Oral nitrate supplementation improves cardiovascular risk markers in COPD: ON-BC, a randomised controlled trial.

BACKGROUND: Short-term studies suggest that dietary nitrate (NO3 -) supplementation may improve the cardiovascular risk profile, lowering blood pressure (BP) and enhancing endothelial function. It is not clear if these beneficial effects are sustained and whether they apply in people with COPD, who have a worse cardiovascular profile than those without COPD. Nitrate-rich beetroot juice (NR-BRJ) is a convenient dietary source of nitrate. METHODS: The ON-BC trial was a randomised, double-blind, placebo-controlled parallel group study in stable COPD patients with home systolic BP (SBP) measurement ≥130 mmHg. Participants were randomly allocated (1:1) using computer-generated, block randomisation to either 70 mL NR-BRJ (400 mg NO3 -) (n=40) or an otherwise identical nitrate-depleted placebo juice (0 mg NO3 -) (n=41), once daily for 12 weeks. The primary end-point was between-group change in home SBP measurement. Secondary outcomes included change in 6-min walk distance (6MWD) and measures of endothelial function (reactive hyperaemia index (RHI) and augmentation index normalised to a heart rate of 75 beats·min-1 (AIx75)) using an EndoPAT device. Plasma nitrate and platelet function were also measured. RESULTS: Compared with placebo, active treatment lowered SBP (Hodges-Lehmann treatment effect -4.5 (95% CI -5.9- -3.0) mmHg), and improved 6MWD (30.0 (95% CI 15.7-44.2) m; p<0.001), RHI (0.34 (95% CI 0.03-0.63); p=0.03) and AIx75 (-7.61% (95% CI -14.3- -0.95%); p=0.026). CONCLUSIONS: In people with COPD, prolonged dietary nitrate supplementation in the form of beetroot juice produces a sustained reduction in BP, associated with an improvement in endothelial function and exercise capacity.

Prevalence and predictors of polypharmacy and comorbidities among patients with chronic obstructive pulmonary disease: a cross-sectional retrospective study in a tertiary hospital in Saudi Arabia.

OBJECTIVE: This study aimed to determine the prevalence of polypharmacy, comorbidities and to investigate factors associated with polypharmacy among adult patients with Chronic Obstructive Pulmonary Disease (COPD). METHODS: This was a retrospective single-centre cross-sectional study. Patients with a confirmed diagnosis of COPD according to the GOLD guidelines between 28 February 2020 and 1 March 2023 were included in this study. Patients were excluded if a pre-emptive diagnosis of COPD was made clinically without spirometry evidence of fixed airflow limitation. Population characteristics were presented as frequency for categorical variable. Logistic regression analysis was used to identify predictors of polypharmacy. RESULTS: The study sample included a total of 705 patients with COPD. Most of the study sample were males (60%). The mean age of the study population was 65 years old. The majority of the study population had comorbid diseases (68%), hypertension and diabetes were the most common co-existent diseases. Around 55% of the study sample had polypharmacy. Females were significantly less likely to be on polypharmacy compared to males (OR = 0.68, 95% CI = [0.50-0.92], P-value = 0.012)). On the other hand, older patients aged 65.4 or more (OR = 2.31, 95% CI = [1.71-3.14], P-value ≤ 0.001), those with high BMI (≥ 29.2) (OR = 1.42, 95% CI = [1.05-1.92], P-value = 0.024), current smokers (OR = 1.9, 95% CI = [1.39-2.62], P-value ≤ 0.001), those who are receiving home care (OR = 5.29, 95% CI = [2.46-11.37], P-value ≤ 0.001), those who have comorbidities (OR = 19.74, 95% CI = [12.70-30.68], P-value ≤ 0.001) were significantly more likely to be on polypharmacy (p ≤ 0.05). CONCLUSIONS: Polypharmacy is common among patients with COPD. Patients with high BMI, previous ICU hospitalization and older age are more likely to have polypharmacy. Future analytical studies are warranted to investigate outcomes in patients with COPD and polypharmacy.

