The Saudi initiative for asthma - 2024 update: Guidelines for the diagnosis and management of asthma in adults and children.

The Saudi Initiative for Asthma 2024 (SINA-2024) is the sixth version of asthma guidelines for the diagnosis and management of asthma for adults and children that was developed by the SINA group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up-to-date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA Panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is aligned for age groups: adults, adolescents, children aged 5-12 years, and children aged <5 years. SINA guidelines have focused more on personalized approaches reflecting a better understanding of disease heterogeneity with the integration of recommendations related to biologic agents, evidence-based updates on treatment, and the role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and the current situation at national and regional levels. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

Prevalence of chronic cough, its risk factors and population attributable risk in the Burden of Obstructive Lung Disease (BOLD) study: a multinational cross-sectional study.

Background: Chronic cough is a common respiratory symptom with an impact on daily activities and quality of life. Global prevalence data are scarce and derive mainly from European and Asian countries and studies with outcomes other than chronic cough. In this study, we aimed to estimate the prevalence of chronic cough across a large number of study sites as well as to identify its main risk factors using a standardised protocol and definition. Methods: We analysed cross-sectional data from 33,983 adults (≥40 years), recruited between Jan 2, 2003 and Dec 26, 2016, in 41 sites (34 countries) from the Burden of Obstructive Lung Disease (BOLD) study. We estimated the prevalence of chronic cough for each site accounting for sampling design. To identify risk factors, we conducted multivariable logistic regression analysis within each site and then pooled estimates using random-effects meta-analysis. We also calculated the population attributable risk (PAR) associated with each of the identifed risk factors. Findings: The prevalence of chronic cough varied from 3% in India (rural Pune) to 24% in the United States of America (Lexington,KY). Chronic cough was more common among females, both current and passive smokers, those working in a dusty job, those with a history of tuberculosis, those who were obese, those with a low level of education and those with hypertension or airflow limitation. The most influential risk factors were current smoking and working in a dusty job. Interpretation: Our findings suggested that the prevalence of chronic cough varies widely across sites in different world regions. Cigarette smoking and exposure to dust in the workplace are its major risk factors. Funding: Wellcome Trust.

Chronic airflow obstruction attributable to poverty in the multinational Burden of Obstructive Lung Disease (BOLD) study.

Poverty is strongly associated with all-cause and chronic obstructive pulmonary disease (COPD) mortality. Less is known about the contribution of poverty to spirometrically defined chronic airflow obstruction (CAO)-a key characteristic of COPD. Using cross-sectional data from an asset-based questionnaire to define poverty in 21 sites of the Burden of Obstructive Lung Disease study, we estimated the risk of CAO attributable to poverty. Up to 6% of the population over 40 years had CAO attributable to poverty. Understanding the relationship between poverty and CAO might suggest ways to improve lung health, especially in low-income and middle-income countries.

The association of spirometric small airways obstruction with respiratory symptoms, cardiometabolic diseases, and quality of life: results from the Burden of Obstructive Lung Disease (BOLD) study.

BACKGROUND: Spirometric small airways obstruction (SAO) is common in the general population. Whether spirometric SAO is associated with respiratory symptoms, cardiometabolic diseases, and quality of life (QoL) is unknown. METHODS: Using data from the Burden of Obstructive Lung Disease study (N = 21,594), we defined spirometric SAO as the mean forced expiratory flow rate between 25 and 75% of the FVC (FEF25-75) less than the lower limit of normal (LLN) or the forced expiratory volume in 3 s to FVC ratio (FEV3/FVC) less than the LLN. We analysed data on respiratory symptoms, cardiometabolic diseases, and QoL collected using standardised questionnaires. We assessed the associations with spirometric SAO using multivariable regression models, and pooled site estimates using random effects meta-analysis. We conducted identical analyses for isolated spirometric SAO (i.e. with FEV1/FVC ≥ LLN). RESULTS: Almost a fifth of the participants had spirometric SAO (19% for FEF25-75; 17% for FEV3/FVC). Using FEF25-75, spirometric SAO was associated with dyspnoea (OR = 2.16, 95% CI 1.77-2.70), chronic cough (OR = 2.56, 95% CI 2.08-3.15), chronic phlegm (OR = 2.29, 95% CI 1.77-4.05), wheeze (OR = 2.87, 95% CI 2.50-3.40) and cardiovascular disease (OR = 1.30, 95% CI 1.11-1.52), but not hypertension or diabetes. Spirometric SAO was associated with worse physical and mental QoL. These associations were similar for FEV3/FVC. Isolated spirometric SAO (10% for FEF25-75; 6% for FEV3/FVC), was also associated with respiratory symptoms and cardiovascular disease. CONCLUSION: Spirometric SAO is associated with respiratory symptoms, cardiovascular disease, and QoL. Consideration should be given to the measurement of FEF25-75 and FEV3/FVC, in addition to traditional spirometry parameters.

