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1.  Evaluation of efficacy of non-invasive ventilation in Non-COPD and non-trauma patients with acute hypoxemic respiratory failure: A systematic review and meta-analysis 
Annals of Thoracic Medicine  2015;10(1):16-24.
Non-invasive ventilation (NIV) has been widely supported in the past two decades as an effective application in avoiding the need for endotracheal intubation (ETI) and reducing associated mortality in acute hypoxemic respiratory failure (AHRF) patients. However, the efficacy of NIV in AHRF patients, non-related to chronic obstructive pulmonary disease (COPD) and trauma is still controversial in the field of medical research. This retrospective study aimed to evaluate the efficacy of NIV as an adjunctive therapy in non-COPD and non-traumatic AHRF patients. Data of 11 randomized control trials (RCTs), which were conducted between 1990 and 2010 to determine the efficacy of NIV in non-COPD and non-traumatic AHRF patients, were reviewed from the PUBMED, MEDLINE, Cochrane Library, and EMBASE databases. Parameters monitored in this study included the ETI rate, fatal complications, mortality rate of patients, and their ICU and hospital duration of stay. Overall results showed a statistically significant decrease in the rate of ETI, mortality, and fatal complications along with reduced ICU and hospital length of stay in non-COPD and non-trauma AHRF patients of various etiologies. This systematic review suggests that non-COPD and non-trauma AHRF patients can potentially benefit from NIV as compared with conventional treatment methods. Observations from various cohort studies, observational studies, and previously published literature advocate on the efficacy of NIV for treating non-COPD and non-traumatic AHRF patients. However, considering the diversity of studied populations, further studies and more specific trials on less heterogeneous AHRF patient groups are needed to focus on this aspect.
doi:10.4103/1817-1737.146855
PMCID: PMC4286839  PMID: 25593602
Acute hypoxemic respiratory failure; endotracheal intubation; non-COPD; non-invasive ventilation; non-trauma
2.  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
3.  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
4.  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
5.  Pulmonary rehabilitation: A regional perspective evidenced-based review 
Pulmonary rehabilitation (PR) is an integral component of the comprehensive management plan of patients with chronic lung diseases by addressing their functional and psychological deficits. PR is generally recommended to symptomatic patients with chronic lung diseases who develop shortness of breath on their own pace at level ground while receiving optimum therapy. From a regional perspective, this review covers the description of a PR program, its establishment and outcome assessment.
doi:10.4103/1817-1737.124408
PMCID: PMC3912684  PMID: 24551010
Chronic lung diseases; chronic obstructive pulmonary disease; pulmonary rehabilitation; quality of life
6.  Atypical radiological manifestations of thoracic sarcoidosis: A review and pictorial essay 
Annals of Thoracic Medicine  2013;8(4):186-196.
Thoracic sarcoidosis is a common disease, with well-described and recognizable radiographic features. Nevertheless, most physicians are not familiar with the rare atypical often-confusing manifestations of thoracic sarcoid. Although these findings have been previously reviewed, but more recent advances in imaging and laboratory science, need to be incorporated. We present a review of literature and illustrate the review with unpublished data, intended to provide a more recent single comprehensive reference to assist with the diagnosis when atypical radiographic findings of thoracic sarcoidosis are encountered. Thoracic involvement accounts for most of morbidity and mortality associated with sarcoidosis. An accurate timely identification is required to minimize morbidity and mortality. It is essential to recognize atypical imaging findings and relate these to clinical manifestations and histology.
doi:10.4103/1817-1737.118490
PMCID: PMC3821277  PMID: 24250731
Atypical; cardiology; chest; radiology; sarcoidosis
7.  Extracorporeal life support for acute respiratory distress syndromes 
Annals of Thoracic Medicine  2013;8(3):133-141.