Awareness and practice of airway pressure release ventilation mode in acute respiratory distress syndrome patients among nurses in Saudi Arabia.

BACKGROUND: This study aimed to assess the knowledge and current practice of using the airway pressure release ventilation (APRV) mode with acute respiratory distress syndrome (ARDS) patients and identify barriers to not using this mode of ventilation among nurses who work in critical areas in Saudi Arabia. METHODS: Between December 2022 and April 2023, a cross-sectional online survey was disseminated to nurses working in critical care areas in Saudi Arabia. The characteristics of the respondents were analyzed using descriptive statistics. Percentages and frequencies were used to report categorical variables. RESULTS: Overall, 1,002 nurses responded to the online survey, of whom 592 (59.1%) were female. Only 248 (24.7%) nurses had ever used APRV mode, whereas only 229 (22.8%) received training on APRV mode. Moreover, 602 (60.0%) nurses did not know whether APRV was utilized in their hospital. Additionally, 658 (65.6%) nurses did not know whether APRV mode was managed using a standard protocol. Prone positioning was the highest recommended intervention by 444 (43.8%) when a conventional MV failed to improve oxygenation in patients with ARDS. 323 (32.2%) respondents stated that the P-high should be set equal to the plateau pressure on a conventional ventilator, while 400 (39.9%) said that the P-low should match PEEP from a conventional ventilator. Almost half of the respondents (446, 44.5%) stated that the T-high should be set between 4 and 6 s, while 415 (41.4%) said that the T-low should be set at 0.4 to 0.8 s. Over half of the nurses (540, 53.9%) thought that the maximum allowed tidal volume during the release phase should be 4-6 ml/kg. Moreover, 475 (47.4%) believed that the maximum allowed P-high setting should be 35 cm H2O. One-third of the responders (329, 32.8%) stated that when weaning patients with ARDS while in APRV mode, the P-high should be reduced gradually to reach a target of 10 cm H2O. However, 444 (44.3%) thought that the T-high should be gradually increased to reach a target of 10 s. Half of the responders (556, 55.5%) felt that the criteria to switch the patient to continuous positive airway pressure (CPAP) were for the patient to have an FiO2 ≤ 0.4, P-high ≤ 10 cm H2O, and T-high ≥ 10 s. Lack of training was the most common barrier to not using APRV by 615 (61.4%). CONCLUSION: The majority of nurses who work in critical care units have not received sufficient training in APRV mode. A significant discrepancy was observed regarding the clinical application and management of APRV parameters. Inadequate training was the most frequently reported barrier to the use of APRV in patients with ARDS.

Clinical training and practice of using digital health solutions among healthcare workers in clinical settings during Hajj season.

Digital health solutions are widely used in Saudi Arabia, but training, clinical practice and challenges related to using digital health applications have not been evaluated from the perspective of healthcare workers during the Haj season in Makkah. The current study was planned to explore clinical training, practices and challenges related to the use of digital health among healthcare workers during the Haj season from June to August 2023. Of the 470 subjects, 347(73.8%) were males and 123(26.2%) were females. The overall median age was 40 years (interquartile range: 27-56 years). In the clinical practice of using digital health, 185(39.4%) of the subjects strongly agreed that digital health was useful and beneficial during transportation difficulties, and 167(35.5%) strongly agreed that digital health applications had changed their working routine during the Haj season. Negative outcome expectations were the challenge least reported by 72(15.3%) respondents.

Oscillatory positive expiratory pressure therapy in COPD (O-COPD): a randomised controlled trial.

