The Contribution of Cell Blocks in the Diagnosis of Mediastinal and Hilar Lymphadenopathy Samples From Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA).

Background Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a diagnostic procedure that allows clinicians to stage lung cancer by sampling lymph nodes in the mediastinum. EBUS-TBNA is recommended as a first step prior to mediastinoscopy for lung cancer mediastinal staging. This procedure has greatly aided pulmonologists in diagnosing mediastinal pathologies with substantial progress. In this study, our aim is to analyze how cell blocks affect the diagnostic yield of mediastinal and hilar lymphadenopathy using an EBUS cytology needle. Methods This retrospective study was conducted at King Abdulaziz University Hospital between May 2021 and September 2021. Patients with mediastinal and hilar lymphadenopathy in the absence of known or suspected primary lung cancer were included. The EBUS procedure was performed using a flexible bronchoscope equipped with a working channel suitable for transbronchial needle aspiration under direct ultrasound guidance. Data were recorded using Microsoft Excel and analyzed using Statistical Package for the Social Sciences (SPSS) v. 26.0 (IBM Corp., Armonk, NY). Diagnostic accuracy measures were determined, and a p-value of 0.05 was established as the final threshold for statistical significance. Results The total number of patients in our study was 151. The sensitivity for cytology specimens, histology specimens, and a combined evaluation for the full group of patients was 77.14%, 83.33%, and 87.5%, respectively, with a negative predictive value of 27.22%, 25%, and 21.42%. The diagnostic accuracy for cytology specimens, histology specimens, and a combined evaluation was 71.42%, 76.19%, and 80%, respectively. Conclusion Our study found that the combined examination of specimens for both cytology and histology in the diagnosis of lung cancer, sarcoidosis, and tuberculosis resulted in a higher diagnostic yield compared to cytological assessment alone using EBUS-TBNA.

Real time endobronchial ultrasound transbronchial needle aspiration for the diagnosis of tuberculous intrathoracic lymphadenopathy: Saudi Arabian Western region experience.

OBJECTIVES: To assess the utility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for presumptive tuberculosis (TB) patients with intrathoracic enlarged lymph nodes in a country with low to moderate TB incidence. METHODS: Thirty-one patients with clinical features of TB and intrathoracic lymphadenopathy, who had EBUS-TBNA sampling and final confirmation of intrathoracic TB lymphadenopathy, were retrospectively reviewed over an 8-year period. Routine clinical and laboratory evaluations including computerized tomography scans were performed before the EBUS-TBNA. Sociodemographic characteristics, clinical profile, pathological, and microbiological findings were collected. RESULTS: The EBUS-TBNA confirmed TB diagnosis in 26 (83.9%) subjects with a consistent pathological finding or positive culture of Mycobacterium tuberculosis. Pathological analysis had findings consistent with TB in 25 (80.6%) patients. Culture of the EBUS-TBNA sample was positive for Mycobacterium tuberculosis in 12 (38.7%) patients. Other supportive investigations like purified protein derivative (PPD) skin test was positive in 28 (90.3%) participants. Overall, the sensitivity of the EBUS-TBNA alone was 83.9%. No complications were recorded during the procedure. The EBUS-TBNA aspirate culture positivity was significantly related to having a larger size lymph node (p=0.048) only, while PPD positivity was significantly related to baseline and clinical features of the participants. CONCLUSION: The EBUS-TBNA demonstrated effective utility and safety in the evaluation and diagnosis of intrathoracic TB lymphadenopathy among individuals with compatible symptoms in a country with low-moderate TB-incidence.

Tezepelumab for Patients with Severe Uncontrolled Asthma: A Systematic Review and Meta-Analysis.

