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.

Effect of endotoxin on ventilation and breath variability: role of cyclooxygenase pathway.

To evaluate the effects of endotoxemia on respiratory controller function, 12 subjects were randomized to receive endotoxin or saline; six also received ibuprofen, a cyclooxygenase inhibitor, and six received placebo. Administration of endotoxin produced fever, increased respiratory frequency, decreased inspiratory time, and widened alveolar-arterial oxygen tension gradient (all p < or = 0.001); these responses were blocked by ibuprofen. Independent of ibuprofen, endotoxin produced dyspnea, and it increased fractional inspiratory time, minute ventilation, and mean inspiratory flow (all p < or = 0.025). Endotoxin altered the autocorrelative behavior of respiratory frequency by increasing its autocorrelation coefficient at a lag of one breath, the number of breath lags with significant serial correlations, and its correlated fraction (all p < 0.05); these responses were blocked by ibuprofen. Changes in correlated behavior of respiratory frequency were related to changes in arterial carbon dioxide tension (r = 0.86; p < 0.03). Endotoxin decreased the oscillatory fraction of inspiratory time in both the placebo (p < 0.05) and ibuprofen groups (p = 0.06). In conclusion, endotoxin produced increases in respiratory motor output and dyspnea independent of fever and symptoms, and it curtailed the freedom to vary respiratory timing-a response that appears to be mediated by the cyclooxygenase pathway.

Effect of isocapnic hypoxia on variational activity of breathing.

In the presence of either hypocapnia or sleep, hypoxia has been shown to induce periodic breathing and increase the total variational activity of breath components. It is not known whether hypoxia induces alterations in breathing variability during wakefulness and in the absence of hypocapnia. To address this issue, we studied nonobtrusively 14 healthy awake subjects before and during the delivery of a hypoxic gas mixture via a plastic hood; the subjects' oxygen saturation decreased from 98 to 79% and end-tidal carbon dioxide tension was kept constant. Compared with air, isocapnic hypoxia increased the gross variability of minute ventilation (V I), tidal volume (VT), inspiratory time (TI), and expiratory time (TE) (all p < 0.004). Isocapnic hypoxia decreased the autocorrelation coefficient at a lag of one breath for TE (p < 0. 008) and V I (p = 0.07), the number of consecutive breath lags having significant autocorrelation coefficients for TE (p = 0.03), and the cycle time of oscillations in V I (p = 0.03). When partitioned, the increase in total variational activity during isocapnic hypoxia was found to result from increases in the random fractions of V I, VT, TI, and TE (all p < 0.05), and the oscillatory fractions of V I, VT, and TE (all p < 0.03). In conclusion, hypoxia induced hidden oscillations in V I, VT, and TE despite wakefulness and an isocapnic state, suggesting that neural responses may have a more important role in the genesis of hypoxia-induced oscillations than previously reported.

Assessment of neural inspiratory time in ventilator-supported patients.

Neural inspiratory time (TI) is a measurement of fundamental importance in studies of patient-ventilator interaction. The measurement is usually based on recordings of flow, esophageal pressure (Pes), and transdiaphragmatic pressure (Pdi), but the concordance of such estimates of neural TI with a more direct measurement of neural activity has not been systematically evaluated. To address this issue, we studied nine ventilator-supported patients in whom we employed esophageal electrode recordings of the diaphragmatic electromyogram (EMG) as the reference measurement of neural TI. Comparison of the indirect estimates of neural TI duration, based on flow, Pes, and Pdi against the reference measurement, revealed a mean difference (bias) ranging from -54 to 612 ms during spontaneous breathing and from -52 to 714 ms during mechanical ventilation; the respective precisions (standard deviations of the differences) ranged from 79 to 175 ms and from 74 to 221 ms. Because an indirect estimate of neural TI duration could be identical to that of the reference measurement and yet be displaced in time, this lag or lead was quantified as the phase angle of neural TI onset. Flow-based estimates of the onset of neural TI displayed a systematic lag, which may be explained at least in part by concurrent intrinsic positive end-expiratory pressure. In conclusion, the indirect estimates of the onset and duration of neural TI in ventilator-dependent patients displayed poor agreement with the diaphragmatic EMG measurement of neural TI.