The Correlation Between Fractional Exhaled Nitric Oxide (FeNO), Blood Eosinophil Count, Immunoglobulin E Levels, and Spirometric Values in Patients With Asthma.

BACKGROUND AND OBJECTIVE: In patients with asthma, fractional exhaled nitric oxide (FeNO) is a biomarker for eosinophilic airway inflammation. However, the correlation with the blood eosinophil count, immunoglobulin E (IgE), and spirometric values is not well established. We aimed to investigate the correlation between FeNO, blood eosinophils, IgE, and spirometric values in asthmatic patients. METHODS: Data were extracted from the electronic medical records of adult asthmatic patients, and included the FeNO, blood eosinophil count, IgE, and spirometric values. The correlation between the markers was investigated using receiver operating characteristics (ROC) and the area under the curve (AUC). RESULTS: A total of 135 adult patients (30% male) were analyzed. The mean FeNO was 36 ppb and almost half (48%) had a FeNO > 25 ppb. The mean blood eosinophil count was 377 cells/mm3, and 42% had a blood eosinophil count > 300 cells/mm3. There was a significant positive correlation between FeNO and the blood eosinophil count (r = 0.42, sensitivity 63%, specificity 77%, AUC 72%, p < 0.0001) as well as with the IgE (r = 0.35, sensitivity 78%, specificity 44%, AUC 68%, p < 0.0007). There was significant negative correlation between FeNO and FEV1% (r = -0.18, sensitivity 35%, specificity 85%, AUC 67%, p = 0.027). CONCLUSION: The blood eosinophil count, IgE, and spirometric values were correlated with the severity of the eosinophilic airway inflammation (high FeNO). Asthmatic patients with a higher FeNO level had a higher eosinophil count, higher IgE levels, and lower FEV1 values.

Association of respiratory symptoms and lung function with occupation in the multinational Burden of Obstructive Lung Disease (BOLD) study.

BACKGROUND: Chronic obstructive pulmonary disease has been associated with exposures in the workplace. We aimed to assess the association of respiratory symptoms and lung function with occupation in the Burden of Obstructive Lung Disease study. METHODS: We analysed cross-sectional data from 28 823 adults (≥40 years) in 34 countries. We considered 11 occupations and grouped them by likelihood of exposure to organic dusts, inorganic dusts and fumes. The association of chronic cough, chronic phlegm, wheeze, dyspnoea, forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1)/FVC with occupation was assessed, per study site, using multivariable regression. These estimates were then meta-analysed. Sensitivity analyses explored differences between sexes and gross national income. RESULTS: Overall, working in settings with potentially high exposure to dusts or fumes was associated with respiratory symptoms but not lung function differences. The most common occupation was farming. Compared to people not working in any of the 11 considered occupations, those who were farmers for ≥20 years were more likely to have chronic cough (OR 1.52, 95% CI 1.19-1.94), wheeze (OR 1.37, 95% CI 1.16-1.63) and dyspnoea (OR 1.83, 95% CI 1.53-2.20), but not lower FVC (ß=0.02 L, 95% CI -0.02-0.06 L) or lower FEV1/FVC (ß=0.04%, 95% CI -0.49-0.58%). Some findings differed by sex and gross national income. CONCLUSION: At a population level, the occupational exposures considered in this study do not appear to be major determinants of differences in lung function, although they are associated with more respiratory symptoms. Because not all work settings were included in this study, respiratory surveillance should still be encouraged among high-risk dusty and fume job workers, especially in low- and middle-income countries.

Chronic airflow obstruction and ambient particulate air pollution.

Smoking is the most well-established cause of chronic airflow obstruction (CAO) but particulate air pollution and poverty have also been implicated. We regressed sex-specific prevalence of CAO from 41 Burden of Obstructive Lung Disease study sites against smoking prevalence from the same study, the gross national income per capita and the local annual mean level of ambient particulate matter (PM2.5) using negative binomial regression. The prevalence of CAO was not independently associated with PM2.5 but was strongly associated with smoking and was also associated with poverty. Strengthening tobacco control and improved understanding of the link between CAO and poverty should be prioritised.

The Saudi Initiative for Asthma - 2021 Update: Guidelines for the diagnosis and management of asthma in adults and children.

