Relationship of the Arabic version of the asthma control test with ventilatory function tests and levels of exhaled nitric oxide in adult asthmatics.

OBJECTIVE: To determine the relationship between the asthma control test (ACT) score using the Arabic version, fractional exhaled nitric oxide (FENO), and lung functions, and to derive the cutoff points for the ACT score with the American Thoracic Society recommended FENO standard levels of inflammation control. METHODS: We recruited 59 adult asthmatics out of which 53 subjects completed the study between July 2011 and June 2012 at King Saud University, Riyadh, Saudi Arabia. The FENO levels were measured by NIOX MINO (Aerocrine AB, Solna, Sweden), and ventilatory functions were recorded by standard techniques. RESULTS: The FENO values were significantly higher in patients with an ACT score <20 (65.5+/= 35.4) compared with those patients with an ACT score >/= 20 (27.4+/=10.5, p<0.001). Among the well-controlled group based on the ACT score criteria, 6 (25%) cases had high FENO levels, while among the poorly controlled group, 23 (79.3%) cases had high FENO levels (odds ratio: 11.5; p<0.0001; confidence interval: 3.16-41.72). There was a significant negative correlation between FENO and ACT score (r=-0.581, p<0.0001). At the international cutoff point of 20, the sensitivity was 95.2, and the specificity was 68.8. The receiver operating curve (ROC) showed that maximum sensitivity and specificity were observed at an ACT score cut off point of 19 (sensitivity: 90.5, and specificity: 81.2). CONCLUSION: The FENO levels correlate negatively with ACT scores however, the relationship between FENO and lung function is not significant. A significant relationship between ACT score and FENO levels indicate that there is an ongoing inflammatory state in patients with poor asthma control.

Abrupt withdrawal of inhaled corticosteroids does not result in spirometric deterioration in chronic obstructive pulmonary disease: Effect of phenotyping?

BACKGROUND AND OBJECTIVE: Some studies show a decline of FEV(1) only one month after withdrawal of inhaled corticosteroids (ICS), while others show no decline. We speculate that the presence of an asthma phenotype in the Chronic Obstructive Pulmonary Disease (COPD) population, and that its exclusion may result in no spirometric deterioration. METHODS: We performed a prospective clinical observation study on 32 patients who fulfilled the Global Initiative for Chronic Obstructive lung disease definition of COPD (Grade II-IV). They were divided into two phenotypic groups. 1. Irreversible asthma (A and B) (n = 13): A. Asthma: Bronchial biopsy shows diffuse thickening of basement membrane (≥ 6.6 µm). B. Airflow limitation (AFL) likely to be asthma: KCO > 80% predicted if the patient refused biopsy. 2. COPD (A and B) (n = 19): A. COPD: hypercapneic respiratory failure with raised bicarbonate, panlobular emphysema with multiple bullas, or bronchial biopsy showing squamous metaplasia and epithelial/subepithelial inflammation without thickening of the basement membrane. B. AFL likely to be COPD: KCO < 80% predicted. RESULTS: The asthma phenotype was significantly younger, had a strong association with hypertrophy of nasal turbinates, and registered a significant improvement of FEV(1) (350 ml) vs a decline of - 26.5 ml in the COPD phenotype following therapy with budesonide/formoterol for one year. Withdrawal of budesonide for 4 weeks in the COPD phenotype resulted in FEV(1) + 1.33% (SD ± 5.71) and FVC + 1.24% (SD ± 5.32); a change of <12% in all patients. CONCLUSIONS: We recorded no spirometric deterioration after exclusion of the asthma phenotype from a COPD group.

Asthma masquerading as chronic obstructive pulmonary disease: a study of smokers fulfilling the GOLD definition of chronic obstructive pulmonary disease.

