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51.  Corticosteroids in the treatment of acute asthma 
Annals of Thoracic Medicine  2014;9(4):187-192.
Asthma is a prevalent chronic disease of the respiratory system and acute asthma exacerbations are among the most common causes of presentation to the emergency department (ED) and admission to hospital particularly in children. Bronchial airways inflammation is the most prominent pathological feature of asthma. Inhaled corticosteroids (ICS), through their anti-inflammatory effects have been the mainstay of treatment of asthma for many years. Systemic and ICS are also used in the treatment of acute asthma exacerbations. Several international asthma management guidelines recommend the use of systemic corticosteroids in the management of moderate to severe acute asthma early upon presentation to the ED. On the other hand, ICS use in the management acute asthma has been studied in different contexts with encouraging results in some and negative in others. This review sheds some light on the role of systemic and ICS in the management of acute asthma and discusses the current evidence behind their different ways of application particularly in relation to new developments in the field.
doi:10.4103/1817-1737.140120
PMCID: PMC4166064  PMID: 25276236
Acute asthma; emergency department; inhaled corticosteroids; systemic corticosteroids
52.  Pictorial review of intrathoracic manifestations of progressive systemic sclerosis 
Annals of Thoracic Medicine  2014;9(4):193-202.
Intra-thoracic manifestations of progressive systemic sclerosis (PSS) are not well known particularly the imaging features, which forms the basis of accurate and timely diagnosis. The aim of this study is to familiarize the physicians and radiologists with these features. The diagnosis can remain elusive because of the non-specific nature of symptoms which mimic many common conditions. Thus, the diagnosis of PSS can be missed leading to continuous morbidity if the correct imaging is not pursued. The authors examined the records of rheumatology patient referrals of over a 5 year period. A hundred and seventy patients with systemic sclerosis and mixed connective tissue disorders were chosen for detailed study of the imaging available, which form the basis of this review. The images included conventional chest radiographs, digital radiographs computed radiography (CT) and high resolution computed tomography (HRCT). Where applicable computed pulmonary angiography (CTPA) and radionuclide scans were also interrogated.
doi:10.4103/1817-1737.140121
PMCID: PMC4166065  PMID: 25276237
Imaging; mixed connective tissue disorders; progressive systemic sclerosis; systemic sclerosis
53.  Pressure-controlled versus volume-controlled ventilation during one-lung ventilation in elderly patients with poor pulmonary function 
Annals of Thoracic Medicine  2014;9(4):203-208.
OBJECTIVE:
The aim was to investigate the effects of two different ventilatory strategies: Pressure-controlled ventilation (PCV) versus volume-controlled ventilation (VCV) in elderly patients with poor pulmonary function during one-lung ventilation (OLV).
PATIENTS AND METHODS:
The patients were enrolled into the study having poor pulmonary function (forced expiratory volume in 1 s <1.5 L) and undergoing radical resection of pulmonary carcinoma requiring at least 2 h of OLV. Patients were respectively allocated to VCV group and PCV group. The intraoperative data, arterial, and mixed venous blood gases were obtained at baseline, 20, 40, 60, 80, 100 and 120 min after OLV and end of surgery. The postoperative data had been recorded and arterial gas measurements were performed at 6, 12 and 24 h after surgery in Intensive Care Unit.
RESULTS:
Comparison of the VCV group and PCV group, PaO2 and P(A-a)O2 were higher and dead space to tidal volume was lower in the PCV group (P < 0.05) after the point of OLV +60, Ppeak was higher in the VCV group (P < 0.05). There were significant advantages in PCV groups with regard to the PaO2 of three points in postoperation, the duration of postoperative ventilation duration, intensive care duration of stay and the days stay in hospital after surgery.
CONCLUSIONS:
The use of PCV compared with VCV during OLV in elderly patients with poor pulmonary function has significant advantages of intraoperative and postoperative oxygenation and it might be a factor, which can beneficial to postoperative recovery.
doi:10.4103/1817-1737.140125
PMCID: PMC4166066  PMID: 25276238
Aged; one-lung ventilation; pressure-controlled ventilation; pulmonary function; volume-controlled ventilation
54.  Pulmonary arterial hypertension in Saudi Arabia: Patients' clinical and physiological characteristics and hemodynamic parameters. A single center experience 
Annals of Thoracic Medicine  2014;9(4):209-215.