The Saudi Initiative for Asthma 2021 (SINA-2021) is the fifth version of asthma guidelines for the diagnosis and management of asthma for adults and children, which is developed by the SINA group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up to date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is aligned for age groups: adults, adolescents, children aged 5-12 years, and children aged less than 5 years. SINA guidelines have focused more on personalized approaches reflecting better understanding of disease heterogeneity with the integration of recommendations related to biologic agents, evidence-based updates on treatment, and the role of immunotherapy in management. Medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and the current situation at national and regional levels. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

Attitudes and behavior related to performance-enhancing substance use among elite Saudi football players.

OBJECTIVE: To investigate the attitudes, beliefs and behavior related to performance enhancing substances (PES) use in elite Saudi football players. METHOD: A cross-sectional survey was conducted. Using a systematic random sample of elite Saudi male football players, the standard World Anti-doping Agency (WADA) Social Science Research Package questionnaire was distributed to 408 players. RESULTS: The overall prevalence rate of PES use was 3.9%, with the overall prevalence rate of doping susceptibility 17.1%. PES use or doping susceptibility is strongly correlated but negatively associated with morality and cheating measures (p <  0.011, the estimate is - 0.139), threat or deterrence appraisal (p <  0.001, the estimate is - 0.301) and beliefs about the reference group's endorsement (p < 0.001, the estimate is - 0.213) but not with legitimacy perceptions (p = 0.513) and beliefs about the benefits of doping (p = 0.678). The strongest relationship was found between threat or deterrence appraisal (p < 0.001), and beliefs about the reference group's endorsement of PES use (p < 0.001). CONCLUSION: Morality and cheating measures, threat or deterrence appraisal and beliefs about the reference group's endorsement are the main predictors for PES use in Saudi Arabia.

The Saudi Initiative for Asthma - 2019 Update: Guidelines for the diagnosis and management of asthma in adults and children.

This is the fourth version of the updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up to date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is now more aligned for different age groups. The guidelines have focused more on personalized approaches reflecting better understanding of disease heterogeneity with integration of recommendations related to biologic agents, evidence-based updates on treatment, and role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and current situation at national and regional levels. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

Prevalence of and attitudes to waterpipe smoking among Saudi Arabian physicians.

BACKGROUND: Tobacco smoking kills more than 5 million people annually and it is the most important cause of preventable death. Waterpipe smoking is common in the Middle East and is prevalent among young people. There is a misconception that it is less harmful than cigarette smoking. Physicians are considered role models in the community and their behaviours and attitudes towards smoking can have direct effects on cessation. AIM: The aim of this study was to estimate current prevalence, attitudes and associated factors in regard to waterpipe smoking among Saudi Arabian physicians. METHODS: Using a self-administered questionnaire, we conducted a cross-sectional study among 454 male and female physicians from 3 specialties, and of various levels of training working in 4 hospitals in Riyadh. RESULTS: The prevalence of waterpipe smoking was 45%, greater in men than in women (58% vs 18%; P ≤ 0.001) and in surgical than in medical specialists (58% vs 38%; P ≤ 0.001). More non-smokers than smokers believed that physicians should serve as role models (79% vs 60%; P ≤ 0.001). Physicians who were waterpipe non-smokers had received more formal training about cessation than smokers (50% vs 36%; P ≤ 0.001). CONCLUSIONS: Waterpipe smoking among Saudi Arabian physicians is frequent and is associated with low exposure to information about the hazards and cessation during medical education.

Adherence to COPD treatment in Turkey and Saudi Arabia: results of the ADCARE study.

BACKGROUND: COPD affects millions of people worldwide. Poor treatment adherence contributes to increased symptom severity, morbidity and mortality. This study was designed to investigate adherence to COPD treatment in Turkey and Saudi Arabia. METHODS: An observational, cross-sectional study in adult COPD patients in Turkey and Saudi Arabia. Through physician-led interviews, data were collected on sociodemographics and disease history, including the impact of COPD on health status using the COPD Assessment Test (CAT); quality of life, using the EuroQol Five-Dimension questionnaire (EQ-5D); and anxiety and depression using the Hospital Anxiety and Depression Scale (HADS). Treatment adherence was measured using the 8-item Morisky Medication Adherence Scale (MMAS-8). Multivariate logistic regression analysis examined the predictors of non-adherence and the impact of adherence on symptom severity. RESULTS: Four hundred and five COPD patients participated: 199 in Turkey and 206 in Saudi Arabia. Overall, 49.2% reported low adherence (MMAS-8 <6). Of those, 74.7% reported high disease impact (CAT >15) compared to 58.4% reporting medium/high adherence (p=0.0008). Patients with low adherence reported a lower mean 3-level EQ-5D utility value (0.54±0.35) compared to those with medium/high adherence (0.64±0.30; p<0.0001). Depression with HADS score 8-10 or >10 was associated with lower adherence (OR 2.50 [95% CI: 1.43-4.39] and 2.43 [95% CI: 1.39-4.25], respectively; p=0.0008). Being a high school/college graduate was associated with better adherence compared with no high school (OR 0.57 [95% CI: 0.33-0.98] and 0.38 [95% CI: 0.15-1.00], respectively; p=0.0310). After adjusting for age, gender, and country, a significant association between treatment adherence (MMAS-8 score ≥6) and lower disease impact (CAT ≤15) was observed (OR 0.56 [95% CI: 0.33-0.95]; p=0.0314). CONCLUSION: Adherence to COPD treatment is poor in Turkey and Saudi Arabia. Non-adherence to treatment is associated with higher disease impact and reduced quality of life. Depression, age, and level of education were independent determinants of adherence.