BACKGROUND: Irreversible airways obstruction in smokers is usually attributed to chronic obstructive pulmonary disease (COPD). We speculate that some of these are cases of asthma indistinguishable from COPD. OBJECTIVES: To determine the prevalence of asthma in a 'COPD' population and how to differentiate the two conditions. METHODS: This was a prospective observational study of smokers fulfilling the Global Initiative for Chronic Obstructive Lung Disease definition of COPD [mean post-salbutamol forced expiratory volume in 1 s (FEV1) 66.9% predicted]. They were classified into 4 groups, as follows: (1) inhaled corticosteroid (ICS)-responsive asthma, defined by normalization of spirometry upon ICS treatment; (2) irreversible asthma, defined as airway obstruction for 1 year and bronchial biopsy indicating asthma; (3) COPD, in the presence of bilateral panlobular emphysema with bullae on high-resolution computed tomography, hypercapneic respiratory failure or bronchial biopsy indicating COPD, and (4) unclassified airflow limitation (AFL). RESULTS: Eighty patients fulfilled the definition of COPD. The initial diagnosis was COPD in 57.5% and asthma in 42.5%. The final diagnosis was ICS-responsive asthma in 48 patients (60%), irreversible asthma in 8 (10%), COPD in 16 (20%) and unclassified AFL in 8 (10%). A normal transfer coefficient for carbon monoxide (KCO) and an FEV1 fluctuation ≥18% during 1 year of follow-up distinguished irreversible asthma and COPD. Seven of the 8 patients with irreversible asthma had improved FEV1 at the end of 1 year (median 320 ml compared with -29 ml in COPD). Five out of the 8 unclassified AFL cases had normal KCO and a large improvement in FEV(1) suggestive of irreversible asthma. CONCLUSIONS: COPD, even in heavy smokers, includes cases of asthma. FEV1 fluctuation during 1 year is a novel concept which may distinguish irreversible asthma and COPD.

Complicated community-acquired Staphylococcus endocarditis and multiple lung abscesses: case report and review of literature.

Background. Isolated tricuspid valve endocarditis in the absence of risk factors in the community setting is very rare and can be easily missed in patients with hitherto normal valves. Case Presentation. We present a case of a 49 year old gentleman who presented with generalized body aches, fever, and jaundice and was initial diagnosed as hepatitis. He subsequently developed recurrent episodes of panic attacks and shortness of breath and later multiple skin abscesses. Further investigations excluded pulmonary embolism but revealed multiple abscesses in the body including the lungs. Blood cultures and culture from abscesses grew S. aureus. An initial transthoracic echocardiogram was normal. A transesophageal echocardiogram subsequently confirmed endocarditis on a normal natural tricuspid valve and multiple lung abscesses. He was successfully treated with appropriate antibiotics. Conclusion. We discuss the pathogenesis of this patient's presentation highlight the need for assessment and proper evaluation of patients with unexplained bacteremia.

Saudi guidelines for testing and treatment of latent tuberculosis infection.

Pulmonary tuberculosis is a common disease in Saudi Arabia. As most cases of tuberculosis are due to reactivation of latent infection, identification of individuals with latent tuberculosis infection (LTBI) who are at increased risk of progression to active disease, is a key element of tuberculosis control programs. Whereas general screening of individuals for LTBI is not cost-effective, targeted testing of individuals at high risk of disease progression is the right approach. Treatment of those patients with LTBI can diminish the risk of progression to active tuberculosis disease in the majority of treated patients. This statement is the first Saudi guideline for testing and treatment of LTBI and is a result of the cooperative efforts of four local Saudi scientific societies. This Guideline is intended to provide physicians and allied health workers in Saudi Arabia with the standard of care for testing and treatment of LTBI.

Reference range values of fractional exhaled nitric oxide in healthy Arab adult males.

OBJECTIVE: To determine the reference values of the fraction of exhaled nitric oxide (FENO) among healthy, non-smoking male adults and its correlation with age, height, weight, and body mass index (BMI). METHODS: This cross-sectional study was conducted at the Departments of Physiology and Medicine, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, from September 2007 to August 2008 on healthy non-atopic, non-smoking male Saudi subjects. The FENO was measured online using the single-breath technique according to recent guidelines of the American Thoracic Society (ATS). RESULTS: We studied 121 subjects with a mean age of 31.00 +/- 12.24 years, BMI of 27.23 +/- 6.64, and FEV1/FVC 85% (81-92%). The FENO ranged between 7.66 parts per billion (ppb) and 46.6 ppb (mean 22.79 +/- 8.13), with >84% of subjects recording levels <30 ppb and >95% with levels <40 ppb. The FENO negatively correlated with body weight (r=0.3888, p=0.001) and BMI (r=0.238, p=0.009). No correlation was observed between FENO, FEV1/FVC ratio, age, and height. CONCLUSION: The reference values of FENO for non-smoking, non-atopic male Saudi adults fall between 7.66 and 46.6 ppb (mean 22.79 +/- 8.13), similar to other populations. The FENO negatively correlates with body weight and BMI.

H1N1 influenza A. Preliminary evaluation in hospitalized patients in a secondary care facility in Saudi Arabia.

