Demographic and clinical patterns of severe asthma in the Middle East.

BACKGROUND: Severe asthma is a major burden on health-economic resources; hence, knowing the epidemiology of these patients is important in planning and provision of asthma care. In addition, identifying and managing the comorbidities helps improve symptoms and reduce associated morbidity and mortality. OBJECTIVES: Epidemiology of difficult asthma has not been well studied in the Middle East, so in this study, we present the demographic and clinical characteristics of severe asthma in the United Arab Emirates (UAE). METHODS: We retrospectively reviewed the notes of severe asthma patients attending three tertiary care hospitals between May 2015 and December 2019. Data on baseline demographics, asthma characteristics, treatment, and comorbidities were collected. RESULTS: We reviewed the notes of 458 patients (271 females and 187 males) that fulfilled the 2019 Global Initiative for Asthma guidelines for the diagnosis of severe asthma. The mean age was 47.7 (standard deviation 17.2) years. Males had significantly higher asthma control test scores (17.9 vs. 16, P = 0.01) and mean blood eosinophils (0.401 vs. 0.294, P <0.01) than females. The most common comorbidity observed was allergic rhinitis (52.2%) followed by gastroesophageal reflux disease (27.1%). In total, 109 (23.8%) patients were on biological therapies with most patients being on omalizumab and dupilumab (29 and 18 patients, respectively). Most patients were nonsmokers (97.2%), and majority were of TH2-high phenotype (75.7%). CONCLUSIONS: In this first report of severe asthma characteristics in the UAE, we found a pattern of female preponderance and most patients having a Th2-high phenotype. The findings are likely to help optimize asthma care in the region in the era of biologic therapies.

Managing malignant pleural effusion.

Malignant pleural effusion can be managed in different ways, including clinical observation, thoracentesis, placement of an indwelling pleural catheter, and chemical pleurodesis. The optimal strategy depends on a variety of clinical factors. This article uses cases to illustrate the rationale for determining the best approach in different situations.

Diffuse alveolar haemorrhage and severe hypoxemia from Strongyloides stercoralis hyperinfection syndrome.

Strongyloides stercoralis hyperinfection syndrome is a rare, yet highly fatal disorder. It occurs most commonly in immunocompromised patients. We report a case of a 36-year-old Ethiopian female who presented with abdominal pain and hypotension. Shortly thereafter, she developed acute respiratory failure and progressed to acute respiratory distress syndrome and septic shock. She was found to have diffuse alveolar hemorrhage due to disseminated strongyloidiasis. We discuss the clinical condition of Strongyloides hyperinfection syndrome presenting with severe hypoxemia and complicated by severe diffuse alveolar hemorrhage leading to death. Similar cases in the literature are also describe.

Linear probe endobronchial ultrasound bronchoscopy with guided transbronchial needle aspiration (EBUS-TBNA) in the evaluation of mediastinal and hilar pathology: introducing the procedure to a teaching institution.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an important tool in the diagnosis of mediastinal and hilar pathology. We describe our experience with EBUS-TBNA performed in a teaching institution primarily under conscious sedation. METHODS: Patients who underwent EBUS-TBNA were included in this retrospective review. We focused on the diagnostic yield of EBUS-TBNA in relationship to the nature of the mediastinal or hilar lesions (suspected malignancy vs. benign disease), incremental 25 procedures aliquots, lymph node (LN) station, LN size, and the number of needle aspirations per LN station. RESULTS: Of the 212 patients who underwent EBUS-TBNA, 200 patients had adequate follow-up information and were included in this analysis. The procedure was performed under conscious sedation in 97 % of patients and 133 patients (67 %) were suspected to have malignancy before the procedure. A total of 690 TBNAs were performed from 294 LN stations. The mean number of LN stations sampled per procedure was 1.47 ± 0.6. The mean number of TBNAs per LN station was 2.35 ± 0.91. The mean number of TBNAs per procedure was 3.45 ± 1.2. The overall sensitivity, specificity, negative predictive value (NPV), and diagnostic accuracy for all procedures were 87.41 % (CI 80.76-91.99), 100 % (CI 93.12-100), 75.36 % (CI 64.04-84.01), and 90.91 % (CI 85.92-94.25), respectively. The NPV increased significantly after the initial 25 procedures and remained high thereafter. EBUS-TBNA was more accurate (96.12 % (CI 91.25-98.33)) with higher NPV (90.74 % (CI 80.09-95.98)) in patients with suspected malignancy compared with patients with suspected benign disease (79.31 % (CI 67.23-87.75), 20 % (7.05-45.19)). Samples from relatively smaller LN (>5 to ≤20 mm) and from all analyzed LN stations were similarly accurate with high sensitivity and NPV. CONCLUSIONS: EBUS-TBNA allows safe real-time sampling of mediastinal and hilar lesions under conscious sedation with high diagnostic accuracy. The NPV is high and increased significantly after the initial 25-50 procedures. This is comparable to available surgical techniques, including mediastinoscopy, when malignancy is suspected. The NPV for specific benign disease remains low in our experience. The diagnostic yield is not affected by the LN station, size, or the number of passes per LN station.