The morbidity and mortality of acute respiratory distress syndrome remain to be high. Over the last 50 years, the clinical management of these patients has undergone vast changes. Significant improvement in the care of these patients involves the development of mechanical ventilation strategies, but the benefits of these strategies remain controversial. With a growing trend of extracorporeal support for critically ill patients, we provide a historical review of extracorporeal membrane oxygenation (ECMO) including its failures and successes as well as discussing extracorporeal devices now available or nearly accessible while examining current clinical indications and trends of ECMO in respiratory failure.
doi:10.4103/1817-1737.114290
PMCID: PMC3731854  PMID: 23922607
Acute respiratory distress syndrome; extracorporeal life support; extracorporeal membrane oxygenation
8.  Approach to acute exacerbation of idiopathic pulmonary fibrosis 
Annals of Thoracic Medicine  2013;8(2):71-77.
Idiopathic pulmonary fibrosis (IPF) is a chronic interstitial pneumonia with a median survival of 3 years after diagnosis. Acute exacerbation of IPF (AE-IPF) is now identified as a life-threatening complication. It presents as worsening dyspnea with new ground glass opacities superimposed upon a radiographic usual interstitial pneumonia (UIP) pattern. It is a diagnosis of exclusion. The prognosis of AE-IPF is poor and treatment strategies lack standardization. In order to rule out any reversible etiology for an acute decompensation of a previously stable IPF patient diagnostic modalities include computerized tomographic angiogram (CTA) coupled with high-resolution computerized tomography (HRCT) imaging of the chest, bronchoalveolar lavage (BAL) and echocardiogram with bubble study. Avoiding risk factors, identifying underlying causes and supportive care are the mainstays of treatment. Anti-inflammatory and immunosuppressant medications have not shown to improve survival in AE-IPF. Most of the patients are managed in a critical care setting with mechanical ventilation. Lung transplantation is a promising option but most institutions are not equipped and not every patient is a candidate.
doi:10.4103/1817-1737.109815
PMCID: PMC3667448  PMID: 23741267
Acute exacerbation of idiopathic pulmonary fibrosis; bronchoalveolar lavage; chest roentgenogram; computerized tomographic angiogram; high resolution computer tomography; idiopathic pulmonary fibrosis; usual interstitial pneumonia
9.  Chronic obstructive pulmonary disease lost in translation: Why are the inhaled corticosteroids skeptics refusing to go? 
Annals of Thoracic Medicine  2013;8(1):8-13.
A survey of pulmonologists attending a clinical meeting of the Saudi Thoracic Society found that only 55% of responders considered that inhaled corticosteroids (ICS) had a positive effect on quality of life in Chronic Obstructive Pulmonary Disease (COPD). Why the divergence of opinion when all the guidelines have concluded that ICS improve quality of life and produce significant bronchodilation? ICS unequivocally reduce the rate of exacerbations by a modest 20%, but this does not extend to serious exacerbations requiring hospitalization. Bronchodilatation with ICS is now documented to be restricted to some phenotypes of COPD. Withdrawal of ICS trials reported a modest decline of FEV1 (<5%) in half the studies and no decline in the other half. In spite of the guidelines statements, there is no concurrence on whether ICS improve the quality of life and there is no conclusive evidence that the combination of long-acting ß2 agonists (LABA) with ICS is superior to LABA alone in that regard. The explanation for these inconclusive results may be related to the fact that COPD consists of three different phenotypes with divergent responses to LABA and ICS. Therapy tailored to phenotype is the future for COPD.
doi:10.4103/1817-1737.105711
PMCID: PMC3573567  PMID: 23441006
COPD; inhaled corticosteroids; phenotyping
10.  Role of ATP binding and hydrolysis in the gating of the cystic fibrosis transmembrane conductance regulator 
Annals of Thoracic Medicine  2012;7(3):115-121.