AIMS:
The main objective of this study is to describe patients' clinical characteristics and physiological and hemodynamic parameters at the time of diagnosis in a pulmonary hypertension center in Saudi Arabia.
MATERIALS AND METHODS:
This study reports the results from a single pulmonary hypertension specialized center in Riyadh, Saudi Arabia, namely Prince Sultan Medical Military City/Cardiac Center (PSMMC & CC). Both newly diagnosed (incidence) and referred (prevalence) cases of pulmonary arterial hypertension are included. All characteristics, including clinical, physiological, and hemodynamic parameters at the time of diagnosis are described.
RESULTS:
A total of 107 patients were identified as having pulmonary arterial hypertension as diagnosed by right heart catheterization. The mean age at diagnosis was 36 (± 9) years, and there was a female preponderance of 62.6%. The mean duration between symptom onset and diagnosis was 27.8 (± 9.0) months. At the time of enrollment, 56.1% of patients were in functional class III and 16.8% were in functional class IV. Fifty five patients (51.4%) were diagnosed as idiopathic pulmonary arterial hypertension, 29 patients (27.1%) as congenital heart disease associated with pulmonary arterial hypertension, 16 patients (15.0%) as connective tissue diseases associated with pulmonary arterial hypertension, 4 patients (3.7%) as heritable pulmonary arterial hypertension, and 3 patients (2.8%) as portopulmonary hypertension.
CONCLUSION:
This data highlights the current situation of pulmonary arterial hypertension in Saudi Arabia. Our patients are much younger than patients described in other international registries but still detected as late in the course of the disease. A majority of patients displays severe functional and hemodynamic compromise.
doi:10.4103/1817-1737.140127
PMCID: PMC4166067  PMID: 25276239
Hemodynamics; pulmonary arterial hypertension; registry; Saudi Arabia; Saudi association for pulmonary hypertension; six minute walk test
55.  Allergic bronchopulmonary aspergillosis: A clinical review of 24 patients: Are we right in frequent serologic monitoring? 
Annals of Thoracic Medicine  2014;9(4):216-220.
BACKGROUND:
Allergic Broncho Pulmonary Aspergillosis (ABPA) is a rare disease characterized by an allergic inflammatory response to the colonization by aspergillus or other fungi in the airways. The aim was to study the clinical, radiological, and serological characteristics of patients of ABPA.
MATERIALS AND METHODS:
A prospective observational study of patients with breathlessness, chronic cough, blood eosinophilia, and infiltrates on chest X-ray were evaluated with serologic and allergic skin fungal tests using 15 common fungal antigens. Total of 24 patients were diagnosed as ABPA.
RESULTS:
Total 24 patients, 15 males (62%), 9 females (38%). Age range: 14-70 years, mean 49.13, standard deviation (SD) 14.12. Central bronchiectasis — sixteen patients, bronchocoele — one patient, consolidation — five patients, collapse with mucous plugging with areas of consolidation — three patients, one patient had bronchiectasis, consolidation with hemorrhagic pleural effusion. Fifty-eight percent of patients had received anti-tuberculosis medications prior to diagnosis. Serum total IgE varied from 340 to 18100 IU/mL. Two patients had IgE levels below 1,000 IU/mL. The mean decrease in Serum total IgE levels at the end of 1 month was 26.1% (range: 0.7-71.9%) and at the end of 2 months was 58.9% (range: 11.11-93.26%) (P value of 0.004). Two patients had skin sensitivity to fungal antigens other than aspergillus species.
CONCLUSION:
ABPA is a disease with varied clinical, radiological, and serological patterns. Serum IgE monitoring may be done at the end of 2 and 6 months. Further studies are required to simplify the diagnosis and treatment algorithms in resource-limited countries.
doi:10.4103/1817-1737.140130
PMCID: PMC4166068  PMID: 25276240
Allergic; aspergillosis; bronchopulmonary; radiological; serological
56.  Association of compliance of ventilator bundle with incidence of ventilator-associated pneumonia and ventilator utilization among critical patients over 4 years 
Annals of Thoracic Medicine  2014;9(4):221-226.