BACKGROUND: Oscillatory positive expiratory pressure (OPEP) devices are intended to facilitate sputum clearance and reduce cough, but there is limited evidence for their effectiveness in COPD, or to guide patient selection. We aimed to assess the impact of OPEP therapy on quality of life and objective measures of cough and sleep disturbance in patients with COPD with regular sputum production. METHODS: We enrolled stable patients with COPD, who reported sputum production every day or most days, into an assessor-blind, parallel-group, randomised controlled trial comparing 3 months of using an Acapella device against usual care (including use of the active cycle of breathing technique). The primary outcome was cough-related quality of life measured using the Leicester Cough Questionnaire (LCQ). Secondary outcomes included fatigue (Functional Assessment of Chronic Illness Therapy, FACIT score) and generic quality of life (EuroQol-5 Dimensions, EQ-5D). In a substudy (n=45), objective monitoring of cough and disturbance/movement during sleep were also available. RESULTS: 122 participants (61/61 OPEP/control) were recruited, 40% female, 17% smokers, FEV1 38 (25-56)% predicted, and age 62±10 years. 103 completed the study (55/48 OPEP/control). Use of OPEP was associated with an improvement in LCQ compared with controls; MD (95% CI) 1.03 (0.71 to 2.10); (p=0.03), FACIT score 4.68 (1.34 to 8.02); (p<0.001) and EQ-5D 4.00 (0.49 to 19.75); (p=0.04). There was also an improvement in cough frequency -60 (-43 to -95) coughs/24 hours (p<0.001), but no statistically significant effect on sleep disturbance was identified. CONCLUSIONS: Regular use of an Acapella device improves symptoms and quality of life in people with COPD who produce sputum daily or most days. TRIAL REGISTRATION NUMBER: ISRCTN44651852.

The efficacy and safety of varenicline nasal spray for the management of dry eye signs: a systematic review and meta-analysis.

BACKGROUND: Dry eye disease (DED) is caused by a persistently unstable tear film leading to ocular discomfort and is treated mainly with tear supplementation. There is emerging evidence that nicotinic acetylcholine receptor (nAChR) agonists (e.g., varenicline and simpinicline) nasal sprays are effective for DED. Our systematic review and meta-analysis assessed the efficacy and safety of varenicline nasal spray (VNS) for DED treatment. METHODS: The Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched. Only randomized controlled trials (RCTs) that evaluated the efficacy of VNS versus placebo were included. The efficacy endpoint was the mean change in the anesthetized Schirmer test score (STS), a measure of basal tear production, from baseline. The safety endpoints were serious adverse events (SAEs) and adverse events (AEs). The standardized mean difference (SMD) was used for continuous outcomes, while the risk ratio (RR) was used to demonstrate dichotomous variables. The certainty of the evidence was rated utilizing the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. The risk of bias assessment was conducted using the Revised Cochrane risk of bias tool for randomized trials. RESULTS: Three RCTs (n = 1063) met the eligibility criteria. All RCTs had a low risk of bias. The meta-analysis found a statistically significant increase in the mean STS change from baseline on day 28. The pooled analysis found no significant difference between VNS and placebo in the frequency of SAEs and ocular AEs. However, VNS had a significant effect on developing nasal cavity-related AEs. CONCLUSION: VNS caused a highly significant improvement regarding the efficacy endpoint but caused an increased frequency of some nasal cavity-related AEs (i.e., cough and throat irritation). However, it caused neither SAEs nor ocular AEs. Included studies had a low risk of bias.

Strategies to deliver smoking cessation interventions during targeted lung health screening - a systematic review and meta-analysis.