The CFTR gene is unique within the ATP-binding cassette (ABC) protein family, predominantly of transporters, by coding a chloride channel. The gating mechanism of ABC proteins has been characterized by the ATP Switch model in terms cycles of dimer formation and dissociation linked to ATP binding and hydrolysis, respectively. It would be of interest to assess the extent that Cystic Fibrosis Transmembrane Conductance Regulator (CFTR), a functional channel, fits the ATP Switch model for ABC transporters. Additional transporter mechanisms, namely those of Pgp and HlyB, are discussed for perspective. Literature search of databases selected key references in comparing and contrasting the gating mechanism. CFTR is a functional chloride channel facilitating transmembrane anion flow down electrochemical gradients. A dysfunctional CFTR protein results in cystic fibrosis, a fatal pleiotropic disease currently managed symptomatically. Understanding the gating mechanism will help target drug development aimed at alleviating and curing the disease.
doi:10.4103/1817-1737.98842
PMCID: PMC3425041  PMID: 22924067
ATP-binding cassette proteins; cystic fibrosis transmembrane conductance regulator; cystic fibrosis; gating mechanism
11.  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
12.  Sleep from an Islamic perspective 
Annals of Thoracic Medicine  2011;6(4):187-192.
Sleep medicine is a relatively new scientific specialty. Sleep is an important topic in Islamic literature, and the Quran and Hadith discuss types of sleep, the importance of sleep, and good sleep practices. Islam considers sleep as one of the signs of the greatness of Allνh (God) and encourages followers to explore this important sign. The Quran describes different types of sleep, and these correspond with sleep stages identified by modern science. The Quran discusses the beneficial effects of sleep and emphasizes the importance of maintaining a pattern of light and darkness. A mid-day nap is an important practice for Muslims, and the Prophet Muhammad peace be upon him (pbuh) promoted naps as beneficial. In accordance with the practice and instructions of Muhammad (pbuh), Muslims have certain sleep habits and these sleep habits correspond to some of the sleep hygiene rules identified by modern science. Details during sleep include sleep position, like encouraging sleep on the right side and discouraging sleep in the prone position. Dream interpretation is an established science in the Islamic literature and Islamic scholars have made significant contributions to theories of dream interpretation. We suggest that sleep scientists examine religious literature in general and Islamic literature in particular, to understand the views, behaviors, and practices of ancient people about the sleep and sleep disorders. Such studies may help to answer some unresolved questions in sleep science or lead to new areas of inquiry.
doi:10.4103/1817-1737.84771
PMCID: PMC3183634  PMID: 21977062
Circadian rhythm; dreams; Islam; Quran; sleep
13.  Evaluation of liver transplant candidates: A pulmonary perspective 
Annals of Thoracic Medicine  2011;6(3):109-114.
Chronic liver disease is one of the leading causes of mortality and morbidity in the worldwide adult population. Liver transplant is the gold standard therapy for end-stage liver disease and many patients are on the waiting list for a transplant. A variety of pulmonary disorders are encountered in cirrhotic patients. Pleura, lung parenchyma, and pulmonary vasculature may be affected in these patients. Hypoxemia is relatively common and can be asymptomatic. Hepatopulmonary syndrome should be investigated in hypoxic cirrhotic patients. Gas exchange abnormalities are common and are generally correlated with the severity of liver disease. Both obstructive and restrictive types of airway disease can be present. Abnormal diffusion capacity is the most frequently observed pulmonary function disorder in patients with cirrhosis. Hepatic hydrothorax is another finding which is usually seen in conjunction with, but occasionally without ascites. Portopulmonary hypertension is a complication of long standing liver dysfunction and when severe, is accepted as a containdication to liver transplant. Since respiratory disorders are common and have significant impact on postoperative outcome in patients undergoing liver transplant, a careful preoperative pulmonary assessment is important.
doi:10.4103/1817-1737.82436
PMCID: PMC3131751  PMID: 21760840
Hepatopulmonary syndrome; liver transplant; respiratory disorders
14.  Pulmonary vascular complications of chronic liver disease: Pathophysiology, imaging, and treatment 
Annals of Thoracic Medicine  2011;6(2):57-65.