OBJECTIVE: To assess the epidemiologic and clinical manifestations of the first wave of H1N1 influenza A patients. METHODS: This study is a retrospective chart review of all patients admitted in King Saud Medical Complex, Riyadh, Kingdom of Saudi Arabia, from 22nd May to 31st August 2009, with a proven diagnosis of H1N1 influenza A. Only patients with a positive nasopharyngeal swab were included, and excluded when the swab was negative. Charts were then analyzed for epidemiological and clinical data. RESULTS: A total of 153 patients with proven H1N1 infection were admitted, with a predominance of male patients (108 [71%]). Most patients were Saudis (111 [73%]), with 83 males (75%), and 28 females (25%). The mean age was 25 years (standard deviation; 9.45 years), and median age was 24 years. The most common symptoms in order of frequency were; fever (143 patients), cough (126 patients), sore throat (70 patients), headache (18 patients), shortness of breath (17 patients), myalgia (11 patients), diarrhea (9 patients), and vomiting (7 patients). Average duration of symptoms before admission was 3.55 days, and the average time of hospitalization was 4.8 days. Full recovery was obtained in 150 patients. Death occurred in 3 patients. CONCLUSION: True to its designation as a pandemic, H1N1 influenza A, has reached Saudi Arabia and poses a risk to the young population without immunity, and those with co-morbid disease, particularly of the lungs (bronchial asthma), and the pregnant. Despite its virulence in infecting people, deaths are far less than anticipated for such a novel virus. Social distancing can be recommended. However, further observation has to continue to substantiate these tentative preliminary findings.

Exhaled nitric oxide in diagnosis and management of respiratory diseases.

The analysis of biomarkers in exhaled breath constituents has recently become of great interest in the diagnosis, treatment and monitoring of many respiratory conditions. Of particular interest is the measurement of fractional exhaled nitric oxide (FENO) in breath. Its measurement is noninvasive, easy and reproducible. The technique has recently been standardized by both American Thoracic Society and European Respiratory Society. The availability of cheap, portable and reliable equipment has made the assay possible in clinics by general physicians and, in the near future, at home by patients. The concentration of exhaled nitric oxide is markedly elevated in bronchial asthma and is positively related to the degree of esinophilic inflammation. Its measurement can be used in the diagnosis of bronchial asthma and titration of dose of steroids as well as to identify steroid responsive patients in chronic obstructive pulmonary disease. In primary ciliary dyskinesia, nasal NO is diagnostically low and of considerable value in diagnosis. Among lung transplant recipients, FENO can be of great value in the early detection of infection, bronchioloitis obliterans syndrome and rejection. This review discusses the biology, factors affecting measurement, and clinical application of FENO in the diagnosis and management of respiratory diseases.

Exhaled nitric oxide in stable chronic obstructive pulmonary disease.

STUDY OBJECTIVE: The objective of the study was to test the hypothesis that fraction of exhaled nitric oxide (FENO) is elevated in nonsmoking subjects with stable chronic obstructive pulmonary disease (COPD) and compare it with the results in patients with asthma and a control population. DESIGN: Cross-sectional study. MATERIALS AND METHODS: Pulmonology Clinic at a University Hospital. Twenty five control subjects, 25 steroid naïve asthmatics and 14 COPD patients were studied. All the patients were nonsmokers and stable at the time of the study. All subjects completed a questionnaire and underwent spirometry. Exhaled nitric oxide was measured online by chemiluminescence, using single-breath technique. RESULTS: All the study subjects were males. Subjects with stable COPD had significantly higher values of FENO than controls (56.54+/-28.01 vs 22.00+/-6.69; P=0.0001) but lower than the subjects with asthma (56.54+/-28.01 vs 84.78+/-39.32 P=0.0285).The FENO values in COPD subjects were inversely related to the FEV/1FVC ratio. There was a significant overlap between the FENO values in COPD and the control subjects. CONCLUSION: There is a significant elevation in FENO in patients with stable COPD, but the elevation is less than in asthmatic subjects. Its value in clinical practice may be limited by the significant overlap with control subjects.

Physicians' practice for prevention of venous thromboembolism in medical patients.