Asthma prevalence among adults in Saudi Arabia.

OBJECTIVES: To investigate asthma prevalence and to measure asthma symptoms among Saudi adults in Riyadh, Kingdom of Saudi Arabia. METHODS: A cross-sectional survey using the European Community Respiratory Health Survey (ECRHS)questionnaire carried out between April and June 2016, among male and female Saudi nationals aged 20-44 years living in Riyadh. Disproportionate cluster sampling method was used. Asthma was defined based on answering "yes" to any of the following: Have you had wheezing when you did not have a cold in the last 12 months? Have you been told by a physician to have asthma? Are you taking medicine for asthma? RESULTS: A total of 2,405 participants completed the survey. The prevalence of wheezing in the last 12 months when not having a cold was 18.2% with no significant difference between males and females (p=0.107). The prevalence of physician-diagnosed asthma was 11.3% with no significant difference between males and females (p=0.239). The prevalence of taking medicine for asthma was 10.6%. There were no significant differences between asthmatic vs. non-asthmatic in terms of residency area (p=0.07), education level (p=0.11) and smoking tobacco (p=0.06). However, significant differences found between asthmatic and non-asthmatic in relation to nasal allergies (p less than 0.001). CONCLUSION: Asthma prevalence is high and much higher than the prevalence reported in most countries using the ECRHS questionnaire.

Assessment of knowledge and education relating to asthma during pregnancy among women of childbearing age.

BACKGROUND: Misconceptions about medications' safety can lead pregnant women with asthma to stop their medications, resulting in asthma-related neonatal morbidity and mortality. Our aim was to assess the level of pregnancy-related asthma knowledge and education about asthma medications' safety, among women of childbearing age with a history of bronchial asthma. METHODS: A cross-sectional survey of convenience sample of outpatient clinic attendees of Pulmonary, Family Medicine and Obstetrics & Gynecology among women of childbearing age with history of asthma at King Abdulaziz Medical City, Riyadh, Saudi Arabia. Participants (n = 171) completed a questionnaire to determine levels of education and knowledge, as well as attitudes and practice relating to asthma treatment. RESULTS: Among participants, 77.1% were pregnant at the time of the survey, 77.8% had used asthma medications during current or previous pregnancy, 70.8% of all respondents who ever been pregnant believed in the safety of asthma medications during pregnancy, 49.1% had received education about asthma, and 46.8% had been educated about the safety of asthma medications during pregnancy. Responses indicated that 46.8% had stopped (or expressed the desire to stop) asthma medications during pregnancy, and 48% believed asthma medications would harm them and their babies more than asthma itself, but 92.4% expressed that they would be willing to use asthma medications during pregnancy if their safety was confirmed by a physician. Education level and employment status were both associated with an increased likelihood of having received asthma education (p values <0.001 and <0.001 respectively), and with awareness of the safety of the medications during pregnancy (p values <0.001 and <0.003 respectively). CONCLUSION: Further efforts is to be taken to develop a program where female asthmatic patients are taught about asthma and its medications' safety during pregnancy.

Medical residents' attitudes and emotions related to Middle East respiratory syndrome in Saudi Arabia. A cross-sectional study.

OBJECTIVES: To determine medical residents' emotions, attitudes, and knowledge related to Middle East respiratory syndrome (MERS) outbreaks. Methods: In this is a cross sectional study, self-administered questionnaires were distributed and collected before resident education activities in 4 tertiary hospitals in Riyadh, Kingdom of Saudi Arabia, between November 2015 and January 2016. The questionnaire included questions related to residents' demographic data and their emotions, attitudes, and knowledge related to an MERS outbreak. Results: Of the 228 participants analyzed, 85.5% believed their work put them at risk of infection, and two-thirds believed their family was exposed to a greater risk of infection. However, only 2.6% would change their job. Nearly half of the residents indicated that their hospital had a clear plan, and only 28% considered themselves not well prepared for an MERS outbreak. Conclusions: Our study highlights medical residents' attitude and emotions related to MERS outbreaks. Residents' concerns and emotions in relation to MERS should be considered in greater detail by hospital policymakers.