INTRODUCTION: Lung cancer screening presents an important teachable moment to promote smoking cessation, but the most effective strategy to deliver support in this context remains to be established. METHODS: We undertook a systematic review and meta-analysis of smoking cessation interventions delivered during lung health screening, published prior to 20/07/2022 MEDLINE, PsychINFO, CENTRAL, EMBASE, CINAHL and Scopus databases. Two reviewers screened titles, and abstracts, four reviewed each full text using prespecified criteria, extracted relevant data, assessed risk of bias and confidence in findings using the GRADE criteria. The review was registered prospectively on PROSPERO (CRD42021242431). RESULTS: 10 randomised controlled trials and three observational studies with a control group were identified. Meta-analysis of nine RCTs demonstrated that smoking cessation interventions delivered during lung screening programmes increased quit rates compared to usual care (odds ratios: 2.01, 95%: 1.49-2.72 p < 0.001). Six RCTs using intensive (≥3 behavioural counselling sessions) interventions demonstrated greater quit rates compared to usual care (OR: 2.11, 95% CI 1.53-2.90, p < 0.001). A meta-analysis of two RCTs found intensive interventions were more effective than non-intensive (OR: 2.07, 95%CI 1.26-3.40 p = 0.004), Meta-analysis of two RCTs of non-intensive interventions (≤2 behavioural counselling sessions or limited to online information audio take home materials such as pamphlets) did not show a higher quit rate than usual care (OR: 0.90, 95% CI 0.39-2.08 p = 0.80). DISCUSSION: Moderate quality evidence supports smoking cessation interventions delivered within a lung screening setting compared to usual care, with high-quality evidence that more intensive interventions are likely to be most effective.

Public awareness about glaucoma, cataract, and diabetic retinopathy in Saudi Arabia: a systematic review and meta-analysis.

PURPOSE: To identify the public level of knowledge about the common ophthalmological conditions in Saudi Arabia. METHODS: We searched Medline, Embase, and CENTRAL for relevant literature. We included questionnaire-based cross-sectional studies performed in Saudi Arabia assessing the public awareness and attitude about general knowledge, causes/risk factors, signs/symptoms, disabilities/consequences, and relieving/management measures of the common ophthalmological conditions including glaucoma, cataract, and diabetic retinopathy (DR). The meta-analysis was performed on outcomes reported in ≥ 2 studies utilizing the random-effects model. Quality assessment was done using the Appraisal tool for Cross-Sectional Studies (AXIS) tool. RESULTS: Twenty-eight studies were deemed eligible for inclusion in this review. A total of 72 questions were reported in ≥ 2 studies and were included in the meta-analysis. The total number of participants was 14,408. The meta-analysis estimated that 57.63% (95% confidence interval (CI) 56.87-60.07%), 69.90% (95% CI 67.02-76.07%), and 68.65% (95% CI 65.94-71.23%) of the Saudi public have you ever heard or read about glaucoma, cataract, and DR, respectively. Of the public surveyed in the included studies, 43.68% (95% CI 41.54-45.85%), 55.43% (95% CI 54.03-56.82%), and 63% (95% CI 60.8-65.1%) believed that glaucoma, cataract, and DR could be treated. CONCLUSION: This systematic review showed that the level of knowledge among the Saudi population about the common ophthalmological conditions was the highest with respect to cataract, followed by DR and glaucoma. The areas of unsatisfactory level of awareness about the common ophthalmological conditions included risk factors, signs/symptoms, complications, and management options. These areas need to be addressed appropriately by future educational interventions.

A robotic-assisted hybrid coronary revascularization program: Establishment and early experience in the Middle East.

BACKGROUND: Hybrid coronary revascularization (HCR) is a technique that merges coronary artery bypass grafting surgery and percutaneous coronary intervention (PCI) approaches for the treatment of multivessel coronary artery disease. The surgical component of the procedure is minimally invasive and can be done using robotic technology that avoids the need for sternotomy. Our objective is to study all patients who underwent robotic-assisted HCR (RHCR) to evaluate the feasibility and safety of the procedure during the establishment phase. METHODS: This study is a retrospective chart review conducted at King Faisal Specialist Hospital and Research Centre in Jeddah (KFSRC-J). The study focuses on patients who underwent RHCR between July 2018 to December 2020. The study was approved by the institutional review board #2020-103. RESULTS: Robotic-assisted HCR was performed on 78 patients (mean age, 56 years (range, 43-72 years); 89.75% males) during the study phase. Left internal mammary artery grafting was used in all patients. There was no hospital mortality, and the mean hospital and intensive care unit (ICU) stay were 5.8 and 1.4 days, respectively. We found that 93.6% of the patients had no blood transfusion. There were no major adverse cardiac events (MACE) and perioperative MI recorded. There was a 3.8% rate of postoperative complications. The percentage of surgeries converted to conventional and re-exploration for bleeding were 1.2% and 2.6%, respectively. The average operation time was 164 min. CONCLUSION: This study emphasizes on the safety and effectiveness of RHCR in treating patients with multivessel coronary artery disease. Moreover, robotic-assisted hybrid coronary revascularization offers an alternative, functionally complete revascularization option to a selected group of patients with minimal surgical trauma, short hospital and ICU length of stay, quick recovery, and little to no blood transfusion requirement.