BACKGROUND:
Several studies showed that the implementation of the Institute for Healthcare Improvement (IHI) ventilator bundle alone or with other preventive measures are associated with reducing Ventilator-Associated Pneumonia (VAP) rates. However, the association with ventilator utilization was rarely examined and the findings were conflicting. The objectives were to validate the bundle association with VAP rate in a traditionally high VAP environment and to examine its association with ventilator utilization.
MATERIALS AND METHODS:
The study was conducted at the adult medical-surgical intensive care unit (ICU) at King Abdulaziz Medical City, Saudi Arabia, between 2010 and 2013. VAP data were collected by a prospective targeted surveillance as per Centers for Disease Control and Prevention (CDC)/National Healthcare Safety Network (NHSN) methodology while bundle data were collected by a cross-sectional design as per IHI methodology.
RESULTS:
Ventilator bundle compliance significantly increased from 90% in 2010 to 97% in 2013 (P for trend < 0.001). On the other hand, VAP rate decreased from 3.6 (per 1000 ventilator days) in 2010 to 1.0 in 2013 (P for trend = 0.054) and ventilator utilization ratio decreased from 0.73 in 2010 to 0.59 in 2013 (P for trend < 0.001). There were negative significant correlations between the trends of ventilator bundle compliance and VAP rate (cross-correlation coefficients −0.63 to 0.07) and ventilator utilization (cross-correlation coefficients −0.18 to −0.63).
CONCLUSION:
More than 70% improvement of VAP rates and approximately 20% improvement of ventilator utilization were observed during IHI ventilator bundle implementation among adult critical patients in a tertiary care center in Saudi Arabia. Replicating the current finding in multicenter randomized trials is required before establishing any causal link.
doi:10.4103/1817-1737.140132
PMCID: PMC4166069  PMID: 25276241
Bundle; health-care-associated infection; Institute for Healthcare Improvement; quality improvement; ventilator-associated pneumonia; ventilator utilization
57.  18F-FDG PET/CT rarely provides additional information other than primary tumor detection in patients with pulmonary carcinoid tumors 
Annals of Thoracic Medicine  2014;9(4):227-231.
AIM:
The purpose of this study was to assess the contribution of 18F-fluorodeoxyglucose (FDG) Positron Emission Tomography (PET)/Computed Tomography (CT) in detection and staging of pulmonary carcinoid tumors.
METHODS:
A total of 22 patients with pulmonary carcinoid tumors (14 typical, 8 atypical) were reviewed in this retrospective study. PET/CT images of all patients were evaluated for primary tumor as well as metastatic regional lymph nodes, bone and other distant metastases. PET/CT positivity of primary tumors was determined by visual interpretation. Tumor size, SUVmax and Hounsfield Unit (HU) values of the tumors were used to test for differences between tumor groups (typical carcinoids and atypical carcinoids).
RESULTS:
SUVmax of carcinoids ranged from 1.24 to 11.1 (mean, 5.0; median, 2.67). The mean largest diameter of primary tumors was 2.7 ± 1.3 cm, ranging from 1 to 5.5 cm. The overall sensitivity of FDG PET/CT for detection of pulmonary carcinoid tumors was 81.8%. Tumor size, SUVmax and Hounsfield Unit (HU) values of the atypical carcinoids were higher than those for typical carcinoids. However, the results were not statistically meaningful (P > 0.05). The sensitivity and specificity of FDG PET/CT in the detection of mediastinal and hilar lymph nodes metastases were 25% and 83% respectively. One patient had bone metastasis.
CONCLUSION:
Although FDG PET/CT can be a useful tool for the detection of pulmonary carcinoid tumors and distant metastasis, it cannot discriminate typical carcinoids from atypical ones and absence of an FDG avid lesion cannot exclude pulmonary carcinoid tumors. Moreover, PET/CT is not a reliable tool in the staging of mediastinal and hilar lymph nodes especially for those patients with typical carcinoids.
doi:10.4103/1817-1737.140134
PMCID: PMC4166070  PMID: 25276242
FDG PET/CT; pulmonary carcinoid tumor; synchronous pulmonary carcinoids
58.  Value of neutrophil/lymphocyte ratio in the differential diagnosis of sarcoidosis and tuberculosis 
Annals of Thoracic Medicine  2014;9(4):232-235.