To review the pathogenesis of pulmonary vascular complications of liver disease, we discuss their clinical implications, and therapeutic considerations, with emphasis on potential reversibility of the hepatopulmonary syndrome after liver transplantation. In this review, we also discuss the role of imaging in pulmonary vascular complications associated with liver disease.
doi:10.4103/1817-1737.78412
PMCID: PMC3081557  PMID: 21572693
Hepatopulmonary syndrome; portopulmonary hypertension; pulmonary arteriovenous shunts; Yttrium-90 microsphere embolization hepatocellular carcinoma
15.  Sleep medicine in Saudi Arabia: Current problems and future challenges 
Annals of Thoracic Medicine  2011;6(1):3-10.
Sleep medicine is a relatively new specialty in the medical community. The practice of sleep medicine in Saudi Arabia (KSA) began in the mid to late nineties. Since its inception, the specialty has grown, and the number of specialists has increased. Nevertheless, sleep medicine is still underdeveloped in the KSA, particularly in the areas of clinical service, education, training and research. Based on available data, it appears that sleep disorders are prevalent among Saudis, and the demand for sleep medicine service is expected to rise significantly in the near future. A number of obstacles have been defined that hinder the progress of the specialty, including a lack of trained technicians, specialists and funding. Awareness about sleep disorders and their serious consequences is low among health care workers, health care authorities, insurance companies and the general public. A major challenge for the future is penetrating the educational system at all levels to demonstrate the high prevalence and serious consequences of sleep disorders. To attain adequate numbers of staff and facilities, the education and training of health care professionals at the level of sleep medicine specialists and sleep technologists is another important challenge that faces the specialty. This review discusses the current position of sleep medicine as a specialty in the KSA and the expected challenges of the future. In addition, it will guide clinicians interested in setting up new sleep medicine services in the KSA or other developing countries through the potential obstacles that may face them in this endeavor.
doi:10.4103/1817-1737.74269
PMCID: PMC3023868  PMID: 21264164
Developing countries; Saudi Arabia; sleep; sleep centers; sleep disordered breathing; sleep laboratories; sleep medicine
16.  Venous thromboembolism prophylaxis for hospitalized medical patients, current status and strategies to improve 
Annals of Thoracic Medicine  2010;5(4):195-200.
Venous thromboembolism (VTE), comprising life-threatening pulmonary embolism (PE) and its precursor deep-vein thrombosis (DVT), is commonly encountered problem. Although most patients survive DVT, they often develop serious and costly long-term complications. Both unfractionated heparin and low molecular weight heparins significantly reduce the incidence of VTE and its associated complications. Despite the evidence demonstrating significant benefit of VTE prophylaxis in acutely ill medical patients, several registries have shown significant underutilization. This underutilization indicates the need for educational and audit programs in order to increase the number of medical patients receiving appropriate prophylaxis. Many health advocacy groups and policy makers are paying more attention to VTE prophylaxis; the National Quality Forum and the Joint Commission recently endorsed strict VTE risk assessment evaluation for each patient upon admission and regularly thereafter. In the article, all major studies addressing this issue in medical patients have been reviewed from the PubMed. The current status of VTE prophylaxis in hospitalized medical patients is addressed and some improvement strategies are discussed.
doi:10.4103/1817-1737.69104
PMCID: PMC2954373  PMID: 20981179
Deep vein thrombosis; heparin; low molecular weight heparin; pulmonary embolism; thromboprophylaxis
17.  Imaging lung manifestations of HIV/AIDS 
Annals of Thoracic Medicine  2010;5(4):201-216.
Advances in our understanding of human immunodeficiency virus (HIV) infection have led to improved care and incremental increases in survival. However, the pulmonary manifestations of HIV/acquired immunodeficiency syndrome (AIDS) remain a major cause of morbidity and mortality. Respiratory complaints are not infrequent in patients who are HIV positive. The great majority of lung complications of HIV/AIDS are of infectious etiology but neoplasm, interstitial pneumonias, Kaposi sarcoma and lymphomas add significantly to patient morbidity and mortality. Imaging plays a vital role in the diagnosis and management of lung of complications associated with HIV. Accurate diagnosis is based on an understanding of the pathogenesis of the processes involved and their imaging findings. Imaging also plays an important role in selection of the most appropriate site for tissue sampling, staging of disease and follow-ups. We present images of lung manifestations of HIV/AIDS, describing the salient features and the differential diagnosis.
doi:10.4103/1817-1737.69106
PMCID: PMC2954374  PMID: 20981180
HIV/AIDS; imaging lung; mediastinal manifestations
18.  Sublingual immunotherapy in allergic asthma: Current evidence and needs to meet 
Annals of Thoracic Medicine  2010;5(3):128-132.