Tezepelumab is a human monoclonal antibody that blocks thymic stromal lymphopoietin, an epithelial-cell-derived cytokine implicated in the pathogenesis of asthma. It was approved by the United States Federal Drug Administration (US FDA) as an add-on maintenance treatment for patients with severe uncontrolled asthma in December 2021. We conducted a systematic review and meta-analysis to investigate the safety and efficacy of tezepelumab on forced expiratory volume (FEV1) (L), the rate of asthma exacerbations, health-related quality of life, fractional exhaled nitric oxide (FeNO) (ppb), and blood eosinophil count (cells/mL) in patients with severe, uncontrolled asthma. Mean changes for efficacy and proportions (safety) with their corresponding 95% confidence intervals (CIs) were used to provide pooled estimates. A total of six randomized controlled trials comprising 2667 patients were included, of whom 1610 were treated with tezepelumab and 1057 received placebo. The pooled analysis showed that tezepelumab treatment resulted in an improvement in FEV1 of 0.15 L (95% CI: 0.12 to 0.17), a reduction in the asthma exacerbation rate per year of 0.60 (95% CI: 0.51 to 0.70), and a reduction in FeNO of -12.41 ppb (95% CI: -14.28 to -10.53) when compared to placebo. Improvements in FEV1 and FeNO levels were maintained at 24 and 52 weeks. As for safety, patients did not experience a higher incidence of adverse drug reactions with tezepelumab (0.79 (95% CI: 0.55 to 1.12)) as compared to placebo. As for quality of life, different doses of the tezepelumab intervention group depicted non-significant improvement in the QoL, from 0.15 (95% CI: -0.09 to 0.38) for 70 mg, 0.18 (95% CI: -0.10 to 0.46) for 210 mg, 0.08 (95% CI: -0.16 to 0.32) for 280 mg as compared to the placebo. Tezepelumab significantly reduced exacerbation rates and improved FEV1 with an acceptable safety profile.

Implications of SARS-CoV-2 infection on the clinical, hematological, and inflammatory parameters in COVID-19 patients: A retrospective cross-sectional study.

BACKGROUND: The current coronavirus pandemic (COVID-19) was caused by severe acute respiratory syndrome virus 2 (SARS-CoV-2). COVID-19 is characterized by atypical pneumonia, mild colds, and more severe illnesses, such as severe acute respiratory distress, thrombosis, organ failure, and various secondary bacterial and fungal infections. Notably, the severity of COVID-19 in different age groups is not well known, and the validity of clinical laboratory data remains unclear. METHODS: In this retrospective cross-sectional study, we examined differential regulation of clinical, hematologic, and inflammatory biomarkers in COVID-19 patients. We divided 104 COVID-19 patients into five different groups according to age (0-17, 18-45, 46-65, 66-79, and >80 years). Baseline data (sex, comorbidities, intensive care admission, and medications), hematologic markers, liver, and renal function tests, coagulation, and inflammatory markers were examined in these groups. Receiver operator characteristic (ROC) analysis was used to determine the optimal threshold for predicting COVID-19 biological markers. RESULTS: We found that the highest percentage (45%) of COVID-19 patients was in the age group of 46-65 years. The hematologic parameters (WBC, HB, and PLT) were normal between the patient groups. The area under the curve in ROC analysis showed significant differences in the levels of creatine, GGT, BUN, CRP, D-dimer, ferritin, AST, and procalcitonin between the patients of age groups 46-65 and 66-79 years. Renal biomarkers were significantly high in most patients, regardless of age. In contrast, the liver biomarkers, did not differ significantly between patient groups. CONCLUSION: The main finding of our study is that laboratory parameters such as GGT, creatinine, BUN, CRP, procalcitonin, ferritin and D-dimer were differentially regulated in COVID -19 patients of different age groups. Importantly, these laboratory parameters may help as clinical predictors to assess the severity of the disease in the population. We conclude here that age is an important factor influencing COVID-19 severity.

Re-infection with a different SARS-CoV-2 clade and prolonged viral shedding in a hematopoietic stem cell transplantation patient.

Immunocompromised patients who have a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection pose many clinical and public health challenges. We describe the case of a hematopoietic stem cell transplantation patient with lymphoma who had a protracted illness requiring three consecutive hospital admissions. Whole genome sequencing confirmed two different SARS-CoV-2 clades. Clinical management issues and the unanswered questions arising from this case are discussed.