Validity and Reliability of an Arabic Version of MD Anderson Dysphagia Inventory (MDADI).

Dysphagia is a common adverse event among head and neck (H&N) cancer patients. We aimed, for the first time, to validate the Arabic version of the MD Anderson Dysphagia Inventory (MDADI) among 82 Saudi Arabian patients with H&N cancer. We followed established validation guidelines and translated the 20-item MDADI using the forward-backward method. Our results revealed 100% feasibility. Test-retest reliability demonstrated acceptable interclass correlation coefficients (ICC) for the subscale domains (emotional = 0.973, physical = 0.971, and functional = 0.956) and composite score (ICC = 0.984). The Cronbach's alpha coefficients for the emotional, functional, and physical subscales were 0.937, 0.825, and 0.945, respectively (composite score = 0.975). We confirmed concurrent validity by demonstrating significant correlations between the domains of the Arabic MDADI and European Organization for Research and Treatment of Cancer (EORTC) Quality-of-Life Head and Neck Module (QLQ-H&N35). Our study validated the Arabic version of the MDADI among H&N cancer patients from Saudi Arabia.

Cochlear implantation in adults and pediatrics with enlarged vestibular aqueduct: a systematic review on the surgical findings and patients' performance.

PURPOSE: Cochlear implantation (CI) has been considered a safe and effective management option for patients with severe to profound hearing loss. Patients with enlarged vestibular aqueduct (EVA) could be challenging with some variations in surgical approaches, intraoperative surgical notes, and clinical outcomes. This study aimed to  review the surgical and clinical outcomes of cochlear implantation among patients with EVA. MATERIALS AND METHODS: A systematic literature search was carried out in five major databases. All original studies reporting cochlear implantation in patients with EVA were included for qualitative data synthesis. The risk of bias was independently assessed through the National Intuitional of Health tool. The review protocol was registered in PROSPERO (reference number: CRD42021225900). RESULTS: A total of 34 studies with 4035 subjects were included. Of them, 853 (21.14%) had EVA and underwent CI. Mondini malformation was the most frequently associated anomaly (n = 78, 11.1%). Unilateral implantation was performed in 258 cases while bilateral in 119 subjects. Postoperative complications included CSF/perilymph gusher (n = 112), CSF oozing (n = 18), and partial electrode insertion (n = 6). Closing the cochleostomy with temporalis fascia, muscle, connective tissue, or fibrin glue was the most frequently reported approach to manage CSF/perilymph gusher (n = 67, 56.7%) while packing was performed in six patients. CONCLUSION: Patients with EVA demonstrated audiometric and speech performance improvement after CI. However, many patients had intra- or postoperative complications. Further research is needed as the outcomes may be affected by associated temporal bone pathology, the timing of implant, and hearing condition.

Identification and Characterization of Novel Mutations in Chronic Kidney Disease (CKD) and Autosomal Dominant Polycystic Kidney Disease (ADPKD) in Saudi Subjects by Whole-Exome Sequencing.