Allergen-specific immunotherapy is aimed at modifying the natural history of allergy by inducing tolerance to the causative allergen. In its traditional, subcutaneous form, immunotherapy has complete evidence of efficacy in allergic asthma. However, subcutaneous immunotherapy (SCIT) has a major flaw in side effects, and especially in possible anaphylactic reactions, and this prompted the search for safer ways of administration of allergen extracts. Sublingual immunotherapy (SLIT) has met such need while maintaining a clinical efficacy comparable to SCIT. In fact, the safety profile, as outlined by a systematic revision of the available literature, was substantially free from serious systemic reactions. A number of meta-analyses clearly showed that SLIT is effective in allergic rhinitis by significantly reducing the clinical symptoms and the use of anti-allergic drugs, while the efficacy in allergic asthma is still debated, with some meta-analyses showing clear effectiveness but other giving contrasting results. Besides the efficacy on symptoms, the preventive activity and the cost-effectiveness are important outcomes of SLIT in asthma. The needs to meet include more data on efficacy in house dust mite asthma, optimal techniques of administration and, as previously done with SCIT, introduction of adjuvants able to enhance the immunologic response and use of recombinant allergens.
doi:10.4103/1817-1737.65038
PMCID: PMC2930649  PMID: 20835305
Allergic asthma; efficacy; specific immunotherapy; sublingual immunotherapy; safety
19.  Genomic and non-genomic actions of glucocorticoids in asthma 
Annals of Thoracic Medicine  2010;5(3):133-139.
Glucocorticoids are the mainstay of asthma therapy. They are primarily used to suppress airway inflammation, which is the central pathological change in asthmatic patients’ airways. This is achieved by many different mechanisms. The classical mechanism is by suppression of the genetic transcription of many inflammatory cytokines that are key in asthma pathophysiology (transrepression). On the other hand, the transcription of certain inhibitory cytokines is activated by glucocorticoids (transactivation), a mechanism that also mediates many of the adverse effects of glucocorticoids. The onset of action through these mechanisms is often delayed (4-24 hours). Other mechanisms mediated through non-genomic pathways are increasingly appreciated. These are delivered in part by binding of glucocorticoids to nonclassical membrane-bound glucocorticoid receptors or by potentiating the α1-adrenergic action on the bronchial arterial smooth muscles, in addition to other mechanisms. These effects are characterized by their rapid onset and short duration of action. Understanding these different mechanisms will help in the development of new and better drugs to treat this common disease and to develop new improved strategies in our approach to its management. Here, the genomic and non-genomic mechanisms of actions of glucocorticoids in asthma are briefly reviewed, with special emphasis on the current updates of the non-genomic mechanisms.
doi:10.4103/1817-1737.65040
PMCID: PMC2930650  PMID: 20835306
Asthma; genomic action; glucocorticoids; mechanism of action; non-genomic action
20.  The calcified lung nodule: What does it mean? 
Annals of Thoracic Medicine  2010;5(2):67-79.