Level and predictors of anxiety in patients undergoing diagnostic bronchoscopy.

AIMS: Flexible bronchoscopy is a common procedure performed in pulmonary medicine, critical care, and thoracic surgery. In this study, we aimed to assess the prevalence and predictors of anxiety in patients undergoing diagnostic bronchoscopy. METHODS: This is a prospective study conducted at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. All patients undergoing diagnostic bronchoscopy filled the State-Trait Anxiety Inventory questionnaire before the procedure. Bronchoscopy was performed either through the mouth or the nose, based on the bronchoscopist preference. Lidocaine (1%-2%) spray was used for administering topical anesthesia. Results were collected, and statistical analysis was performed using t-test to measure statistically significant (P < 0.05). RESULTS: A total of 117 patients participated in this study. High anxiety score was found in 45% of the patients. Older patients significantly showed higher anxiety score than younger patients (53 years vs. 46 years, P = 0.034). Similarly, patients with higher body mass index (BMI) showed a statistically significant increase in anxiety score (28 vs. 25, P = 0.041). Premedication with pethidine significantly reduced the anxiety levels (26.9% vs. 73.1%, P = 0.031). Logistic regression demonstrated that old age and outpatient settings were significant predictors of higher anxiety scores. CONCLUSION: Diagnostic bronchoscopy can cause high anxiety in many patients. Prebronchoscopy anxiety assessment can help bronchoscopists to anticipate the anxiety levels of patients, and then further use it to tailor sedation requirements. Special attention should be given to older patients, patients with high BMI, and the ones undergoing bronchoscopy in outpatient settings.

Role of Convex Probe Endobronchial Ultrasound in the Diagnosis and Treatment of Nonmalignant Diseases.

Here we present a comprehensive review of the literature concerning the utility of convex probe endobronchial ultrasound (CP-EBUS) in the diagnosis and treatment of nonmalignant conditions and discuss the associated complications. CP-EBUS has been conventionally used for the staging of lung cancer and sampling of mediastinal and hilar nodes. However, its application is not limited to malignant conditions, and it is gaining acceptance as a diagnostic modality of choice for nonmalignant conditions such as tuberculosis, sarcoidosis, pulmonary embolism, thyroid lesions, and cysts. Moreover, its therapeutic value allows for extended applications such as mediastinal and thyroid cyst drainage, fiducial marker placement for radiation therapy, and transbronchial needle injection. The noninvasiveness, low complication rate, high diagnostic yield, and satisfactory sensitivity and specificity values are the main attributes that lend credence to the use of CP-EBUS as a standalone primary diagnostic and therapeutic tool in pulmonary medicine in the foreseeable future.

Frequency of sleep disorders in patients with rheumatoid arthritis.

Purpose: To determine the prevalence of common sleep problems among patients with rheumatoid arthritis (RA) and their relationship with the disease activity and quality of life. Patients and methods: The study sample consisted of 101 patients who attended a rheumatology clinic at a university hospital between October 2015 and May 2016. All subjects were clinically examined and interviewed by physicians using a questionnaire. The collected information included sociodemographic characteristics, the patients' medical histories, the Disease Activity Score (DAS28), the Berlin questionnaire to assess the risk of obstructive sleep apnea (OSA), the Epworth Sleepiness Scale to assess excessive daytime sleepiness (EDS), the Athens Insomnia Scale to assess insomnia, the International RLS Study Group score to diagnose restless legs syndrome (RLS), and the Health Assessment Questionnaire (HAQ) to assess the quality of life. Results: The mean age of the participants was 48.7±14.6 years, and 95% of the participants were females. Approximately 60% of the participants were in the remission/low category of disease activity, and the average DAS28 score was 3.3±0.8 years. The prevalence rates of insomnia, EDS, sleep disturbance, risk of OSA, and RLS were 63%, 20%, 20%, 37%, and 63%, respectively. Furthermore, the distribution of sleep disorders was not affected by the disease activity. The association between the HAQ and sleep disorders among the RA patients was not significant. Conclusion: Sleep disorders are common among RA patients and may require further attention by treating clinicians; nevertheless, these disorders are not associated with disease activity and do not affect the quality of life.