OBJECTIVE: To audit physicians' practice of providing prophylaxis for venous thromboembolism (VTE) in patients admitted to acute- care medical wards and to determine the consequences of lack of prophylaxis. DESIGN: Case-control comparative study. PLACE AND DURATION OF STUDY: All patients admitted to medical service of Riyadh Medical Complex (RMC) who stayed longer than six days were studied between July 2001 and 2002. PATIENTS AND METHODS: Demographic data as well as risk factors for VTE were identified for all patients who were divided in two groups. Patients who received prophylaxis (group-A) and those who did not (group-B) were both followed up. Type of prophylaxis and any complications were documented. Duplex ultrasound of the lower limbs was done in all patients in both groups and the outcome for all patients were documented. RESULTS: Two hundred and forty-nine (249) patients were studied. Ninety-eight (39.35%) patients (group-A) received prophylaxis for VTE, while 151 (60.65%) patients (group-B) did not receive prophylaxis. Twenty-five point eight percent (25.8%), 37.5%, and 50% of patients with 3, 4 and 5 risk factors respectively did not receive thromboprophylaxis. Duplex sonography did not reveal deep venous thrombosis (DVT) in any patient of the two groups in hospital and upto one month after discharge. There was no statistical difference in mortality between the two groups. CONCLUSION: Physicians' practice showed low threshold for providing VTE prophylaxis for medical patients. This was not translated to higher incidence of VTE or higher hospital mortality.

Management of acute myocardial infarction. Do we follow guidelines applied in practice?

OBJECTIVE: Acute myocardial infarction (MI) is a major health problem with a substantial fatality and morbidity. The management of patients with acute MI has been addressed in major trials to improve the survival and enhance the quality of life of the patients. Numerous guidelines have been established for the management of such patients. The objective of this study is to determine whether the current practice in managing patients admitted with acute MI in a major community hospital in Riyadh is evidence based compliant. METHODS: The data were collected from patients admitted to the Coronary Care Unit (CCU), Riyadh Medical Complex (RMC), Riyadh, Kingdom of Saudi Arabia, a 1500 bed community hospital, with a diagnosis of acute MI over one-year period (April 1999 to April 2000). The administration of different therapeutic modalities upon admission as well as discharge medications was obtained. Patients outcome (all cause mortality) post treatment were collected. The data was analyzed and compared with the current guidelines. RESULTS: A total of 335 patients, 315 males (94%), were admitted to the CCU of RMC with a diagnosis of acute MI. Two hundred and seventy-one patients (80.9%) received thrombolytic therapy. Discharge medications were beta-blocker in 255 (76.1%), angiotensin converting enzyme inhibitors in 206 (61.5%), nitrates in 281 (83.9%), hypolipidemic agents in 15 patients (4.5%), and aspirin in all patients. The outcome of these patients obtained either alive or dead was 313 (93.4%) and 22 (6.6%) (p<0.00001). CONCLUSION: The patients with acute MI received management compliant with evidence-based practice. However, more awareness to the use of angiotensin converting enzyme inhibitors as well as hypolipidemic agents is needed to provide maximum benefit to these patients. Moreover, national guidelines for the management of acute MI are needed for improvement of quality of care.

Asymptomatic full term pregnant patient with a grossly abnormal chest radiograph.

An asymptomatic full term pregnant lady with a grossly abnormal chest radiograph is presented as a clinical quiz. The diagnosis is discussed and the topic reviewed in detail.

Predicting nodal malignancy from clinical data.

OBJECTIVE: A large variety of disorders can lead to lymphadenopathy. It is important and beneficial to patient management to rapidly differentiate between benign and malignant causes. The objective of the study is to identify factors predicting nodal malignancy from readily available clinical data. METHODS: A retrospective study was carried out on patients admitted to Riyadh Medical Complex, Riyadh, Kingdom of Saudi Arabia between April 1996 and March 2000 with lymphadenopathy, who underwent lymph node biopsy. RESULTS: Univariate analysis suggests 6 variables (age, sex, the presence of other physical signs, abnormal complete blood count, abnormal liver function test and negative Mantoux test) to have independent association with nodal malignancy. The multivariate logistic regression model revealed patients aged more than 40 years, males, generalized lymphadenopathy, presence of other physical signs, abnormal liver function tests and negative Mantoux test to be statistically significantly associated with nodal malignancy (p>0.05). CONCLUSION: The present logistic model can be useful in predicting nodal malignancy using routinely collected clinical data.

Door to needle time in administering thrombolytic therapy for acute myocardial infarction.