INTRODUCTION:
The differential diagnosis of sarcoidosis creates a challange due to tuberculosis also having lung and lymph node involvement. Because both diseases show granulomatous inflammation, it may not be possible to distinguish tuberculosis and sarcoidosis in pathological specimens. As a result of the complexity in the differential diagnosis of sarcoidosis and tuberculosis, new markers for differentiation are being investigated.
OBJECTIVE:
The aim of our study is to investigate the value of neutrophil/lymphocyte ratio (NLR) as a possible marker in differentiating sarcoidosis and tuberculosis.
MATERIALS AND METHODS:
In our study, 51 acid-fast bacilli (AFB) positive and/or culture-positive patients with pulmonary tuberculosis, ​​40 patients with biopsy-proven sarcoidosis and a control group consisting of 43 patients were included. In our study, information was collected retrospectively based on hospital records.
RESULTS:
Leukocyte and neutrophil counts, NLR, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) were significantly higher, and albumin was significantly lower in the tuberculosis group compared with sarcoidosis (for all parameters P < 0.001). The most appropriate cut-off value of NLR to distinguish tuberculosis from sarcoidosis was determined as 2.55. For this cut-off value of NLR there was 79% sensitivity, 69% specificity, 73% positive predictive value (PPV), 75% negative predictive value (NPV), and area under the curve (AUC) was 0.788. For differentiation of sarcoidosis from tuberculosis, accuracy of the NLR test according to this cut-off value was found as 76%.
CONCLUSION:
NLR as a little known marker in respiratory medicine was found to be supportive in differentiation of tuberculosis and sarcoidosis. More studies on this issue is needed.
doi:10.4103/1817-1737.140135
PMCID: PMC4166071  PMID: 25276243
Granulomatous inflammation; neutrophil-lymphocyte ratio; sarcoidosis; tuberculosis
59.  Prevalence of sleep-related accidents among drivers in Saudi Arabia 
Annals of Thoracic Medicine  2014;9(4):236-241.
INTRODUCTION:
The prevalence of sleepy driving and sleep-related accidents (SRA) varies widely, and no data exist regarding the prevalence of sleepy driving in Saudi Arabia. Therefore, this study was designed to determine the prevalence and predictors of sleepy driving, near-misses, and SRA among drivers in Saudi Arabia.
MATERIALS AND METHODS:
A questionnaire was developed to assess sleep and driving in detail based on previously published data regarding sleepy driving. The questionnaire included 50 questions addressing socio-demographics, the Epworth Sleepiness Scale (ESS), driving items, and the Berlin Questionnaire. In total, 1,219 male drivers in public places were interviewed face-to-face.
RESULTS:
The included drivers had a mean age of 32.4 ± 11.7 years and displayed a mean ESS score of 7.2 ± 3.8. Among these drivers, 33.1% reported at least one near-miss accident caused by sleepiness. Among those who had actual accidents, 11.6% were attributed to sleepiness. In the past six months, drivers reported the following: 25.2% reported falling asleep at least once during, driving and 20.8% had to stop driving at least once because of severe sleepiness. Young age, feeling very sleepy during driving, and having at least one near-miss accident caused by sleepiness in the past six months were the only predictors of accidents.
CONCLUSION:
Sleepy driving is prevalent among male drivers in Saudi Arabia. Near-miss accidents caused by sleepiness are an important risk factor for car accidents and should be considered as a strong warning signal of future accidents.
doi:10.4103/1817-1737.140138
PMCID: PMC4166072  PMID: 25276244
Accidents; drowsiness; near-miss accidents; sleepiness; sleepy driving
60.  Hemoptysis due to pulmonary pseudosequestration secondary to gastro-pulmonary fistula after a revisional bariatric operation 
Annals of Thoracic Medicine  2014;9(4):242-244.