The use of performance-enhancing substances (doping) by athletes in Saudi Arabia.

BACKGROUND: Data on doping violation in Saudi Arabia are scarce. Our aim was to investigate the Saudi experience of anti-doping and review all positive samples and adverse analytical findings (AAFs) of Saudi athletes. MATERIALS AND METHODS: This study analyzed databases of the Saudi Arabian Anti-Doping Committee from 2008 to May 2016. The samples originated from various sporting events and were collected in and outside sport competitions. The substances investigated were those included in the annual lists of prohibited substances produced by the World Anti-Doping Agency (WADA). All urine samples were tested in laboratories accredited by the WADA. Samples were declared positive if they contained any prohibited substance on the WADA list for that year. RESULTS: In 4482 urine samples tested, 141 positive samples (3.1%) and 195 AAFs of prohibited substances were detected. The prevalence of positive samples was highest in 2012 (6.6%) and lowest in 2015 (1%). The most prevalent prohibited substances detected were anabolic steroids (32.8%) and stimulants (27.6%). The most frequently detected compounds were amphetamines (22%) and tetrahydrocannabinol (12.8%). The highest prevalence of AAFs was in bodybuilders. CONCLUSION: The prevalence of doping in Saudi Arabia seems to be higher than western countries, but this needs to be confirmed with further research.

The association between chronic airflow obstruction and poverty in 12 sites of the multinational BOLD study.

Poverty is strongly associated with mortality from COPD, but little is known of its relation to airflow obstruction.In a cross-sectional study of adults aged ≥40 years from 12 sites (N=9255), participating in the Burden of Obstructive Lung Disease (BOLD) study, poverty was evaluated using a wealth score (0-10) based on household assets. Obstruction, measured as forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) (%) after administration of 200 µg salbutamol, and prevalence of FEV1/FVC

Perception and Attitude of Emergency Room Resident Physicians toward Middle East Respiratory Syndrome Outbreak.

Introduction. Middle East respiratory syndrome (MERS) outbreaks have had a considerable negative impact on health systems in Saudi Arabia. We aimed to study the psychological impact of a Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak on emergency room resident physicians (ERRPs). Methods. We assessed the MERS-related psychological impact and concerns of ERRPs using a self-report questionnaire. Results. The majority (91%) of the ERRPs agreed that their work put them at risk of infection, but most (65%) did not agree that they should not be looking after patients infected with MERS. Despite that, 54% of ERRPs reported being afraid of contracting the infection from infected patients and only 4.2% of them were willing to change their current job. The majority of the ERRPs (85%) felt that their job would expose their families to risk of infection. Conclusions. Our study demonstrated the considerable psychological impact of MERS outbreaks on ERRPs. The ERRPs' concerns and the psychological impact of MERS outbreaks should be considered in greater detail by hospital policymakers.

Clinical Presentation, Risk Factors, and Treatment Modalities of Hepatocellular Carcinoma: A Single Tertiary Care Center Experience.

Objective. To investigate the risk factors, clinical characteristics, treatment modalities, and outcomes in Saudi patients with HCC and propose points for early detection of the disease. Methods. Patients were stratified according to underlying risk factors for the development of HCC. Barcelona Clinic Liver Cancer (BCLC) was used for cancer staging. Treatment was classified into surgical resection/liver transplantation; locoregional ablation therapy; transarterial embolization; systemic chemotherapy; and best supportive care. Results. A total of 235 patients were included. Males had higher tumor size and incidence of portal vein thrombosis. Viral hepatitis was a risk factor in 75.7%. The most common BCLC stages were B (34.5%) and A (33.6%), and the most common radiological presentation was a single nodule of less than 5 cm. Metastases were present in 13.2%. Overall, 77 patients (32.8%) underwent a potentially curative treatment as the initial therapy. The most commonly utilized treatment modality was chemoembolization with 113 sessions in 71 patients. The overall median survival was 15.97 ± 27.18 months. Conclusion. HCC in Saudi Arabia is associated with high prevalence of HCV. Potentially curative therapies were underutilized in our patients. Cancer stage BCLC-B was the most frequent (34.5%) followed by BCLC-A (33.6%). The overall median survival was shorter than other studies.