The aim of this review is to present a pictorial essay emphasizing the various patterns of calcification in pulmonary nodules (PN) to aid diagnosis and to discuss the differential diagnosis and the pathogenesis where it is known. The imaging evaluation of PN is based on clinical history, size, distribution and the gross appearance of the nodule as well as feasibility of obtaining a tissue diagnosis. Imaging is instrumental in the management of PN and one should strive not only to identify small malignant tumors with high survival rates but to spare patients with benign PN from undergoing unnecessary surgery. The review emphasizes how to achieve these goals. One of the most reliable imaging features of a benign lesion is a benign pattern of calcification and periodic follow-up with computed tomography showing no growth for 2 years. Calcification in PN is generally considered as a pointer toward a possible benign disease. However, as we show here, calcification in PN as a criterion to determine benign nature is fallacious and can be misleading. The differential considerations of a calcified lesion include calcified granuloma, hamartoma, carcinoid, osteosarcoma, chondrosarcoma and lung metastases or a primary bronchogenic carcinoma among others. We describe and illustrate different patterns of calcification as seen in PN on imaging.
doi:10.4103/1817-1737.62469
PMCID: PMC2883201  PMID: 20582171
Benign pulmonary nodules; malignant pulmonary nodules; calcification
21.  Portopulmonary hypertension 
Portopulmoanry hypertension (POPH) is a form of pulmonary arterial hypertension (PAH) associated with portal hypertension with or without underlying chronic liver disease. POPH is increasingly recognized and recent evidence suggests that it is one of the leading causes of PAH. The pathophysiology of POPH is poorly understood although the pathological changes in pulmonary vasculature in advanced POPH are similar to those seen in idiopathic pulmonary hypertension. The prognosis in patients with liver disease who also suffer from significant POPH is considered to be poor. Higher degree of pulmonary artery pressure (PAP) may preclude a patient from liver transplant as mortality in these patients is high. The treatment with vasodilator therapy has shown to improve both hemodynamics and clinical outcome in POPH in retrospective studies and in some case series. The aim of medical management is to bring PAP <35 mmHg that may make a patient with POPH and advanced liver disease eligible for liver transplant, which otherwise would have been denied because of high PAP.
doi:10.4103/1817-1737.58953
PMCID: PMC2841810  PMID: 20351954
Liver transplant; portopulmonary hypertension; pulmonary arterial hypertension; portal hypertension; vasodilator therapy
22.  Obstructive sleep apnea and cardiac arrhythmias 
Annals of Thoracic Medicine  2010;5(1):10-17.
Sleep-disordered breathing (SDB), which includes obstructive sleep apnea (OSA) as its most extreme variant, is characterized by intermittent episodes of partial or complete obstruction of the upper airway, leading to cessation of breathing while asleep. Cardiac arrhythmias are common problems in OSA patients, although the true prevalence and clinical relevance of cardiac arrhythmias remains to be determined. The presence and complexity of tachyarrhythmias and bradyarrhythmias may influence morbidity, mortality and quality of life for patients with OSA. Although the exact mechanisms underlying the link between OSA and cardiac arrhythmias are not well established, they could be some of the same proposed mechanisms relating OSA to different cardiovascular diseases, such as repetitive pharyngeal collapse during sleep, which leads to markedly reduced or absent airflow, followed by oxyhemoglobin desaturation, persistent inspiratory efforts against an occluded airway and termination by arousal from sleep. These mechanisms elicit a variety of autonomic, hemodynamic, humoral and neuroendocrine responses that evoke acute and chronic changes in cardiovascular function. However, despite substantial research effort, the goals of determining in advance which patients will respond most favorably to certain treatment options (such as continuous positive airway pressure, tracheostomy or cardioversion) and the developing alternative treatments remain largely elusive. Therefore, this literature review aims to summarize a broad array of the pathophysiological mechanisms underlying the relationship between OSA and cardiac arrhythmias and the extent of this association from an epidemiological perspective, thereby attempting to assess the effects of OSA treatment on the presence of cardiac arrhythmias.
doi:10.4103/1817-1737.58954
PMCID: PMC2841803  PMID: 20351955
Arrhythmia; OSA; sleep apnea
23.  Exhaled nitric oxide in diagnosis and management of respiratory diseases 
Annals of Thoracic Medicine  2009;4(4):173-181.