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.

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.

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.

Continuous recordings of mixed venous oxygen saturation during weaning from mechanical ventilation and the ramifications thereof.

To define the importance of hemodynamic performance and global tissue oxygenation in determining weaning outcome, we recorded mixed venous oxygen saturation (SvO2) continuously in eight ventilator-supported patients who failed a trial of spontaneous breathing and 11 patients who tolerated a trial and were successfully extubated. Immediately before the weaning trial, SvO2 was not statistically different in the two groups (p = 0.28). On discontinuation of the ventilator, SvO2 fell progressively in the failure group (p < 0.01), whereas it did not change in the success group. During the trial of spontaneous breathing, O2 demand was similar in the two groups, but it differed in the manner with which it was met. The success group demonstrated an increase in cardiac index (p < 0.05) and O2 transport (p < 0.02). The failure group did not increase O2 transport, partly because of elevations in right- and left-ventricular afterload, but, instead, increased O2 extraction ratio (p < 0.02) with a consequent fall in SvO2. In turn, the low SvO2 combined with greater venous admixture (p < 0.0006) led to rapid arterial desaturation (p < 0.006) and a relative decrease in O2 being supplied to the tissues. In conclusion, ventilator-supported patients who failed a trial of spontaneous breathing developed a progressive decrease in SvO2 caused by the combination of a relative decrease in convective O2 transport and an increase in O2 extraction by the tissues.

Cycling of inspiratory and expiratory muscle groups with the ventilator in airflow limitation.

Research on patient-ventilator interactions has largely focused on inspiratory events, with little attention paid to expiration. We sought to determine the importance of the timing and magnitude of expiratory muscle activity in causing patient-ventilator dyssynchrony. Our study was done with healthy subjects receiving pressure support in whom we induced airflow limitation with a Starling resistor. The timing and magnitude of expiratory muscle activity were obtained by wire electromyographic recording of the activity of the transversus abdominis muscle, and were compared with the cycling of the ventilator and inspiratory muscle activity as determined from a flow tracing and diaphragmatic electromyogram (EMG), respectively. Induction of airflow limitation produced significant phase differences in the cycling of the subjects' expiratory muscle group and that of the machine. Some inspiratory efforts failed to trigger the ventilator, owing in part to an increase in elastic recoil consequent to the commencement of expiratory efforts before the termination of mechanical inflation. A delay in relaxation of the expiratory muscles did not interfere with the success of subsequent inspiratory efforts to trigger the ventilator. We also investigated the accuracy of two approaches for distinguishing between the contributions of expiratory muscle activity and elastic recoil to intrinsic positive end-expiratory pressure (PEEPi): the expiratory increase in gastric pressure (Pga) correlated better with transversus abdominis electromyographic activity (r = 0.7 to 0.95) than did the early inspiratory decrease in Pga (r = 0.04 to 0.53). In conclusion, the continuation of mechanical inflation into neural expiration was associated with failure of the subsequent inspiratory attempt to trigger the ventilator.

Partitioning of lung and chest-wall mechanics before and after lung-volume-reduction surgery.

In the study reported here, we partitioned the mechanics of the respiratory system into lung and chest-wall components, using the rapid occlusion technique in seven patients with severe emphysema before lung-volume-reduction surgery and 3 mo later. Patients showed improvements in 6-min walk (p < 0.01) and dyspnea (p < 0.05). The resistances of the respiratory system and chest wall were not altered by surgery. Ohmic airway resistance did not change, but the component of lung resistance (DeltaRL) due to viscoelastic behavior (stress relaxation) and time-constant inhomogeneities (pendelluft) decreased in six patients (p < 0.03). Dynamic elastance of the lung (Edyn,L) decreased after surgery (p < 0.02), whereas dynamic elastance of the chest wall did not change. The ratio of dynamic intrinsic positive end-expiratory pressure (PEEPi) to static PEEPi, which also reflects viscoelastic properties and time-constant inhomogeneities, increased after surgery (p < 0.05). The decrease in dyspnea was related to the decrease in Edyn,L (r = 0.81, p = 0.03), and tended to be related to the decrease in DeltaRL (r = 0.71, p = 0. 07). In conclusion, lung-volume-reduction surgery decreased dynamic pressure dissipations caused by stress relaxation and time-constant inhomogeneities within lung tissue, and it had no effect on the static mechanical properties of the chest wall.

