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On February 23, 2018, PubMed Central Canada (PMC Canada) will be taken offline permanently. No author manuscripts will be deleted, and the approximately 2,900 manuscripts authored by Canadian Institutes of Health Research (CIHR)-funded researchers currently in the archive will be copied to the National Research Council’s (NRC) Digital Repository over the coming months. These manuscripts along with all other content will also remain publicly searchable on PubMed Central (US) and Europe PubMed Central, meaning such manuscripts will continue to be compliant with the Tri-Agency Open Access Policy on Publications.

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1.  The Saudi Thoracic Society guidelines for diagnosis and management of noncystic fibrosis bronchiectasis 
Annals of Thoracic Medicine  2017;12(3):135-161.
This is the first guideline developed by the Saudi Thoracic Society for the diagnosis and management of noncystic fibrosis bronchiectasis. Local experts including pulmonologists, infectious disease specialists, thoracic surgeons, respiratory therapists, and others from adult and pediatric departments provided the best practice evidence recommendations based on the available international and local literature. The main objective of this guideline is to utilize the current published evidence to develop recommendations about management of bronchiectasis suitable to our local health-care system and available resources. We aim to provide clinicians with tools to standardize the diagnosis and management of bronchiectasis. This guideline targets primary care physicians, family medicine practitioners, practicing internists and respiratory physicians, and all other health-care providers involved in the care of the patients with bronchiectasis.
doi:10.4103/atm.ATM_171_17
PMCID: PMC5541962
Bronchiectasis; cystic fibrosis; Saudi
2.  World Congress Integrative Medicine & Health 2017: Part one 
Brinkhaus, Benno | Falkenberg, Torkel | Haramati, Aviad | Willich, Stefan N. | Briggs, Josephine P. | Willcox, Merlin | Linde, Klaus | Theorell, Töres | Wong, Lisa M. | Dusek, Jeffrey | Wu, Darong | Eisenberg, David | Haramati, Aviad | Berger, Bettina | Kemper, Kathi | Stock-Schröer, Beate | Sützl-Klein, Hedda | Ferreri, Rosaria | Kaplan, Gary | Matthes, Harald | Rotter, Gabriele | Schiff, Elad | Arnon, Zahi | Hahn, Eckhard | Luberto, Christina M. | Martin, David | Schwarz, Silke | Tauschel, Diethard | Flower, Andrew | Gramminger, Harsha | Gupta, Hedwig H. | Gupta, S. N. | Kerckhoff, Annette | Kessler, Christian S. | Michalsen, Andreas | Kessler, Christian S. | Kim, Eun S. | Jang, Eun H. | Kim, Rana | Jan, Sae B. | Mittwede, Martin | Mohme, Wiebke | Ben-Arye, Eran | Bonucci, Massimo | Saad, Bashar | Breitkreuz, Thomas | Rossi, Elio | Kebudi, Rejin | Daher, Michel | Razaq, Samaher | Gafer, Nahla | Nimri, Omar | Hablas, Mohamed | Kienle, Gunver Sophia | Samuels, Noah | Silbermann, Michael | Bandelin, Lena | Lang, Anna-Lena | Wartner, Eva | Holtermann, Christoph | Binstock, Maxwell | Riebau, Robert | Mujkanovic, Edin | Cramer, Holger | Lauche, Romy | Michalsen, Andres | Ward, Lesley | Cramer, Holger | Irnich, Dominik | Stör, Wolfram | Burnstock, Geoffrey | Schaible, Hans-Georg | Ots, Thomas | Langhorst, Jost | Lauche, Romy | Sundberg, Tobias | Falkenberg, Torkel | Amarell, Catherina | Amarell, Catherina | Anheyer, Melanie | Eckert, Marion | Eckert, Marion | Ogal, Mercedes | Eckert, Marion | Amarell, Catherina | Schönauer, Annette | Reisenberger, Birgit | Brand, Bernhard | Anheyer, Dennis | Dobos, Gustav | Kroez, Matthias | Martin, David | Matthes, Harald | Ammendola, Aldo | Mao, Jun J. | Witt, Claudia | Yang, Yufei | Dobos, Gustav | Oritz, Miriam | Horneber, Markus | Voiß, Petra | Reisenberger, Birgit | von Rosenstiel, Alexandra | Eckert, Marion | Ogal, Mercedes | Amarell, Catharina | Anheyer, Melanie | Schad, Friedemann | Schläppi, Marc | Kröz, Matthias | Büssing, Arndt | Bar-Sela, Gil | Matthes, Harald | Schiff, Elad | Ben-Arye, Eran | Arnon, Zahi | Avshalomov, David | Attias, Samuel | Schönauer, Annette | Haramati, Aviad | Witt, Claudia | Brinkhaus, Benno | Cotton, Sian | Jong, Miek | Jong, Mats | Scheffer, Christian | Haramati, Aviad | Tauschel, Diethard | Edelhäuser, Friedrich | AlBedah, Abdullah | Lee, Myeong Soo | Khalil, Mohamed | Ogawa, Keiko | Motoo, Yoshiharu | Arimitsu, Junsuke | Ogawa, Masao | Shimizu, Genki | Stange, Rainer | Kraft, Karin | Kuchta, Kenny | Watanabe, Kenji | Bonin, D | Büssing, Arndt | Gruber, Harald | Koch, Sabine | Gruber, Harald | Pohlmann, Urs | Caldwell, Christine | Krantz, Barbara | Kortum, Ria | Martin, Lily | Wieland, Lisa S. | Kligler, Ben | Gould-Fogerite, Susan | Zhang, Yuqing | Wieland, Lisa S. | Riva, John J. | Lumpkin, Michael | Ratner, Emily | Ping, Liu | Jian, Pei | Hamme, Gesa-Meyer | Mao, Xiaosong | Chouping, Han | Schröder, Sven | Hummelsberger, Josef | Wullinger, Michael | Brodzky, Marc | Zalpour, Christoff | Langley, Julia | Weber, Wendy | Mudd, Lanay M. | Wayne, Peter | Witt, Clauda | Weidenhammer, Wolfgang | Fønnebø, Vinjar | Boon, Heather | Steel, Amie | Bugarcic, Andrea | Rangitakatu, Melisa | Steel, Amie | Adams, Jon | Sibbritt, David | Wardle, Jon | Leach, Matthew | Schloss, Janet | Dieze, Helene | Boon, Heather | Ijaz, Nadine | Willcox, Merlin | Heinrich, Michael | Lewith, George | Flower, Andrew | Graz, Bertrand | Adam, Daniela | Grabenhenrich, Linus | Ortiz, Miriam | Binting, Sylvia | Reinhold, Thomas | Brinkhaus, Benno | Andermo, Susanne | Sundberg, Tobias | Falkenberg, Torkel | Nordberg, Johanna Hök | Arman, Maria | Bhasin, Manoj | Fan, Xueyi | Libermann, Towia | Fricchione, Gregory | Denninger, John | Benson, Herbert | Berger, Bettina | Stange, Rainer | Michalsen, Andreas | Martin, David D. | Boers, Inge | Vlieger, Arine | Jong, Miek | Brinkhaus, Benno | Teut, Michael | Ullmann, Alexander | Ortiz, Miriam | Rotter, Gabriele | Binting, Sylvia | Lotz, Fabian | Roll, Stephanie | Canella, Claudia | Mikolasek, Michael | Rostock, Matthias | Beyer, Jörg | Guckenberger, Matthias | Jenewein, Josef | Linka, Esther | Six, Claudia | Stoll, Sarah | Stupp, Roger | Witt, Claudia M. | Chuang, Elisabeth | Kligler, Ben | McKee, Melissa D. | Cramer, Holger | Lauche, Romy | Klose, Petra | Lange, Silke | Langhorst, Jost | Dobos, Gustav | Chung, Vincent C. H. | Wong, Hoi L. C. | Wu, Xin Y. | Wen, Grace Y. G. | Ho, Robin S. T. | Ching, Jessica Y. L. | Wu, Justin C. Y. | Coakley, Amanda | Flanagan, Jane | Annese, Christine | Empoliti, Joanne | Gao, Zishan | Liu, Xugang | Yu, Shuguang | Yan, Xianzhong | Liang, Fanrong | Hohmann, Christoph D. | Steckhan, Nico | Ostermann, Thomas | Paetow, Arion | Hoff, Evelyn | Michalsen, Andreas | Hu, Xiao-Yang | Wu, Ruo-Han | Logue, Martin | Blonde, Clara | Lai, Lily Y. | Stuart, Beth | Flower, Andrew | Fei, Yu-Tong | Moore, Michael | Liu, Jian-Ping | Lewith, George | Hu, Xiao-Yang | Wu, Ruo-Han | Logue, Martin | Blonde, Clara | Lai, Lily Y. | Stuart, Beth | Flower, Andrew | Fei, Yu-Tong | Moore, Michael | Liu, Jian-Ping | Lewith, George | Jeitler, Michael | Zillgen, Hannah | Högl, Manuel | Steckhan, Nico | Stöckigt, Barbara | Seifert, Georg | Michalsen, Andreas | Kessler, Christian | Khadivzadeh, Talat | Bashtian, Maryam Hassanzadeh | Aval, Shapour Badiee | Esmaily, Habibollah | Kim, Jihye | Kim, Keun H. | Klocke, Carina | Joos, Stefanie | Koshak, Abdulrahman | Wie, Li | Koshak, Emad | Wali, Siraj | Alamoudi, Omer | Demerdash, Abdulrahman | Qutub, Majdy | Pushparaj, Peter | Heinrich, Michael | Kruse, Sigrid | Fischer, Isabell | Tremel, Nadine | Rosenecker, Joseph | Leung, Brenda | Takeda, Wendy | Liang, Ning | Feng, Xue | Liu, Jian-ping | Cao, Hui-juan | Luberto, Christina M. | Shinday, Nina | Philpotts, Lisa | Park, Elyse | Fricchione, Gregory L. | Yeh, Gloria | Munk, Niki | Zakeresfahani, Arash | Foote, Trevor R. | Ralston, Rick | Boulanger, Karen | Özbe, Dominik | Gräßel, Elmar | Luttenberger, Katharina | Pendergrass, Anna | Pach, Daniel | Bellmann-Strobl, Judit | Chang, Yinhui | Pasura, Laura | Liu, Bin | Jäger, Sven F. | Loerch, Ronny | Jin, Li | Brinkhaus, Benno | Ortiz, Miriam | Reinhold, Thomas | Roll, Stephanie | Binting, Sylvia | Icke, Katja | Shi, Xuemin | Paul, Friedemann | Witt, Claudia M. | Rütz, Michaela | Lynen, Andreas | Schömitz, Meike | Vahle, Maik | Salomon, Nir | Lang, Alon | Lahat, Adi | Kopylov, Uri | Ben-Horin, Shomron | Har-Noi, Ofir | Avidan, Benjamin | Elyakim, Rami | Gamus, Dorit | NG, Siew | Chang, Jessica | Wu, Justin | Kaimiklotis, John | Schumann, Dania | Buttó, Ludovica | Langhorst, Jost | Dobos, Gustav | Haller, Dirk | Cramer, Holger | Smith, Caroline | de Lacey, Sheryl | Chapman, Michael | Ratcliffe, Julie | Johnson, Neil | Lyttleton, Jane | Boothroyd, Clare | Fahey, Paul | Tjaden, Bram | van Vliet, Marja | van Wietmarschen, Herman | Jong, Miek | Tröger, Wilfried | Vuolanto, Pia | Aarva, Paulina | Sorsa, Minna | Helin, Kaija | Wenzel, Claudia | Zoderer, Iris | Pammer, Patricia | Simon, Patrick | Tucek, Gerhard | Wode, Kathrin | Henriksson, Roger | Sharp, Lena | Stoltenberg, Anna | Nordberg, Johanna Hök | Xiao-ying, Yang | Wang, Li-qiong | Li, Jin-gen | Liang, Ning | Wang, Ying | Liu, Jian-ping | Balneaves, Lynda | Capler, Rielle | Bocci, Chiara | Guffi, Marta | Paolini, Marina | Meaglia, Ilaria | Porcu, Patrizia | Ivaldi, Giovanni B. | Dragan, Simona | Bucuras, Petru | Pah, Ana M. | Badalica-Petrescu, Marius | Buleu, Florina | Hogea-Stoichescu, Gheorghe | Christodorescu, Ruxandra | Kao, Lan | Cho, Yumin | Klafke, Nadja | Mahler, Cornelia | von Hagens, Cornelia | Uhlmann, Lorenz | Bentner, Martina | Schneeweiss, Andreas | Mueller, Andreas | Szecsenyi, Joachim | Joos, Stefanie | Neri, Isabella | Ortiz, Miriam | Schnabel, Katharina | Teut, Michael | Rotter, Gabriele | Binting, Sylvia | Cree, Margit | Lotz, Fabian | Suhr, Ralf | Brinkhaus, Benno | Rossi, Elio | Baccetti, Sonia | Firenzuoli, Fabio | Monechi, Maria V. | Di Stefano, Mariella | Amunni, Gianni | Wong, Wendy | Chen, Bingzhong | Wu, Justin | Amri, Hakima | Haramati, Aviad | Kotlyanskaya, Lucy | Anderson, Belinda | Evans, Roni | Kligler, Ben | Marantz, Paul | Bradley, Ryan | Booth-LaForce, Cathryn | Zwickey, Heather | Kligler, Benjamin | Brooks, Audrey | Kreitzer, Mary J. | Lebensohn, Patricia | Goldblatt, Elisabeth | Esmel-Esmel, Neus | Jiménez-Herrera, Maria | Ijaz, Nadine | Boon, Heather | Jocham, Alexandra | Stock-Schröer, Beate | Berberat, Pascal O. | Schneider, Antonius | Linde, Klaus | Masetti, Morgana | Murakozy, Henriette | Van Vliet, Marja | Jong, Mats | Jong, Miek | Agdal, Rita | Atarzadeh, Fatemeh | Jaladat, Amir M. | Hoseini, Leila | Amini, Fatemeh | Bai, Chen | Liu, Tiegang | Zheng, Zian | Wan, Yuxiang | Xu, Jingnan | Wang, Xuan | Yu, He | Gu, Xiaohong | Daneshfard, Babak | Nimrouzi, Majid | Tafazoli, Vahid | Alorizi, Seyed M. Emami | Saghebi, Seyed A. | Fattahi, Mohammad R. | Salehi, Alireza | Rezaeizadeh, Hossein | Zarshenas, Mohammad M. | Nimrouzi, Majid | Fox, Kealoha | Hughes, John | Kostanjsek, Nenad | Espinosa, Stéphane | Lewith, George | Fisher, Peter | Latif, Abdul | Lefeber, Donald | Paske, William | Öztürk, Ali Ö. | Öztürk, Gizemnur | Boers, Inge | Tissing, Wim | Naafs, Marianne | Busch, Martine | Jong, Miek | Daneshfard, Babak | Sanaye, Mohammad R. | Dräger, Kilian | Fisher, Peter | Kreitzer, Mary J. | Evans, Roni | Leininger, Brent | Shafto, Kate | Breen, Jenny | Sanaye, Mohammad R. | Daneshfard, Babak | Simões-Wüst, Ana P. | Moltó-Puigmartí, Carolina | van Dongen, Martien | Dagnelie, Pieter | Thijs, Carel | White, Shelley | Wiesener, Solveig | Salamonsen, Anita | Stub, Trine | Fønnebø, Vinjar | Abanades, Sergio | Blanco, Mar | Masllorens, Laia | Sala, Roser | Al-Ahnoumy, Shafekah | Han, Dongwoon | He, Luzhu | Kim, Ha Yun | In Choi, Da | Alræk, Terje | Stub, Trine | Kristoffersen, Agnete | von Sceidt, Christel | Michalsen, Andreas | Bruset, Stig | Musial, Frauke | Anheyer, Dennis | Cramer, Holger | Lauche, Romy | Saha, Felix J. | Dobos, Gustav | Anheyer, Dennis | Haller, Heidemarie | Lauche, Romy | Dobos, Gustav | Cramer, Holger | Azizi, Hoda | Khadem, Nayereh | Hassanzadeh, Malihe | Estiri, Nazanin | Azizi, Hamideh | Tavassoli, Fatemeh | Lotfalizadeh, Marzieh | Zabihi, Reza | Esmaily, Habibollah | Azizi, Hoda | Shabestari, Mahmoud Mohammadzadeh | Paeizi, Reza | Azari, Masoumeh Alvandi | Bahrami-Taghanaki, Hamidreza | Zabihi, Reza | Azizi, Hamideh | Esmaily, Habibollah | Baars, Erik | De Bruin, Anja | Ponstein, Anne | Baccetti, Sonia | Di Stefano, Mariella | Rossi, Elio | Firenzuoli, Fabio | Segantini, Sergio | Monechi, Maria Valeria | Voller, Fabio | Barth, Jürgen | Kern, Alexandra | Lüthi, Sebastian | Witt, Claudia | Barth, Jürgen | Zieger, Anja | Otto, Fabius | Witt, Claudia | Beccia, Ariel | Dunlap, Corina | Courneene, Brendan | Bedregal, Paula | Passi, Alvaro | Rodríguez, Alfredo | Chang, Mayling | Gutiérrez, Soledad | Beissner, Florian | Beissner, Florian | Preibisch, Christine | Schweizer-Arau, Annemarie | Popovici, Roxana | Meissner, Karin | Beljanski, Sylvie | Belland, Laura | Rivera-Reyes, Laura | Hwang, Ula | Berger, Bettina | Sethe, Dominik | Hilgard, Dörte | Heusser, Peter | Bishop, Felicity | Al-Abbadey, Miznah | Bradbury, Katherine | Carnes, Dawn | Dimitrov, Borislav | Fawkes, Carol | Foster, Jo | MacPherson, Hugh | Roberts, Lisa | Yardley, Lucy | Lewith, George | Bishop, Felicity | Al-Abbadey, Miznah | Bradbury, Katherine | Carnes, Dawn | Dimitrov, Borislav | Fawkes, Carol | Foster, Jo | MacPherson, Hugh | Roberts, Lisa | Yardley, Lucy | Lewith, George | Bishop, Felicity | Holmes, Michelle | Lewith, George | Yardley, Lucy | Little, Paul | Cooper, Cyrus | Bogani, Patrizia | Maggini, Valentina | Gallo, Eugenia | Miceli, Elisangela | Biffi, Sauro | Mengoni, Alessio | Fani, Renato | Firenzuoli, Fabio | Brands-Guendling, Nadine | Guendling, Peter W. | Bronfort, Gert | Evans, Roni | Haas, Mitch | Leininger, Brent | Schulz, Craig | Bu, Xiangwei | Wang, J. | Fang, T. | Shen, Z. | He, Y. | Zhang, X. | Zhang, Zhengju | Wang, Dali | Meng, Fengxian | Büssing, Arndt | Baumann, Klaus | Frick, Eckhard | Jacobs, Christoph | Büssing, Arndt | Grünther, Ralph-Achim | Lötzke, Désirée | Büssing, Arndt | Jung, Sonny | Lötzke, Désirée | Recchia, Daniela R. | Robens, Sibylle | Ostermann, Thomas | Berger, Bettina | Stankewitz, Josephin | Kröz, Matthias | Jeitler, Mika | Kessler, Christian | Michalsen, Andreas | Cheon, Chunhoo | Jang, Bo H. | Ko, Seong G. | Huang, Ching W. | Sasaki, Yui | Ko, Youme | Cheshire, Anna | Ridge, Damien | Hughes, John | Peters, David | Panagioti, Maria | Simon, Chantal | Lewith, George | Cho, Hyun J. | Han, Dongwoon | Choi, Soo J. | Jung, Young S. | Im, Hyea B | Cooley, Kieran | Tummon-Simmons, Laura | Cotton, Sian | Luberto, Christina M. | Wasson, Rachel | Kraemer, Kristen | Sears, Richard | Hueber, Carly | Derk, Gwendolyn | Lill, JR | An, Ruopeng | Steinberg, Lois | Rodriguez, Lourdes Diaz | la Fuente, Francisca García-de | De la Vega, Miguel | Vargas-Román, Keyla | Fernández-Ruiz, Jonatan | Cantarero-Villanueva, Irene | Rodriguez, Lourdes Diaz | García-De la Fuente, Francisca | Jiménez-Guerrero, Fanny | Vargas-Román, Keyla | Fernández-Ruiz, Jonatan | Galiano-Castillo, Noelia | Diaz-Saez, Gualberto | Torres-Jimenez, José I. | Garcia-Gomez, Olga | Hortal-Muñoz, Luis | Diaz-Diez, Camino | Dicen, Demijon | Diezel, Helene | Adams, Jon | Steel, Amie | Wardle, Jon | Diezel, Helene | Steel, Amie | Frawley, Jane | Wardle, Jon | Broom, Alex | Adams, Jon | Dong, Fei | Yu, He | Liu, Tiegang | Ma, Xueyan | Yan, Liyi | Wan, Yuxiang | Zheng, Zian | Gu, Xiaohong | Dong, Fei | Yu, He | Wu, Liqun | Liu, Tiegang | Ma, Xueyan | Ma, Jiaju | Yan, Liyi | Wan, Yuxiang | Zheng, Zian | Zhen, Jianhua | Gu, Xiaohong | Dubois, Julie | Rodondi, Pierre-Yves | Edelhäuser, Friedrich | Schwartze, Sophia | Trapp, Barbara | Cysarz, Dirk
doi:10.1186/s12906-017-1782-4
PMCID: PMC5498855
3.  Prevalence and risk factors of obstructive sleep apnea syndrome in a Saudi Arabian population 
Annals of Thoracic Medicine  2017;12(2):88-94.
BACKGROUND:
Obstructive sleep apnea (OSA) is a common disorder worldwide; however, epidemiological studies on its prevalence lack in Saudi Arabia. This study aimed to determine the prevalence and risk factors of OSA in Saudi Arabia.
METHODS:
The study was performed from 2013 to 2015 in two stages. The screening stage was first; a random sample of Saudi employees (n = 2682) 30–60 years of age completed a survey that included the Wisconsin questionnaire. According to these data, the subjects were categorized as habitual, moderate, or nonsnorers (NSs). The confirmatory second stage was a case–control study conducted on 346 individuals selected from each group using polysomnography (PSG).
RESULTS:
In the first stage, the prevalence of habitual snoring was 23.5%, moderate snoring was16.6%, while 59.9% of the sample was NSs. Among the 346 individuals who underwent PSG, a total of 235 (67.9%) subjects had OSA with an apnea-hypopnea index (AHI) of ≥5; 76 (22.0%) had OSA syndrome (OSAS), defined by an AHI of ≥5 plus daytime sleepiness; and 227 (65.6%) had clinically diagnosed OSA syndrome (COSAS), as defined by the American Academy of Sleep Medicine. A conservative estimate of at least 8.8% (12.8% in men and 5.1% in women) was calculated for the overall prevalence of OSA. Similarly, the overall estimated prevalence of OSAS and COSAS was 2.8% (4.0% in men and 1.8% in women) and 8.5% (12.4% in men and 4.8% in women), respectively. A multivariate analysis revealed age, gender, obesity, and hypertension as independent risk factors of OSA.