We report the case of a patient with a history of a complicated revisional bariatric operation who developed a lung pseudosequestration secondary to a gastro-pulmonary fistula. As the patient presented with recurrent hemoptysis, she was initially submitted to embolization of the aberrant vessels and later to a definite operation, which consisted on a diversion of the gastric fistula into a Roux-en-Y intestinal loop. It is an exceptional case about late complications of bariatric surgery, and it underlines the importance of discarding these complications even when the clinical manifestations affect another anatomic region different from the operated abdomen.
doi:10.4103/1817-1737.140141
PMCID: PMC4166073  PMID: 25276245
Bariatric surgery complications; gastrobronchial fistula; gastric mucocele; lung pseudosequestration
61.  Recurrent intrathoracic solitary fibrous tumor: Remarkable response to radiotherapy 
Annals of Thoracic Medicine  2014;9(4):245-247.
Solitary Fibrous Tumor of the Pleura (SFTP) is an uncommon neoplasm which grows slowly. For some cases, surgery is warranted. However, for unresectable ones, the standard strategy has not been established yet. We presented a rare case of recurrent malignant intrathoracic solitary fibrous tumor. It was impossible to resect the tumor. Radiotherapy alone achieved a significant improvement effect.
doi:10.4103/1817-1737.140142
PMCID: PMC4166074  PMID: 25276246
Radiotherapy; recurrent; solitary fibrous tumor of the pleura
63.  Improving the care of sepsis: Between system redesign and professional responsibility: A roundtable discussion in the world sepsis day, September 25, 2013, Riyadh, Saudi Arabia 
Annals of Thoracic Medicine  2014;9(3):134-137.
This paper summarizes the roundtable discussion in September 25, 2013, Riyadh, Saudi Arabia as part of the World Sepsis Day held in King Abdulaziz Medical City, Riyadh. The objectives of the roundtable discussion were to (1) review the chasm between the current management of sepsis and best practice, (2) discuss system redesign and role of the microsystem in sepsis management, (3) emphasize the multidisciplinary nature of the care of sepsis and that improvement of the care of sepsis is the responsibility of all, (4) discuss the bundle concept in sepsis management, and (5) reflect on the individual responsibility of the health care team toward sepsis with a focus on accountability and the moral agent.
doi:10.4103/1817-1737.134066
PMCID: PMC4073568  PMID: 24987470
Accountability; moral responsibility; sepsis bundle; World Sepsis Day
64.  Save or sacrifice the internal mammary pedicle during anterior mediastinotomy? 
Annals of Thoracic Medicine  2014;9(3):138-143.
Ligation and dissection of internal mammary vessels is the most under-estimated complication of anterior mediastinotomy. However, patients requiring anterior mediastinotomy may experience long survival that makes the development of ischemic heart disease throughout their life possible. Therefore, the un-judicial sacrifice of the internal mammary pedicle may deprive them from the benefit to have their internal mammary artery used as a graft in order to successfully bypass severe left anterior descending artery stenoses. We recommend the preservation of the internal mammary pedicle during anterior mediastinotomy, which should be a common message among our colleagues from the beginning of their training.
doi:10.4103/1817-1737.134067
PMCID: PMC4073569  PMID: 24987471
Anterior mediastinotomy; coronary artery disease; internal mammary artery graft; lung cancer; mediastinal tumors
65.  Pulmonary rehabilitation improves only some domains of health-related quality of life measured by the Short Form-36 questionnaire 
Annals of Thoracic Medicine  2014;9(3):144-148.
BACKGROUND:
Pulmonary rehabilitation (PR) has inconsistent effects on health-related quality of life (HRQL) in patients with chronic lung diseases. We evaluated the effect of PR on HRQL outcomes using the 36-item short form of the medical outcomes (SF-36).
METHODS:
We retrospectively reviewed the files of all patients who completed PR in 2010, 2011, and first half of 2012. We collected information on demographics, symptoms, pulmonary function tests, 6-minute walk tests (6-MWT), and responses on the SF-36 survey, including the physical component score (PCS) and mental component score (MCS).