Survey of flexible bronchoscopy practice in adults in Saudi Arabia.

OBJECTIVES: To assess current adherence to international guidelines for practitioners of bronchoscopy in the Kingdom of Saudi Arabia. Methods: A cross-sectional survey was conducted in Saudi Arabia between December 2016 and March 2017. Pulmonologists, thoracic surgeons, and intensivists were invited to answer an emailed self-administered questionnaire survey seeking information on how they performed flexible bronchoscopy in adults. The data collected were compared between the 3 specialties. Results: Eighty-two (18%) of 456 invited practitioners completed the survey. Fifty-eight (72%) of the 82 respondents were pulmonologists. Forty (53%) of 76 respondents (93%) who had received bronchoscopy training received it abroad. Twenty-seven respondents (33%) had also received training in endobronchial ultrasound, electrocautery, brachytherapy, stent insertion, and laser procedures. Fifty-eight respondents (70%) preferred patients to undergo fasting for at least 4 hours before the procedure. Lidocaine was used for topical anesthesia, mainly by aerosol spray or nebulization. Midazolam was used by 62%, fentanyl by 50%, and propofol by 12% of respondents. Ninety percent of pulmonologists reported requesting a chest radiograph after transbronchial lung biopsy. Safety procedures for bronchoscopists, for example, wearing masks and eye protection, and for patients, for example, availability of anesthetic reversal agents, were not universally applied. Conclusion: Bronchoscopy is not standardized in Saudi Arabia. National guidelines for the indications and practice of bronchoscopy are required.

Predictors of virtual reality simulation bronchoscopy performance among novice bronchoscopists.

INTRODUCTION: Simulation-based training is gradually replacing the classic "apprenticeship" training model. Predictors of better performance of virtual reality simulation bronchoscopy are not clear. OBJECTIVE: We aim to explore the predictors of performance of simulation bronchoscopy among novice bronchoscopists. MATERIALS AND METHODS: This is a descriptive observational cohort study conducted at King Abdulaziz University Clinical Skills and Simulation Center, Jeddah, Saudi Arabia. All participants filled a demographic questionnaire and attended a pre-simulation orientation about the requested tasks. The Simbionix bronchoscopy simulator was used in this study. First, each resident performed three trails of basic scope manipulation task to test hand-eye coordination skills. Thereafter, each resident performed the guided anatomical navigation task to accurately examine as many lung segments as possible. Results and metrics were retrieved from the simulator, and statistical analysis was performed using t-test to measure statistically significant P-value (<0.05). RESULTS: Fifty-three internal medicine residents participated in this study. Male residents significantly achieved higher score in the basic scope manipulation task than female residents (65% vs 46%, P<0.001). Furthermore, the percentage of time spent at mid lumen during the scope manipulation was significantly higher for males compared to female residents (48% vs 37%, P=0.003). Residents who were interested in pursuing procedure-based specialty training spent significantly less time in contact with wall (14.6% vs 20.3%, P=0.045). Smokers needed more time to finish the first task (mean 2.5 minutes vs mean 1.1 minutes, P=0.005). CONCLUSION: Simulation bronchoscopy performance was different between genders, smoking status and future interest in pursuing a procedure-based career. Overall, male residents performed better than female residents in basic scope manipulation. Gender differences in performing simulation bronchoscopy need to be examined in future studies. Tailored educational programs may be needed to fit gender-specific skills and requirements as well as future career interests.

Utility and safety of endobronchial ultrasound-guided transbronchial needle aspiration in patients with mediastinal and hilar lymphadenopathy: Western region experience.