CONCLUSIONS:
Our study demonstrated that the rate and risk factors of OSA in the Saudi population are similar to those observed in Western studies.
doi:10.4103/1817-1737.203746
PMCID: PMC5399696
Daytime sleepiness; obstructive sleep apnea; prevalence; risk factors; syndrome
4.  Sleep quantity, quality, and insomnia symptoms of medical students during clinical years 
Saudi Medical Journal  2016;37(2):173-182.
Objectives:
To determine sleep habits and sleep quality in medical students during their clinical years using validated measures; and to investigate associations with academic performance and psychological stress.
Methods:
In this cross-sectional study, medical students (n=320) were randomly selected from a list of all enrolled clinical-year students in a Saudi medical school from 2011-2012. Students filled a questionnaire including demographic and lifestyle factors, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, and Perceived Stress Scale.
Results:
Students acquired on average, 5.8 hours of sleep each night, with an average bedtime at 01:53. Approximately 8% reported acquiring sleep during the day, and not during nighttime. Poor sleep quality was present in 30%, excessive daytime sleepiness (EDS) in 40%, and insomnia symptoms in 33% of students. Multivariable regression models revealed significant associations between stress, poor sleep quality, and EDS. Poorer academic performance and stress were associated with symptoms of insomnia.
Conclusion:
Sleep deprivation, poor sleep quality, and EDS are common among clinical years medical students. High levels of stress and the pressure of maintaining grade point averages may be influencing their quality of sleep.
doi:10.15537/smj.2016.2.14288
PMCID: PMC4800917  PMID: 26837401
5.  Risk of obstructive sleep apnea among Saudis with chronic renal failure on hemodialysis 
Annals of Thoracic Medicine  2015;10(4):263-268.
AIM:
The prevalence of obstructive sleep apnea (OSA) in end-stage renal disease (ESRD) patients was reported to be 10-fold that in the general population. OSA can worsen the clinical symptoms and cardiovascular complications of ESRD. We aimed to investigate the prevalence of symptoms and risk of OSA among Saudi patients with ESRD.
SETTINGS AND DESIGN:
This multi-center, cross-sectional study was conducted in Jeddah, Saudi Arabia, between June 2012 and September 2013.
METHODS:
The prevalence of OSA was assessed using the Berlin questionnaire. The presence of daytime sleepiness was evaluated using the Epworth sleepiness scale. Data were also collected on the medical history, clinical, and laboratory findings of participants.
RESULTS:
In all, 355 patients (61% male) were enrolled (mean age: 45.5 ± 15.4 years). The overall prevalence of high-risk of OSA was 44.2% (males, 47.3%; females, 44.8%; P = 0.65). The prevalence of excessive daytime sleepiness (EDS) was 74%. Controlling for age, gender and body mass index, multivariate analysis revealed that hypertension and hepatitis C infection were the only comorbidities significantly associated with OSA (odds ratio [OR]: 3.827 and 0.559; confidence interval [CI]: 2.120-6.906 and 0.324-0.964; P < 0.0001 and 0.036, respectively). OSA was also strongly associated with EDS (OR: 3.054; CI: 1.676-5.565; P < 0.0001).
CONCLUSIONS:
In Saudi Arabia, the risk of OSA is more common in ESRD patients than in the general population. OSA is strongly associated with EDS. Interestingly, a significant negative correlation between OSA and hepatitis C infection was noted, which warrants further investigation.
doi:10.4103/1817-1737.164300
PMCID: PMC4652292  PMID: 26664564
Chronic renal failure; excessive daytime sleepiness; prevalence; risk of obstructive sleep apnea
6.  Prevalence and predictors of habitual snoring in a sample of Saudi middle-aged adults 
Saudi Medical Journal  2015;36(8):920-927.
Objectives:
To determine the prevalence of habitual snoring among a sample of middle-aged Saudi adults, and its potential predictors.
Methods:
A cross-sectional study was conducted from March 2013 until June 2013 in randomly selected Saudi Schools in Jeddah, Kingdom of Saudi Arabia. The enrolled subjects were 2682 school employees (aged 30-60 years, 52.1% females) who were randomly selected and interviewed. The questionnaire used for the interview included: the Wisconsin Sleep Questionnaire to assess for snoring, medical history, and socio-demographic data. Anthropometric measurements and blood pressure readings were recorded using standard methods.
Results:
Forty percent of the 2682 enrolled subjects were snorers: 23.5% were habitual snorers, 16.6% were moderate snorers, and 59.9%, were non-snorers. A multivariate analysis revealed that independent predictors of snoring were ageing, male gender, daytime sleepiness, hypertension, family history of both snoring and obstructive sleep apnea, water-pipe smoking, and consanguinity.
Conclusion:
This study shows that snoring is a common condition among the Saudi population. Previously reported risk factors were reemphasized but consanguinity was identified as a new independent predictive risk factor of snoring. Exploring snoring history should be part of the clinical evaluation.
doi:10.15537/smj.2015.8.11848
PMCID: PMC4549587  PMID: 26219441
7.  Prevalence of restless legs syndrome and associated risk factors among middle-aged Saudi population 
Annals of Thoracic Medicine  2015;10(3):193-198.
BACKGROUND AND AIM:
The prevalence of restless legs syndrome (RLS) in the general population ranges from 5 to 15%; however, locally, such data are scarce. The aim of this study was to estimate the prevalence of RLS in the middle-aged Saudi population.
