparable to that seen in patients with COPD. Hyperinflation induced an increase in inspiratory abdominal paradox, 1.0 +/- 0.7% at baseline versus 3.6 +/- 1.7% at 30 cm H2O (p < 0.05), but this is unlikely to be clinically significant. A significant increase in asynchrony or rib cage paradox did not develop with hyperinflation. In conclusion, the primary factor contributing to abnormal chest wall motion in patients with COPD is likely to be increased airway resistance, and hyperinflation makes only a minor contribution.

Pathophysiologic basis of acute respiratory distress in patients who fail a trial of weaning from mechanical ventilation.

To determine the mechanisms of acute respiratory distress and failure in patients with chronic obstructive pulmonary disease (COPD), we studied 17 ventilator-supported patients who failed a trial of spontaneous breathing and 14 patients who tolerated such a trial and were successfully extubated. Immediately before the weaning trials, maximal inspiratory pressure was not statistically different between the two groups (p = 0.48). On discontinuation of the ventilator, the failure group immediately developed rapid shallow breathing, and higher values of dynamic lung elastance (EdynL) (p < 0.01) and intrinsic positive end-expiratory pressure (PEEPi, p < 0.03) than did the success group. Between the onset and end of the trial, the failure group developed further increases in EdynL (p < 0.0001) and PEEPi (p < 0.0001), and increases in inspiratory resistance (p < 0.009) and inspiratory pressure-time product (PTP) (p < 0.0001). Partitioning of PTP at the end of the trial revealed a 111% increase in the PEEPi component, a 33% increase in the non-PEEPi elastic component, and a 42% increase in the resistive component (all p < 0.0001). Despite the increase in PTP, 13 of the failure patients developed an increase in PaCO2. The product of PTP and PaCO2, an index of inefficient CO2 clearance, was more than twice as high in the failure group than in the success group at the end of the trial (p < 0.0005). Thus, development of acute respiratory distress during a failed weaning attempt was due to worsening of pulmonary mechanics, which in conjunction with rapid shallow breathing led to inefficient clearance of CO2.