AIMS: The aim of the study was to evaluate the clinical utility and safety of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in patients with mediastinal and hilar lymphadenopathy and to explicitly describe the utility of this procedure in patient's outcome. METHODS: A retrospective review and analysis was conducted on 52 patients with mediastinal or hilar lymphadenopathy who underwent EBUS-TBNA from June 2012 to June 2016. All the patients were evaluated by computed tomography (CT) chest with contrast before EBUS examination. Enlarged mediastinal or hilar lymph node was defined as >1 cm short axis on the enhanced CT. RESULTS: Among the 52 patients studied, 57.7% were presented with mediastinal or hilar lymphadenopathy for diagnosis and 42.3% presented with suspected mediastinal malignancy. Paratracheal stations were the most common site for puncture in 33 lymph nodes (43%). The best diagnostic yield was obtained from subcarinal stations and the lowest yield from the hilar stations. Surgical biopsies confirmed lymphoma in six patients, tuberculosis (TB) in three, sarcoidosis in two and one had metastatic adenocarcinoma of unknown primary. The sensitivity, specificity, positive predictive value, and negative predictive value of EBUS-TBNA for diagnosis of mediastinal and hilar lymph node abnormalities were 78.6%, 100%, 100%, and 80%, respectively. The diagnostic yield of EBUS-TBNA in malignant and benign conditions was 79.0%. CONCLUSIONS: EBUS-TBNA is a safe and efficacious procedure which can be performed using conscious sedation with high yields. It can be used for the staging of malignancies as well as for the diagnosis of inflammatory and infectious conditions such as sarcoidosis and TB.

Mortality of patients hospitalized for active tuberculosis in King Abdulaziz University Hospital, Jeddah, Saudi Arabia.

OBJECTIVES: To determine the mortality rates and predictors among patients hospitalized with active tuberculosis (TB) at King Abdulaziz University Hospital (KAUH) in Jeddah. METHODS: A retrospective study was performed on 291 active TB patients hospitalized in KAUH, Jeddah, Saudi Arabia from December 2011 to December 2016. Medical records were collected and evaluated using a dedicated data extraction sheet. The records included demographics, clinical, radiological, laboratory, and drug resistance data. RESULTS: Of the 291 patients, 168 had pulmonary TB, 39 had extrapulmonary TB, and 84 had both pulmonary and extrapulmonary TB. After a mean hospital stay of 1.74 months, 85.9% were successfully treated and discharged. However, 14% died in the hospital after a mean stay of 1.87 months. Predictors of inpatient TB mortality were older age, congestive heart failure, renal failure, diabetes mellitus, chronic lung disease, hepatitis B virus infection, bilateral pulmonary TB, miliary TB, pleural effusion, and leukopenia. In particular, a logistic regression model revealed a mortality probability of 90% in patients older than 65 with congestive heart failure and bilateral lung involvement. However, drug resistance did not significantly affect the mortality rate. Conclusions: The inpatient TB mortality rate was lower than mortality rates described previously. Nevertheless, early recognition, appropriate treatments, and education for patients and caregivers concerning treatment, efficient medical management, and effective preventive measures can further reduce mortality.

Aspiration-related organizing pneumonia complicating laparoscopic adjustable gastric banding: A lung cancer mimicker.

There are several described pulmonary complications due to laparoscopic adjustable gastric banding. We report a rare case of a 32-year-old male who presented with pulmonary symptoms and a solitary lung mass 12 years after laparoscopic adjustable gastric banding. A bronchoscopic lung biopsy showed organizing pneumonia that was induced by aspiration pneumonia. The atypical radiological appearance of the aspiration pneumonia may pose a diagnostic challenge, and clinicians' awareness regarding such an entity is needed to avoid unnecessary intervention.

Internal medicine residents' perspectives and practice about do not resuscitate orders: survey analysis in the western region of Saudi Arabia.