Background: Autosomal dominant polycystic kidney disease (ADPKD) is a condition usually caused by a single gene mutation and manifested by both renal and extrarenal features, eventually leading to end-stage renal disease (ESRD) by the median age of 60 years worldwide. Approximately 89% of ADPKD patients had either PKD1 or PKD2 gene mutations. The majority (85%) of the mutations are in the PKD1 gene, especially in the context of family history. Objectives: This study investigated the genetic basis and the undiscovered genes that are involved in ADPKD development among the Saudi population. Materials and Methods: In this study, 11 patients with chronic kidney disease were enrolled. The diagnosis of ADPKD was based on history and diagnostic images: CT images include enlargement of renal outlines, renal echogenicity, and presence of multiple renal cysts with dilated collecting ducts, loss of corticomedullary differentiation, and changes in GFR and serum creatinine levels. Next-generation whole-exome sequencing was conducted using the Ion Torrent PGM platform. Results: Of the 11 Saudi patients diagnosed with chronic kidney disease (CKD) and ADPKD, the most common heterozygote nonsynonymous variant in the PKD1 gene was exon15: (c.4264G > A). Two missense mutations were identified with a PKD1 (c.1758A > C and c.9774T > G), and one patient had a PKD2 mutation (c.1445T > G). Three detected variants were novel, identified at PKD1 (c.1758A > C), PKD2L2 (c.1364A > T), and TSC2 (deletion of a'a at the 3'UTR, R1680C) genes. Other variants in PKD1L1 (c.3813_381 4delinsTG) and PKD1L2 (c.404C > T) were also detected. The median age of end-stage renal disease for ADPK patients in Saudi Arabia was 30 years. Conclusion: This study reported a common variant in the PKD1 gene in Saudi patients with typical ADPKD. We also reported (to our knowledge) for the first time two novel missense variants in PKD1 and PKD2L2 genes and one indel mutation at the 3'UTR of the TSC2 gene. This study establishes that the reported mutations in the affected genes resulted in ADPKD development in the Saudi population by a median age of 30. Nevertheless, future protein−protein interaction studies to investigate the influence of these mutations on PKD1 and PKD2 functions are required. Furthermore, large-scale population-based studies to verify these findings are recommended.

Future Acceptability of Respiratory Virus Infection Control Interventions in General Population to Prevent Respiratory Infections.

Background and Objectives: In both pandemic and non-pandemic situations, nonpharmaceutical public health measures may offer easy, low-cost, and effective means of reducing the spread and impact of acute respiratory infections. It is unknown whether such measures would be acceptable to the Saudi community beyond the current pandemic. Materials and Methods: A validated survey was used to test community acceptance of the measures. Respondents were asked which infection control practices they planned to maintain and which they believed should be policies for the community as a whole after the COVID-19 pandemic has subsided. Results: The survey was completed by 2057 people (95% completion rate), 1486 (72%) of whom were female, 259 (12.5%) of whom were current smokers, and 72 (3.5%) of whom had chronic lung disease. The most prevalent age groups were 18−30 years (933; 45.4%) and 31−40 years (483; 23.5%), with 641 individuals over 40 years old. Of the responses, 93% indicated that they would continue washing their hands more often; 92% wanted both clinicians and patients to wear masks in hospitals; 86% would continue avoiding smoking in indoor and outdoor areas; 73% would continue wearing a face covering on public transportation; 70% indicated that they would continue wearing a face covering in indoor public places. Regarding the respiratory virus infection control measures, 85% (11/13) received significant support (≥70% acceptability level) for continuation as policies in the future. Wearing face coverings outdoors and social distancing outdoors received little support (45% and 66%, respectively). Of the respiratory virus infection control measures, 54% received less support from current smokers than non-smokers (acceptability level < 70%). People with chronic respiratory disease supported 77% of the measures being regarded as policies in the future. Conclusion: The Saudi community supports nonpharmacological respiratory infection control measures that reduce the likelihood of infection. Public health campaigns should target smokers to increase awareness of the importance of these measures in lowering infections. Based on the findings of this study, nonpharmacological treatments should be presented and included in future recommendations for both the public and patients diagnosed with chronic respiratory diseases.

Caregiver burden among family caregivers of incurable cancer patients in two eastern Mediterranean countries.