RESULTS:
The study included 19 women and 22 men. The mean age was 69.8 ± 8.5 years. The diagnoses included chronic obstructive pulmonary disease (COPD; n = 31), asthma (n = 3), interstitial lung disease (n = 5), and obstructive sleep apnea (OSA; n = 2). The mean forced expiratory volume-one second (FEV1) was 1.16 ± 0.52 L (against 60.5 ± 15.9% of predicted value). There was a significant improvement in 6-MWT (P < 0.0001). The PCS improved post-PR from 33.8 to 34.5 (P = 0.02); the MCS did not change.
CONCLUSION:
These patients had low SF-36 scores compared to the general population; changes in scores after PR were low. These patients may need frequent HRQL assessment during rehabilitation, and PR programs should consider program modification in patients with small changes in mental health.
doi:10.4103/1817-1737.134068
PMCID: PMC4073570  PMID: 24987472
Health-related quality of life; pulmonary rehabilitation; Short Form-36; SF-36
66.  Computer tomography-guided core biopsies in a county hospital in Sweden: Complication rate and diagnostic yield 
Annals of Thoracic Medicine  2014;9(3):149-153.
BACKGROUND:
Core biopsies are valuable in obtaining sufficient tissue to ensure diagnosis of diseases in the thorax.
OBJECTIVE:
To evaluate the complication rate and the diagnostic yield in computer tomography (CT)-guided core biopsies performed in a county hospital in Sweden.
METHODS:
Medical journals, spirometry results, pathology reports and CT scans were reviewed in 463 consecutive cases, where a transthoracic core biopsy was performed between January 2005 and December 2010. Of these 380 (82%) were lung lesions, 48 (10%) were mediastinal lesions and 35 (8%) were pleural lesions.
RESULTS:
All patients underwent a chest X-ray 4 hours post-biopsy and pneumothorax was seen in 156/463 (34%) patients: 137 after lung biopsy and 17 after mediastinal biopsy. Chest tube insertion was required for 27 (17%) of these patients (6% of all core biopsies). Small intraparenchymal hemorrhages and hemoptysis were observed with subjective difficulty in one case. The diagnostic yield for the 463 patients was 212 (46%) cases of lung cancer, 188 (41%) benign lesions and 39 (8%) pulmonary metastases.
CONCLUSIONS:
A transthoracic core biopsy ensures diagnosis with a low complication rate and is suitable as an outpatient procedure. An increased risk for pneumothorax was observed when the biopsied lesion was small or when emphysema was in the path of the biopsy needle. Reduced lung function pre-biopsy or emphysema in the path of the biopsy needle increased the need for chest tube treatment of pneumothorax. A CT-guided core biopsy is safe and applicable in a county hospital.
doi:10.4103/1817-1737.134069
PMCID: PMC4073571  PMID: 24987473
Core biopsies; emphysema; FEV1; hemorrhage; pneumothorax
67.  Will any future increase in cigarette price reduce smoking in Saudi Arabia? 
Annals of Thoracic Medicine  2014;9(3):154-157.
CONTEXT:
In Saudi Arabia, no studies have been conducted on the correlation between any possible cigarette's price increase and its effects on cigarette consumption.
AIMS:
The aim of this study was to determine the prevalence of cigarette smoking in Saudi Arabia and to predict the effect of price increase on cigarette consumption.
SETTINGS AND DESIGN:
A cross-sectional study was conducted in April and May 2013.
METHODS:
We developed an Arabic questionnaire with information on demographic and socioeconomic factors, smoking history, and personal opinion on the effect of price increase on cigarette consumption. The questionnaire was distributed in public places such as malls and posted on famous Saudi athlete media's twitter accounts.
RESULTS:
Among the 2057 included responses, 802 (39%) were current smokers. The smokers’ population constituted of 746 (92%) males, of which 546 (68%) had a monthly income equal or greater to 800 US dollars, and 446 (55%) were aged between 21 and 30 years. Multivariate analyses of the risk factors for smoking showed that male gender and older age were associated with greater risk. Despite the current low prices of 2.67 US dollars, 454 smokers (56%) thought that cigarette prices are expensive. When asked about the price of cigarettes that will lead to smoking cessation, 443 smokers (55%) expected that a price of 8.27 US dollars and more per pack will make them quit.