METHODS:
This was a cross-sectional study that was conducted from February 2013 to June 2013 in Jeddah, Saudi Arabia. The target study population was Saudi school employees. Saudi employees aged 30-60 years were randomly selected and interviewed individually. Trained interviewers completed the Wisconsin Sleep Questionnaire, questions about demographics, the Epworth Sleepiness Scale to measure daytime sleepiness, and questions regarding symptoms of RLS based on the criteria defined by the International Restless Legs Syndrome Study Group (IRLSSG).
RESULTS:
This survey revealed that 8.4% (95% confidence interval (CI): (7.35-9.45)) of the 2,682 participants (62.5% of them were males) had RLS. There was no age effect on the prevalence of RLS. RLS was found to be significantly associated with other sleep disorders, including excessive daytime sleepiness and habitual snoring. A univariate analysis revealed significant correlation of many factors with the RLS, including gender, consanguinity, snoring, diabetes, hypertension, asthma, chronic bronchitis, and smoking. However, when a multivariate logistic regression analysis performed, RLS continued to be associated with male gender, diabetes, asthma, and habitual snoring only.
CONCLUSION:
The prevalence of RLS is 8.4%, which is within the range reported by Western studies. However, unlike findings of most studies, RLS significantly affects males more than females. In addition, snoring, asthma, and consanguinity are potential new risk factors for RLS.
doi:10.4103/1817-1737.160839
PMCID: PMC4518350  PMID: 26229562
Prevalence; restless legs syndrome; risk factors
8.  Prevalence of obstructive sleep apnea among patients with coronary artery disease in Saudi Arabia 
Background
Despite the association between obstructive sleep apnea (OSA) and coronary artery disease (CAD), few studies have investigated this issue in Saudi Arabia.
Objectives
This study aimed to identify the prevalence of OSA among CAD patients.
Subjects and methods
This was a cross-sectional (descriptive) study conducted at King Abdul-Aziz University Hospital in Jeddah, Saudi Arabia from April 2012 to December 2013. All consecutive patients referred to the cardiac catheterization lab for coronary angiography who exhibited evidence of CAD were included in this study. This study was conducted in two stages. During the first stage, each participant was interviewed individually. The administered interview collected data pertaining to demographics, comorbidities, and the STOP-BANG questionnaire score. The second stage of this study consisted of a diagnostic overnight polysomnography (PSG) of 50% of the subjects at high risk for OSA according to the STOP-BANG questionnaire.
Results
Among the patients with CAD (N = 156), 128 (82%) were categorized as high risk for developing OSA. PSG was conducted on 48 patients. The estimated prevalence of OSA in the study sample was 56.4%. Approximately 61% of the documented sleep apnea patients suffered from moderate to severe OSA.
Conclusion
This local study concurs with reports in the literature indicating that OSA is very common among CAD patients.
doi:10.1016/j.jsha.2015.03.004
PMCID: PMC4614902  PMID: 26557740
Sleep apnea; Coronary artery disease; Prevalence; Severity
9.  Restless legs syndrome among Saudi end-stage renal disease patients on hemodialysis 
Saudi Medical Journal  2015;36(2):204-210.
Objectives:
To determine the prevalence of restless legs syndrome (RLS) in Saudi patients with end-stage renal disease (ESRD) on hemodialysis.
Methods:
A cross-sectional study was carried out in 3 hemodialysis centers in Jeddah, Saudi Arabia, between June 2012 and September 2013. All patients were individually interviewed and data was collected on the following demographic features, medical history, laboratory test, the International Restless Legs Syndrome Study Group questionnaire, Epworth Sleepiness Scale (ESS), and Berlin Questionnaire.
Results:
Three hundred and fifty-five patients were recruited. The prevalence of RLS among ESRD patients was 19.4%, with most patients having moderate to severe disease. The RLS was significantly associated with obstructive sleep apnea (p<0.0001) and excessive daytime sleepiness based on the ESS (p=0.009). The RLS showed no correlation with hemodialysis adequacy, chronicity, frequency per week, and hemodialysis duration per session; however, there was a weak negative relation between adequacy of hemodialysis and RLS severity. None of the comorbidities showed any association with RLS. The odds of developing RLS increased significantly with an increasing body mass index (p=0.001). Administration of aspirin (p=0.037) and anticoagulants (p=0.035) were also associated with increased risk of RLS.
Conclusion:
Restless legs syndrome is common in ESRD patients on hemodialysis, and it is an important source of sleep disruption. In addition to body mass index, Aspirin and anticoagulants may be important risk factors.
doi:10.15537/smj.2015.2.10036
PMCID: PMC4375699  PMID: 25719586
10.  Idiopathic pulmonary fibrosis in Saudi Arabia: Demographic, clinical, and survival data from two tertiary care hospitals 
Annals of Thoracic Medicine  2014;9(3):168-172.
BACKGROUND:
Idiopathic pulmonary fibrosis (IPF) is rare and can be challenging to diagnose. Limited data is available from the Middle Eastern region, especially Saudi Arabia.
METHODS:
This was a retrospective study that looked at all the patients diagnosed with IPF between 2007 and 2012 at two tertiary care hospitals in Saudi Arabia. We collected the demographical, clinical, laboratory and radiological data from the patients’ medical records. Medications administered and 1 year survival was also assessed.
RESULTS:
Between 2007and 2012, 134 IPF patients were identified. Their baseline characteristics (Mean ± SD) included: age 64 ± 13 years, body mass index 29 ± 8 kg/m2, FEV1 56 ± 15 percent of predicted, FVC 53 ± 13 percent of predicted, FEV1/FVC 0.81 ± 0.09, total lung capacity 75 ± 13 percent of predicted, diffusing capacity of the lung for carbon monoxide 57 ± 15 percent of predicted, on home oxygen at presentation 71 (53%), mean ejection fraction 0.50 ± 0.07, mean pulmonary artery systolic pressure (via echocardiogram) 40 + 22 mmHg, presentation mean SpO292 ± 7%, presentation 6-min walk distance 338 ± 64 m and lowest SpO2 during 6-min walk test 88 ± 5%. Patients were predominantly female (56%), and 42% of patients had diabetes and were active smokers. The IPF patients’ frequency of hospital admission (n = 99) was 2.4 ± 1.7 per year and duration of hospital stay (n = 99) was 17.4 ± 23.8 days. Overall 1 year survival in all IPF patients was good, 93% (124) patients remained alive after 1 year.