BACKGROUND: Although family caregivers (FCs) play an important role in the care provided to incurable cancer patients in our region, little is known about the burden they experience. This study was conducted to determine the prevalence of caregiver burden (CB) among FCs of incurable cancer patients in two Eastern Mediterranean countries and to identify factors that may be associated with significant CB. METHODS: The study included 218 FCs, 165 from Egypt and 53 from Saudi Arabia. The 22-item Zarit Burden Interview (ZBI-22) was used to assess caregiver burden CB. Significant CB was defined as a ZBI-22 score ≥ 21. The assistance with basic ADLs was classified into 3 levels according to FCs' assistance with early/middle/late-loss basic ADLs. The relationship between CB and the assistance with ADLs and other factors was studied. RESULTS: The mean (SD) ZBI-22 score among FCs was 23.4 (9.3) and the majority (128/218, 59%) had significant CB. Eighty-nine percent of FCs assisted with at least one basic ADL. Assistance with late-loss basic ADLs, best supportive care treatment plan and poorer performance status were associated with higher CB (p < 0.0001, =0.018 and = 0.005). However, in logistic regression analysis, only assistance with late-loss ADLs was independently associated with significant CB (OR = 3.4 [95%CI:1.2-9.7], p = 0.024). CONCLUSION: A substantial proportion of FCs of incurable cancer patients in our region experience significant CB. Family caregivers assisting with late-loss basic ADLs are at risk of significant CB and should be routinely screened for CB.

Use of oscillatory positive expiratory pressure (OPEP) devices to augment sputum clearance in COPD: a systematic review and meta-analysis.

INTRODUCTION: Oscillating positive expiratory pressure (OPEP) devices are intended to facilitate sputum clearance in chronic obstructive pulmonary disease (COPD), but there is uncertainty as to their place in treatment pathways. We aimed to review the existing literature to establish the evidence base for their use. METHODS: A systematic search of records up to March 2020 was performed on PubMed, CINAHL, Medline (Ovid), Cochrane and Embase to retrieve clinical trials that evaluated the efficacy of OPEP devices in patients with COPD. Two independent reviewers retrieved the titles, abstracts and full texts, and completed the data extraction. RESULTS: Following full-text review of 77 articles, eight (six randomised control trials and 2 cross-over studies) were eligible for inclusion. Pooled analysis showed low-grade evidence that the use of OPEP devices was associated with decreased COPD symptoms and exacerbations (OR 0.37, 95% CI 0.19 to 0.72), and enhanced exercise capacity; 6 min walk distance (mean difference (95% CI), 49.8 m (14.2 m to 85.5 m); p=0.009]). However, studies were mostly short term with the majority having a high risk of bias. The average acceptance, completion and drop-out rates were 82%, 91% and 8%, respectively. CONCLUSION: The use of OPEP devices can have a positive impact in COPD, but confidence in effect sizes is low and there is a need for further, higher quality studies to examine their long-term efficacy in COPD as well as to identify specific patient phenotypes that are more likely to respond. PROSPERO REGISTRATION NUMBER: CRD 42016041835.

Anterior circulation large vessel occlusion stroke in Saudi Arabia: Prevalence, predictors, and outcome.