BACKGROUND: The purpose of this study was to analyze the perceptions and practices of internal medicine residents in the western region of Saudi Arabia regarding the implementation of do not resuscitate (DNR) orders to improve future training practices among physicians. METHODS: Medical residents involved in training programs in the western region of Saudi Arabia, including Jeddah, Makah, Medinah, and Taif, were invited to participate in a cross-sectional, anonymous, online survey regarding DNR orders. The 16-question survey was distributed to residents in all training programs in the region using surveymonkey.com, and the results were collected and tabulated. RESULTS: Of 364 residents, 157 completed the questionnaire, resulting in a 43% response rate. The study showed that most (66%) internal medicine residents in the western region of Saudi Arabia participate in DNR discussions with patients and family or surrogate decision-makers. In addition, 43% were observed by faculty members, and half of them (51.9%) reported feeling comfortable during these discussions. Furthermore, most residents believed that additional educational programs would enhance their competence in addressing issues related to DNR discussions. CONCLUSION: This study highlights the need for a structured curriculum to teach skills relating to end-of-life issues such as DNR orders to residents in the Saudi Arabian medical system. The majority of residents surveyed believe they would benefit from additional training in DNR discussions. Therefore, an evidence-based curriculum providing instruction for improving discussions regarding DNR orders would improve physician confidence and effectiveness in caring for critically ill patients.

Prevalence of chronic obstructive pulmonary disease in Saudi Arabia.

OBJECTIVE: To assess the prevalence of epidemiologically defined chronic obstructive pulmonary disease (COPD) in Saudi Arabia. METHODS: This cross-sectional, observational, population-based survey of COPD was conducted between June 2010 and December 2011 across the country of Saudi Arabia. A total of 56,000 randomly selected telephone numbers were called, which identified 10,001 eligible subjects; of whom 9,779 agreed to participate. A screening questionnaire included 6 questions related to cigarette consumption and water-pipe use was administered to each participant. Subjects with positive screening results were invited to provide input for a detailed COPD questionnaire. RESULTS: The adjusted proportion of subjects who reported a current, or past smoking history was 27.9%. Gender specific smoking rates adjusted by age were 38.7% (95% confidence interval [CI]: 37.5-39.9%) in men, and 7.4% (95% CI: 6.5-8.3%) in women. The epidemiological definition of symptomatic COPD was met by a total of 249 subjects. The age and gender-adjusted prevalence of COPD was 2.4% (95% CI: 2.1-2.7%). Overall, COPD was more frequently documented (p<0.0001) in men (3.5% [95% CI: 3-4%]) than in women (1% [95% CI: 0.7-1.3%]). CONCLUSION: The prevalence of epidemiologically defined COPD in the general population of Saudi Arabia is 2.4%, which is lower than that reported in industrialized countries.

Tunneled pleural catheters in the management of chylothorax from central venous catheter-related superior vena cava obstruction.

Chylothorax is characterized by the accumulation of chyle in the pleural space, of which the most common cause is trauma or neoplasm. Although chylothorax accounts for a small proportion of clinical pleural effusions, prompt recognition is needed to avoid malnutrition, immunodeficiency, and fibrothorax. We report 2 patients with superior vena cava obstruction caused by tunneled venous catheters resulting in chylothorax and demonstrate the potential safety of tunneled pleural catheters for prolonged chylothorax drainage in an outpatient setting with rigorous follow-up. Changes in pleural fluid chemistries of the effusions and the possible pathophysiology were assessed with a review of the literature on pleural fluid chemistries in superior vena cava obstruction.

Lemierre's syndrome with paradoxical emboli.

Lemierre's syndrome is a rare anaerobic oropharyngeal infection complicated by internal jugular thrombosis, the predominant etiology is Fusobacterium necrophorum. Septic emboli to lungs and distant organs have been described, however, to date there have been no published cases associated with embolization across a patent foramen ovale. We describe a case of Lemierre's syndrome with septic arterial emboli resulting in multiple cerebral abscesses and cutaneous manifestations. The outcome was favorable with appropriate antimicrobial therapy.