CONCLUSIONS:
Increasing the price of popular cigarettes pack from 2.67 US dollars to 8.27 US dollars is expected to lead to smoking cessation in a large number of smokers in the Saudi population.
doi:10.4103/1817-1737.134070
PMCID: PMC4073572  PMID: 24987474
Cessation; cigarette; price increase; Saudi Arabia; smokers; smoking; tobacco
68.  Properties of novel composite meshes in chest wall reconstruction: A comparative animal study 
Annals of Thoracic Medicine  2014;9(3):158-161.
PURPOSE:
Novel composite meshes routinely used in laparoscopic hernia repair reportedly lead to fewer and less dense visceral adhesions and may provide a viable alternative in thoracic surgery as well.
METHODS:
A total of 15 adult domestic pigs underwent full thickness chest wall resection and reconstruction with Parietene (polypropylene composite; PTE, n = 5), Parietex (polyester composite; PTX, n = 5) or Bard (purely polypropylene, n = 5) mesh. After an observation period of 90 days all animals were sacrificed, intrathoracic adhesions classified via thoracoscopy (VATS), meshes explanted and peak peal strength required for lung/mesh separation recorded.
RESULTS:
Adhesions assessed through VATS-exploration were strongest in the PTX-Group while PTE and BM showed comparable results. Tensiometric analyses of peak peal strength confirmed lower values in BM than for PTE and PTX. Both composite materials showed good overall bioincorporation with post-surgical perigraft-fibrosis being strongest in BM.
CONCLUSION:
We consider composite grafts a suitable alternative for chest wall reconstruction. They are characterized by good overall biointegration and limited perigraft-fibrosis, thus potentially facilitating redo-procedures, even though a hydrophilic coating per se does not appear to prevent intrathoracic adhesion formation.
doi:10.4103/1817-1737.134071
PMCID: PMC4073573  PMID: 24987475
Composite grafts; chest wall resection; chest wall reconstruction
69.  Interleukin-6 and procalcitonin as biomarkers in mortality prediction of hospitalized patients with community acquired pneumonia 
Annals of Thoracic Medicine  2014;9(3):162-167.
INTRODUCTION:
Community acquired pneumonia (CAP) may present as life-threatening infection with uncertain progression and outcome of treatment. Primary aim of the trial was determination of the cut-off value of serum interleukin-6 (IL-6) and procalcitonin (PCT) above which, 30-day mortality in hospitalized patients with CAP, could be predicted with high sensitivity and specificity. We investigated correlation between serum levels of IL-6 and PCT at admission and available scoring systems of CAP (pneumonia severity index-PSI, modified early warning score-MEWS and (Confusion, Urea nitrogen, respiratory rate, Blood pressure, ≥65 years of age-CURB65).
METHODS:
This was prospective, non-randomized trial which included 101 patients with diagnosed CAP. PSI, MEWS and CURB65 were assessed on first day of hospitalization. IL-6 and PCT were also sampled on the first day of hospitalization.
RESULTS:
Based on ROC curve analysis (AUC ± SE = 0.934 ± 0.035; 95%CI(0.864-1.0); P = 0.000) hospitalized CAP patients with elevated IL-6 level have 93.4% higher risk level for lethal outcome. Cut-off value of 20.2 pg/ml IL-6 shows sensitivity of 84% and specificity of 87% in mortality prediction. ROC curve analysis confirmed significant role of procalcitonin as a mortality predictor in CAP patients (AUC ± SE = 0.667 ± 0.062; 95%CI(0.546-0.789); P = 0.012). Patients with elevated PCT level have 66.7% higher risk level for lethal outcome. As a predictor of mortality at the cut-off value of 2.56 ng/ml PCT shows sensitivity of 76% and specificity of 61.8%.
CONCLUSIONS:
Both IL-6 and PCI are significant for prediction of 30-day mortality in hospitalized patients with CAP. Serum levels of IL6 correlate with major CAP scoring systems.
doi:10.4103/1817-1737.134072
PMCID: PMC4073574  PMID: 24987476
Community acquired pneumonia; interleukin-6; mortality; procalcitonin; risk assessment
70.  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
71.  Patterns of tobacco consumption in food facilities in Riyadh, Saudi Arabia 
Annals of Thoracic Medicine  2014;9(3):173-178.