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.

Respiratory muscle dysfunction in mechanically-ventilated patients.

The interaction between a patient and a ventilator is the major determinant of the amount of respiratory muscle rest achieved by the machine. We are beginning to acquire a better understanding of the mechanisms that underlie this complex interaction, but this information has yet to be integrated into the routine clinical management of ventilator-supported patients. To achieve that goal, we need better techniques of detecting and monitoring patient-ventilation asynchrony, and the development of simple algorithms that can minimize its occurrence. Finally, research is needed to determine the occurrence and importance of respiratory muscle fatigue during failed weaning attempts so as to better guide the timing and pace of the weaning process in problematic patients.

Effect of resistive loading on variational activity of breathing.

To examine the effect of resistive loading on variational activity of breathing, we studied 18 healthy subjects breathing at rest and with inspiratory resistive loads of 3 and 6 cm H2O/L/s, applied randomly for 1 h each. Compared with resting breathing, a resistive load of 3 cm H2O/L/s decreased the total variational activity of expiratory time (TE) and minute ventilation (V I), whereas a load of 6 cm H2O/L/s increased the total variational activity of inspiratory time (TI). Compared with the load of 3 cm H2O/L/s, the load of 6 cm H2O/L/s increased total variational activity of tidal volume (VT), TI, TE, and V I. Partitioning of the total variational activity revealed that these alterations were due to changes in the random uncorrelated fraction. Compared with rest, both the resistive loads of 3 and 6 cm H2O/L/s increased the number of breath lags displaying significant serial correlations ("short-term memory") of TI. Compared with rest, the load of 3 cm H2O/L/s increased the autocorrelation coefficient at a lag of one breath for VT and the load of 6 cm H2O/L/s increased the correlated fraction of variational activity of VT. Thus, three measures of correlated behavior-autocorrelation coefficient at a lag of 1 breath, "short-term memory," and the correlated fraction of total variational activity- increased with loading. In conclusion, resistive loading changed total variational activity according to the size of the load: the random fraction decreased with the smaller load but increased with the larger load; in contrast, correlated behavior increased with both loads. The different behaviors of random and correlated variability with loading may reflect different physiologic influences on respiratory control.

Effect of lung volume reduction surgery on neuromechanical coupling of the diaphragm.

The mechanisms for symptomatic improvement following lung volume reduction surgery for emphysema are poorly understood. We hypothesized that enhanced neuromechanical coupling of the diaphragm is an important factor in this improvement. We studied seven patients with diffuse emphysema before and 3 mo after surgery. Patients showed improvements in 6-min walking distance (p = 0.002) and dyspnea (p = 0.04). The pressure output of the respiratory muscles, quantified as pressure-time product per minute (PTP/min), decreased after surgery (p = 0.03), as did PaCO2 (p = 0.02). Maximal transdiaphragmatic pressures (Pdi(max)) increased from 80.3 +/- 9.5 (SE) to 110.8 +/- 9.3 cm H2O after surgery (p = 0.03), and the twitch transdiaphragmatic pressure response to phrenic nerve stimulation (Pdi(tw)) increased from 17.2 +/- 2.4 to 25.9 +/- 3.0 cm H2O (p = 0.02); these increases were greater than could be accounted for by a decrease in lung volume. The contribution of the diaphragm to tidal breathing, assessed by relative changes in gastric and transdiaphragmatic pressures, increased after surgery (p = 0.008). Net diaphragmatic neuromechanical coupling, quantified as the quotient of tidal volume (normalized to total lung capacity) to tidal change in Pdi (normalized to Pdi(max)), improved after surgery (p = 0.03) and was related to the increase in 6-min walking distance (r = 0.86, p = 0.03) and decrease in dyspnea (r = 0.76, p = 0.08). In conclusion, lung volume reduction surgery effects an improvement in diaphragmatic function, greater than can be accounted for by a decrease in operating lung volume, and enhances diaphragmatic neuromechanical coupling.