OBJECTIVE: Anterior circulation Large Vessel Occlusion (LVO) stroke comes with significant morbidity and mortality. With the advent of endovascular interventions, its management has revolutionized. For health authorities to build systems and allocate resources, its burden, predictors, and outcome must be determined. METHODS: In a single tertiary care center, we retrospectively collected data from 1495 ischemic stroke patients to determine anterior circulation LVO prevalence, predictors, and outcome. Patients must have radiologically proven ischemic stroke within 24 hours before arrival at the emergency department. Anterior circulation LVO related stroke was defined as evidence of new anterior circulation infarct detected on neuroimaging, and vascular imaging confirming anterior circulation Large Vessel Occlusion. Data on demographics, vascular risk factors, treatment with reperfusion therapy, modified Rankin Scale (mRS) at admission, National Institute of Health Stroke Scale (NIHSS) at admission, length of stay (LOS) in days, and in-hospital comorbidities and death were collected. Regression analysis was done to determine the predictors and outcomes of anterior circulation LVO ischemic strokes. RESULTS: We found anterior circulation LVO in 27.8% (95 % CI 25.5-30.0) of all ischemic stroke patients. Atrial fibrillation and admission National Institute of Health Stroke Scale (NIHSS) were the strongest predictors of LVO [OR 2.33, P = 0.0011 and OR 1.17, P < 0.0001] respectively. Occurrence of LVO was associated with worse disability score (mRS ≥ 3) [47.22 vs. 19.81% (P = 0.0073)], longer hospitalization in days [Median 9.0 vs. 3.0, IQR (14.0 vs. 5.0) P = 0.0432)], and was more likely to results in patient admission to intensive care unit [Mean 17.59 vs. 3.70 % (P = 0.0002)]. CONCLUSION: Stroke with large vessel occlusion in Saudi Arabia is not uncommon. Its burden and outcome deserve national attention, as effective treatment is now readily available.

Fatal serotonin syndrome in a patient with Marchiafava-Bignami disease: Combined neurological and psychiatric emergency.

Marchiafava-Bignami disease (MBD) is a rare fatal neurological disorder characterized by demyelination, primary degeneration, and necrosis of the corpus callosum. Although MBD is mostly associated with chronic alcohol consumption and malnutrition, it has been reported in non-alcoholic patients. Serotonin syndrome is a rare but potentially fatal side effect of antidepressants that results from overstimulation of both central and peripheral serotonergic receptors. In this report, we present a case with fatal serotonin syndrome happening in a non-alcoholic patient with the chronic form of MBD. To our knowledge, this case is the first report of fatal serotonin syndrome due to citalopram in an MBD patient. The present report may indicate that citalopram and other SSRIs should not be used in patients with MBD. Our case is also among few reported cases in the literature where no cause was identified in a patient with no previous history of alcohol intake.

Adalimumab-induced central nervous system demyelination in a patient with rheumatoid arthritis.

Adalimumab (Humira) is a human monoclonal antibody that belongs to the tumor necrosis factor (TNF) alpha antagonist class of medications. Central Nervous System (CNS) demyelination is a rare side effect of adalimumab, and only a few cases have been reported in the literature of patients who developed multiple sclerosis or other demyelinating patterns after using adalimumab. In this report, we present a case of CNS demyelination in a patient with rheumatoid arthritis that developed a few months after using adalimumab. Performing brain MRI for asymptomatic individuals prior to initiating anti-TNF alpha agents to exclude a pre-existing demyelinating disease may be worthwhile. Routine brain MRI for monitoring and surveillance may facilitate detecting cases early and avoid the development of permanent neurological disability. Further studies are needed to clarify the neurological safety of anti-TNF alpha agents.

Medical Imaging in Pregnancy: Safety, Appropriate Utilization, and Alternative Modalities for Imaging Pregnant Patients.

This article reviews the existing literature on diagnostic and medical imaging of pregnant women, the risks and safety measures of different medical imaging modalities, and alternative modalities for imaging pregnant patients. Different medical imaging modalities such as MRI, CT scan, ultrasound, nuclear medicine, and X-ray imaging help to evaluate women with recognized or unrecognized pregnancies and identify any underlying complications among pregnant patients. Fetuses are more sensitive to radiation and the effects of medical imaging as compared to adults since they have a rapidly developing cell system. During cell proliferation, migration, and differentiation, fetuses suffer greatly from imaging radiation since they are developing under a dynamic system. To ensure safety, pregnant women should discuss the benefits and risks of medical imaging with their physicians. In addition, radiologists should not perform any medical imaging procedure without the patient's consent, unless the patient cannot make any sound decision. Fetal risks of medical imaging include slow growth and development of the fetus, abortion, malformations, impaired brain function, abnormal childhood growth, and neurological development. Diagnostic imaging procedures are necessary when a condition that needs medical evaluation arises during pregnancy such as appendicitis.