Primary mucoepidermoid carcinoma of the lung.

Mucoepidermoid carcinoma (MEC) of the lung is a rare endobronchial tumor accounting for up to 0.2% of primary lung cancer. We report a patient with MEC who presented with cough, hemoptysis, and localized findings on chest examination. This case emphasizes the importance of obtaining adequate biopsy to establish the correct diagnosis. In addition, it highlights that MEC of the lung usually presents in the low-grade form, carrying a favorable prognosis.

Respiratory disorders in the Middle East: a review.

The spectrum of pulmonary pathology in the Middle East is as versatile as its civilizations and cultures. In this review, we outline the key challenges confronting pulmonologists in the Middle East. We shed light on the diverse conditions commonly encountered in the region, from the centuries-old illnesses of tuberculosis, to contemporary problems such as lung complications from chemical warfare. We specifically highlighted unique aspects related to respiratory illnesses in the Middle East, for example, climate factors in the desert region, cultural habits, for example, water-pipe smoking and disorders unique to the region, such as Behçet's disease. Pulmonologists are also faced with the consequences of modernization, including large immigrant population and associated social and health issues, rising incidence of obesity and sleep apnoea, and drug-resistant tuberculosis. Tackling these health issues will require an integrated approach involving public health, primary care as well as specialist pulmonology input, taking into consideration the unique cultural and environmental factors to ensure effective management and compliance to medical care.

Monitoring recovery from diaphragm paralysis with ultrasound.

BACKGROUND: Diaphragmatic paralysis is an uncommon, yet underdiagnosed cause of dyspnea. Data regarding the time course and potential for recovery has come from a few small case series. The methods that have been traditionally employed to diagnose diaphragmatic weakness or paralysis are either invasive or limited in sensitivity and specificity. A new technique utilizing two-dimensional, B-mode ultrasound (US) measurements of diaphragm muscle thickening during inspiration (Deltatdi%) has been validated in the diagnosis of diaphragm paralysis (DP). The purpose of this study was to assess whether serial US evaluation might be utilized to monitor the potential recovery of diaphragm function. METHODS: Twenty-one consecutive patients with clinically suspected DP were referred to the pulmonary physiology laboratory. Sixteen patients were found to have DP by US (unilateral, 10 patients; bilateral, 6 patients). Subjects were followed up for up to 60 months. On initial and subsequent visits, Deltatdi% was measured by US. Additional measurements included upright and supine vital capacity (VC), maximal inspiratory pressure (Pimax), and maximal expiratory pressure. RESULTS: Eleven of 16 patients functionally recovered from DP. The mean (+/- SD) recovery time was 14.9 +/- 6.1 months. No diaphragm thickening was noted in those patients who did not recover. Positive correlations were found between improvement in Deltatdi% and interval changes in VC, Pimax, and end-expiratory measurements of diaphragm thickness. CONCLUSIONS: US may be used to assess for potential functional recovery from diaphragm weakness or DP. As in previous series, recovery occurs in a substantial number of individuals, but recovery time may be prolonged.

Elevated international normalized ratio in the ED: clinical course and physician adherence to the published recommendations.

OBJECTIVE: Describe the course of patients with an elevated international normalized ratio (INR) in the emergency department (ED) and determine physicians' adherence with treatment recommendations. METHODS: One-year retrospective review of all ED patients with an INR >5.0. RESULTS: Ninety-four patients met the entry criteria. Bleeding was present in 28.7% patients. Two thirds of the major bleeding episodes were of gastrointestinal origin. Physicians' adherence decreased as bleeding and INR increased. At the lowest risk, adherence was 66.6%, whereas at the highest risk, it was 36.3%. Two thirds of patients were admitted to the hospital, one fourth were discharged, and 7.4% were observed in an observation unit. Average length of stay was 3.8 days. CONCLUSION: Adherence to the recommendations regarding managing elevated INR was suboptimal. There is a need for formal endorsement of recommendations by emergency medicine organizations and development of disposition criteria based on bleeding status and site of bleeding.