CONCLUSIONS:
In Saudi Arabia, IPF patients tended to be slightly older and the disease progression was somewhat slower than reported IPF cohorts in other populations. They had frequent hospital admissions and a long hospital length of stay. The influence of genetics and co-morbid diseases on the incidence and outcome of IPF should be explored further.
doi:10.4103/1817-1737.134073
PMCID: PMC4073575  PMID: 24987477
Characteristics; idiopathic pulmonary fibrosis; survival; Saudi Arabia
11.  The Saudi Guidelines for the Diagnosis and Management of COPD 
Annals of Thoracic Medicine  2014;9(2):55-76.
The Saudi Thoracic Society (STS) launched the Saudi Initiative for Chronic Airway Diseases (SICAD) to develop a guideline for the diagnosis and management of chronic obstructive pulmonary disease (COPD). This guideline is primarily aimed for internists and general practitioners. Though there is scanty epidemiological data related to COPD, the SICAD panel believes that COPD prevalence is increasing in Saudi Arabia due to increasing prevalence of tobacco smoking among men and women. To overcome the issue of underutilization of spirometry for diagnosing COPD, handheld spirometry is recommended to screen individuals at risk for COPD. A unique feature about this guideline is the simplified practical approach to classify COPD into three classes based on the symptoms as per COPD Assessment Test (CAT) and the risk of exacerbations and hospitalization. Those patients with low risk of exacerbation (<2 in the past year) can be classified as either Class I when they have less symptoms (CAT < 10) or Class II when they have more symptoms (CAT ≥ 10). High-risk COPD patients, as manifested with ≥2 exacerbation or hospitalization in the past year irrespective of the baseline symptoms, are classified as Class III. Class I and II patients require bronchodilators for symptom relief, while Class III patients are recommended to use medications that reduce the risks of exacerbations. The guideline recommends screening for co-morbidities and suggests a comprehensive management approach including pulmonary rehabilitation for those with a CAT score ≥10. The article also discusses the diagnosis and management of acute exacerbations in COPD.
doi:10.4103/1817-1737.128843
PMCID: PMC4005164  PMID: 24791168
Chronic bronchitis; chronic obstructive pulmonary disease; emphysema; guidelines; Saudi Arabia
12.  Effect of on-call-related sleep deprivation on physicians’ mood and alertness 
Annals of Thoracic Medicine  2013;8(1):22-27.
BACKGROUND AND OBJECTIVE:
Physicians may experience periods of acute sleep deprivation while on-call, in addition to baseline chronic sleep deprivation which may affect physicians’ performance and patients’ safety. The purpose of this study was to determine the effect of acute sleep deprivation due to working long on-call shifts on mood and alertness, both of which may impair physicians’ performance.
METHODS:
Eighty-eight junior physicians working in one university hospital completed a questionnaire, before and after completion of a shift, that collected data regarding socio-demographic factors, patterns of work and sleep, Profile of Mood States (POMS), and Stanford Sleepiness Scale. Based on duration of sleep the physicians had during on-call in comparison to their usual average sleep, the participants were categorized into group 1 (those who slept many fewer hours), group 2 (those who slept fewer hours), or group 3 (those who slept the same number of hours).
RESULTS:
More than 87% of the participant slept 5 or fewer hours while working an on-call shift. Among all participants, the percentage of physicians who were alert post-on-call was significantly reduced compared to the percentage pre-on-call (P = 0.001). The post-on-call total POMS scores of groups 1 and 2 were significantly worse than their pre-on-call scores (P = 0.001 and 0.038, respectively), while there was no significant difference between the pre- and post-on-call POMS scores of group 3 (P = 0.165).
CONCLUSION:
Acute sleep loss due to working long on-call shifts significantly decreases daytime alertness and negatively affects the mood state of junior physicians.
doi:10.4103/1817-1737.105715
PMCID: PMC3573553  PMID: 23439930
Acute sleep deprivation; alertness; profile of mood states; sleepiness
13.  An update on the drainage of pyogenic lung abscesses 
Most lung abscesses (80–90%) are now successfully treated with antibiotics; however, this conservative approach may occasionally fail. When medical treatment fails, pulmonary resection is usually advised. Alternatively, percutaneous transthoracic tube drainage or endoscopic drainage can be considered, though both remain controversial. In this communication, the medical literature focusing on percutaneous tube drainage efficacy, indications, techniques, complications, and mortality, as well as available data regarding endoscopic drainage are reviewed.
doi:10.4103/1817-1737.91552
PMCID: PMC3277038  PMID: 22347342
Percutaneous drainage; pyogenic lung abscess; endoscpoic drainage
14.  Prevalence of chronic obstructive pulmonary disease among smokers attending primary healthcare clinics in Saudi Arabia 
Annals of Saudi Medicine  2011;31(2):129-133.
BACKGROUND AND OBJECTIVES:
The prevalence of chronic obstructive pulmonary disease (COPD) in Saudi Arabia is unknown. The aim of this study was to estimate the prevalence of COPD among smokers more than 40 years of age attending primary healthcare clinics in Saudi Arabia.
DESIGN AND SETTING:
A questionnaire was used in a cross-sectional collection of demographic data and other items related to diagnosis of COPD in patients visiting primary healthcare clinics.
METHODS:
Eligible subjects were current or ex-smokers and aged 40 years or above. Spirometry was performed according to American Thoracic Society criteria. Airflow obstruction was classified according to the 2003 update of the World Health Organization and Global Initiative for Chronic Obstructive Lung Disease criteria. COPD was defined as a ratio less than 0.70 of post-bronchodilator-predicted forced expiratory volume in the first second to forced vital capacity (FEV1/FVC <0.70).