OBJECTIVE: Thrombolytic therapy is a standard treatment for patients presenting with acute myocardial infarction (MI). Early administration of these agents is crucial for the outcome of management. This audit was conducted to evaluate the time between arrival to emergency department (ED) and the administration of thrombolysis (door to needle time). METHODS: Data was collected from patients admitted to the Coronary Care Unit of Riyadh Medical Complex (RMC), Riyadh, Kingdom of Saudi Arabia, a 1500-bed community hospital, with a diagnosis of acute MI and received thrombolytic therapy over a one-year period (April 1999 to April 2000). The time between arrival to the ED to the time of administration of thrombolytic therapy was obtained as well as the time of onset of chest pain up to presentation to the hospital, and the outcome (all cause mortality) post treatment. RESULTS: A total of 271 patients (256 males) admitted to RMC with a diagnosis of acute MI received thrombolytic therapy over a one-year duration. The median door to needle time was 95 minutes. The median time of onset of chest pain to arrival to ED was 5 hours (300 minutes). The outcome of these patients obtained either alive was 260 (96%) or dead was 11 (4%) (P < 0.00001). CONCLUSION: The door to needle time was relatively similar to other centers. The delay in administering thrombolytic therapy should be reduced to a target of <70 minutes from onset of symptoms. Delay in presentation to the hospital was more important and factors contributing to this delay should be looked for and corrected. Another audit is needed to evaluate the implementation of these recommendations.

Clinical spectrum of Swyer-James-Macleod syndrome in adults.

OBJECTIVE: The aim of this study is to describe the clinical and imaging features of Swyer-James-Macleod syndrome (SJMS) in 9 adults. METHODS: We reviewed the charts of 9 patients diagnosed with SJMS at the King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia over a 10 year period. RESULTS: The patients mean age was 38.1 years; males were more affected than females (7:2). Seven of the patients had symptoms referable to the chest and a similar number had compatible abnormalities on physical examination. The left lung was involved in all cases. Bronchiectasis was present in 7 (77.8%). Eight patients who underwent pulmonary function tests had combined defects. Two patients demonstrated significant reversibility. All patients had a stable course over at least before a 3 year follow-up period. CONCLUSION: Swyer-James-Macleod syndrome has a diverse manifestations in adults and can mimic other pulmonary disorders, which may lead to incorrect diagnosis and inappropriate therapy. The course is generally a stable one.

An audit of oxygen therapy on the medical ward in 2 different hospitals in Central Saudi Arabia.

OBJECTIVE: To study the use of oxygen therapy on the medical wards in 2 hospitals in Riyadh, Kingdom of Saudi Arabia. One was academic, King Khalid University Hospital and the other a community hospital, Riyadh Medical Complex. METHODS: This study was carried out over a one year period, 6 April 2000 through to 6 April 2001. Oxygen saturation was measured randomly by pulse oximetry in patients receiving oxygen therapy. Charts of the patients were inspected for relevant information related to oxygen therapy, including indications, dose, monitoring and documentation of the order. If oxygen saturation was >97% oxygen flow was reduced to maintain oxygen saturation between 92% and 94%. The potential savings by such reduction were calculated. RESULTS: A total of 108 patients were studied. The most frequent indications for oxygen therapy were hypoxemia and dyspnea. Arterial oxygen tension before starting oxygen was carried out for 78 patients (72.2%) and showed that the majority (60 patients, 76.9%) were hypoxemic arterial oxygen tension <= 65 mm Hg). The last documented arterial oxygen tension values after initiating oxygen were found in 79 patients (73.1%) and these were carried out at mean interval of 111 hours (range one-1200) before our assessment. Most patients (32 patients, 40.5%) had excessive values (>85 mmHg), 24 patients (30.4%) were hypoxemic (arterial oxygen tension <=65 mmHg) and only 23 patients (29.1%) had acceptable values (arterial oxygen tension > 65-85 mmHg). Our measurements also showed that arterial oxygen tension was excessive (>97%) in 59 patients (54.6%), adequate (>=92%-97%) in 44 patients (40.7%), and only a minority (5 patients, 4.6%) were hypoxemic (<92%). Oxygen dose could be reduced in 31 patients (28.7%) by a mean of 42% (range 18%-66%) and stopped in 38 patients (35%) while maintaining aterial oxygen tension between 92%-94%. Errors in oxygen prescription were more apparent in the non-academic setting (P<0.05%). CONCLUSION: Oxygen prescription was sub-optimal in both the academic and non-academic setting. The study highlights the need to adopt and evaluate cost-effective measures such as oxygen titration protocols using pulse oximetry, and physician education programs.