AIM:
This study aimed at assessing prevailing patterns and risk factors of tobacco consumption among clients, food handlers and employers of food facilities, in Riyadh, Saudi Arabia.
METHODS:
A cross-sectional approach to a representative sample of food facilities in Riyadh was used. A sample of 3000 participants included clients (75%); food handlers/hospitality workers (20 %) and employers (5 %). Participants were reached at restaurants, food courts or cafes. A modified version of the WHO-CDC-Global Youth Tobacco Survey questionnaire was used for data collection.
RESULTS:
The prevalence of tobacco use at food facilities was found to be 40.3 %, of which 74% were customers, 18.8% were food handlers and 7.2% were managers. The consumption of tobacco was higher at restaurants (39.9%), but lowest at food courts of shopping malls. Water pipe (55.3%) was the main consumption type, followed by cigarettes (42.6%) and chewing tobacco (2.1%). Multivariate analysis showed that gender (male), marital status (single), and type of food facility (Estaraha and café/coffee shop) were independent risk factors associated with tobacco use at food facilities.
CONCLUSION:
Tobacco use is very common in food facilities in Riyadh as reflected by results of our study, especially among single males Saudis. We should build on success encountered in banning smoking in airports, airplanes, shopping malls, market places, educational institutions and healthcare facilities, extending the ban to include food facilities as well. This is important for the health of non-smokers as well as smokers themselves.
doi:10.4103/1817-1737.134075
PMCID: PMC4073576  PMID: 24987478
Food facilities; Riyadh; Saudi Arabia; tobacco use
72.  Reply to the editor 
Annals of Thoracic Medicine  2014;9(3):180-181.
doi:10.4103/1817-1737.134078
PMCID: PMC4073578  PMID: 24987480
73.  Respiratory morbidity in obesity, beyond obstructive sleep apnea 
Annals of Thoracic Medicine  2014;9(3):182-183.
doi:10.4103/1817-1737.134081
PMCID: PMC4073581  PMID: 24987483
74.  Reply to the editor 
Annals of Thoracic Medicine  2014;9(3):183-184.
doi:10.4103/1817-1737.134082
PMCID: PMC4073582  PMID: 24987484
75.  Saudi Guidelines on the Diagnosis and Treatment of Pulmonary Hypertension: Schistosomiasis and pulmonary arterial hypertension 
Annals of Thoracic Medicine  2014;9(Suppl 1):S38-S41.
Schistosomiasis is caused by infection with the parasite Schistosoma, which is a flat-worm or fluke. The dominant species are Schistosoma mansoni, Schistosoma japonicum, and Schistosoma haematobium. Schistosomiasis is the third most common parasitic disease in the world after malaria and amoebiasis. It is endemic in more than 70 countries affecting about 200 million people worldwide, of whom 80% are in sub-Saharan Africa. There are pockets of infection in north-eastern Brazil, near the Yangtze River in China, and some pockets in south East Asia. In the East Mediterranean regions, the Schistosoma have been reported in Iraq and Egypt as well as in Sudan. The latter has the highest infection rate nowadays, particularly in the Al Jazeera area, due to the poor Schistosoma control program. In the Arabian peninsula, schistosomiasis has been reported in southwest part of Saudi Arabia, mainly in the Asir province and Jizan province, which lay in the southwest corner of Saudi Arabia and directly north of the border with Yemen. The efforts to control schistosomiasis have been very successful in Saudi Arabia due to the irrigation system control. However, the infection is prone in Yemen, where the schistosomiasis control is much less strict. Thus as a result, the problem still exists due to transmigration of the populations from both countries.
As a cause of pulmonary arterial hypertension (PAH), schistosomiasis is still under diagnosed and undertreated. This article with give a highlight about the pathophysiology of the disease and both diagnostic and therapeutic strategies.
doi:10.4103/1817-1737.134019
PMCID: PMC4114265  PMID: 25076995
Schistosomiasis; pulmonary arterial hypertension; praziquantel; Saudi association for pulmonary hypertension

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