RESULTS:
Because of incomplete data or poor performance on spirometry, of 1380 subjects eligible for the study, only 501 subjects were eligible for data analysis. Seventy-one patients had an FEV1/FVC ratio <0.70, comprising 14.2% of the study population, of which 95.8% were males. Current smokers comprised 57 (80.3%) subjects. Of the 71 subjects who fulfilled the criteria for COPD diagnosis, none were found to be in COPD stage I; 40 (56.3%) were in stage II and 31 (43.6%) were in stage III of the disease.
CONCLUSION:
Underdiagnosis of COPD in primary healthcare clinics in Saudi Arabia is common, but its extent is not different from the corresponding data available in the literature for other countries. Use of spirometry as a routine test for all patients older than 40 years of age and with a smoking history can help in early detection and proper diagnosis of COPD, which subsequently will help in implementation of preventive measures.
doi:10.4103/0256-4947.77485
PMCID: PMC3102470  PMID: 21403413
15.  Author's reply 
Annals of Thoracic Medicine  2010;5(1):55-56.
PMCID: PMC2841815  PMID: 20351966
16.  Mycobacterium chelonae empyema with bronchopleural fistula in an immunocompetent patient 
Annals of Thoracic Medicine  2009;4(4):213-215.
Mycobacterium chelonae is one of the rapidly growing mycobacteria that rarely cause lung disease. M chelonae more commonly causes skin and soft tissue infections primarily in immunosuppressed individuals. Thoracic empyema caused by rapidly growing mycobacteria and complicated with bronchopleural fistula is rarely reported, especially in immunocompetent patients. In this article we report the first immunocompetent Arabian patient presented with M chelonae-related empyema with bronchopleural fistula which mimics, clinically and radiologically, empyema caused by Mycobacterium tuberculosis.
doi:10.4103/1817-1737.56004
PMCID: PMC2801048  PMID: 19881169
Bronchopleural fistula; empyema; Mycobacterium chelonae; nontuberculous mycobacteria; rapidly growing mycobacteria
17.  The presence of atypical mycobacteria in the mouthwashes of normal subjects: Role of tap water and oral hygiene 
BACKGROUND:
The nontuberculous mycobacteria (NTM) have been found in different environmental sources. They tend to colonize different body surfaces and secretions. The purpose of this study is to evaluate the presence of NTM in the oral cavity of healthy individuals and its relationship to tap water or oral hygiene.
MATERIALS AND METHODS:
One hundred sixty-seven healthy subjects were recruited. Three consecutive early morning mouthwashes using tap water were performed and examined for the presence of Mycobacterium tuberculosis (MTB) and NTM. In addition we obtained mouthwashes from 30 control healthy individuals with good oral hygiene using sterile water and examined these for the presence of MTB and NTM.
RESULTS:
NTM was isolated from the mouthwash of 44 (26.3%) subjects that used tap water. On the other hand, NTM was isolated from the mouthwash of 10 (33%) subjects that used sterile water. Age, gender, social class oral hygiene and the regular use of toothbrush made no statistically significant differences in the isolation rate of NTM.
CONCLUSION:
The rate of isolation of NTM from mouthwash is high in normal subjects. It is independent of oral hygiene, the use of tap water or teeth brushing. Smear-positive sputum could be NTM rather than M. tuberculosis. Tuberculosis polymerase chain reaction or culture confirmation is essential in developing countries to avoid the unnecessary use of antituberculosis therapy when the clinical suspicion is very low.
doi:10.4103/1817-1737.37890
PMCID: PMC2700426  PMID: 19561875
Mycobacterial isolates; nontuberculous mycobacteria; oral flora; oral hygiene
18.  Update on pleural diseases - 2007 
Annals of Thoracic Medicine  2007;2(3):128-142.
BACKGROUND:
New information is available on pleural diseases. The authors selected articles to make recommendations on diagnostic and treatment aspects of pleural diseases.
MATERIALS AND METHODS:
Eleven articles published in the English language between 2004 and 2007 were chosen. The basis of selection of the articles was the impact on daily practice, change in prior thinking of a disease process or specific treatment modality, as well as proper design and execution of the study. 5-amino-laevulinic acid with fluorescent light combined with white light may allow further diagnostic yield in undiagnosed pleural disease. FDG-PET may allow prognostication of patients with pleural tumors. Utilizing ultrasound by trained Emergency Department physicians is a rapid and effective technique to evaluate non-traumatic pleural effusions in symptomatic patients. Serum osteopontin levels may distinguish patients exposed to asbestos with benign disease from those with pleural mesothelioma. Administration of streptokinase in patients with empyema does not need for surgical drainage, length of hospital stay, or mortality as compared to conventional treatment with chest tube drainage and intravenous antibiotics. Silver nitrate may be an alternative agent to talc for producing pleurodesis. Routine use of graded talc (50% particles greater than 25 microns) is recommended to reduce the morbidity associated with talc pleurodesis. Study design does not permit us to conclude that aspiration of spontaneous pneumothorax is as effective as chest tube drainage. Pleural catheter may prove to be an important palliative modality in treating debilitated patients or patients with trapped lung who show symptomatic improvement with drainage; however, at the present time, these catheters cannot be considered a first line treatment option for patients with malignant pleural effusion. One of the studies reviewed showed no significant difference in tract metastasis in patients with malignant mesothelioma undergoing an invasive pleural procedure with or without irradiation to the procedure site. However, the design of the trial does not allow us to make this conclusion at the present time.
doi:10.4103/1817-1737.33704
PMCID: PMC2732091  PMID: 19727362
Pleural; empyema; effusions; mesothelioma; ultrasound; pleurodesis; pneumothorax; thoracoscopy

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