The analysis of biomarkers in exhaled breath constituents has recently become of great interest in the diagnosis, treatment and monitoring of many respiratory conditions. Of particular interest is the measurement of fractional exhaled nitric oxide (FENO) in breath. Its measurement is noninvasive, easy and reproducible. The technique has recently been standardized by both American Thoracic Society and European Respiratory Society. The availability of cheap, portable and reliable equipment has made the assay possible in clinics by general physicians and, in the near future, at home by patients. The concentration of exhaled nitric oxide is markedly elevated in bronchial asthma and is positively related to the degree of esinophilic inflammation. Its measurement can be used in the diagnosis of bronchial asthma and titration of dose of steroids as well as to identify steroid responsive patients in chronic obstructive pulmonary disease. In primary ciliary dyskinesia, nasal NO is diagnostically low and of considerable value in diagnosis. Among lung transplant recipients, FENO can be of great value in the early detection of infection, bronchioloitis obliterans syndrome and rejection. This review discusses the biology, factors affecting measurement, and clinical application of FENO in the diagnosis and management of respiratory diseases.
doi:10.4103/1817-1737.56009
PMCID: PMC2801041  PMID: 19881162
Diseases; exhaled nitric oxide; measurement; respiratory
24.  The novel influenza A (H1N1) virus pandemic: An update 
Annals of Thoracic Medicine  2009;4(4):163-172.
In the 4 months since it was first recognized, the pandemic strain of a novel influenza A (H1N1) virus has spread to all continents and, after documentation of human-to-human transmission of the virus in at least three countries in two separate World Health Organization (WHO) regions, the pandemic alert was raised to level 6. The agent responsible for this pandemic, a swine-origin influenza A (H1N1) virus (S-OIV), is characterized by a unique combination of gene segments that has not previously been identified among human or swine influenza A viruses. As of 31th July 2009, 168 countries and overseas territories/communities have each reported at least one laboratory-confirmed case of pandemic H1N1 infection. There have been a total of 162,380 reported cases and 1154 associated deaths. Influenza epidemics usually take off in autumn, and it is important to prepare for an earlier start this season. Estimates from Europe indicate that 230 millions Europe inhabitants will have clinical signs and symptoms of S-OIV this autumn, and 7–35% of the clinical cases will have a fatal outcome, which means that there will be 160,000–750,000 H1N1-related deaths. A vaccine against H1N1 is expected to be the most effective tool for controlling influenza A (H1N1) infection in terms of reducing morbidity and mortality and limiting diffusion. However, there are several issues with regard to vaccine manufacture and approval, as well as production capacity, that remain unsettled. We searched the literature indexed in PubMed as well as the websites of major international health agencies to obtain the material presented in this update on the current S-OIV pandemic.
doi:10.4103/1817-1737.56008
PMCID: PMC2801040  PMID: 19881161
Epidemiology; H1N1; influenza
25.  Pulmonary manifestations of gastroesophageal reflux disease 
Annals of Thoracic Medicine  2009;4(3):115-123.
Gastroesophageal reflux disease (GERD) may cause, trigger or exacerbate many pulmonary diseases. The physiological link between GERD and pulmonary disease has been extensively studied in chronic cough and asthma. A primary care physician often encounters patients with extra esophageal manifestations of GERD in the absence of heartburn. Patients may present with symptoms involving the pulmonary system; noncardiac chest pain; and ear, nose and throat disorders. Local irritation in the esophagus can cause symptoms that vary from indigestion, like chest discomfort and abdominal pain, to coughing and wheezing. If the gastric acid reaches the back of the throat, it may cause a bitter taste in the mouth and/or aspiration of the gastric acid into the lungs. The acid can cause throat irritation, postnasal drip and hoarseness, as well as recurrent cough, chest congestion and lung inflammation leading to asthma and/or bronchitis/ pneumonia. This clinical review examines the potential pathophysiological mechanisms of pulmonary manifestations of GERD. It also reviews relevant clinical information concerning GERD-related chronic cough and asthma. Finally, a potential management strategy for GERD in pulmonary patients is discussed.
doi:10.4103/1817-1737.53347
PMCID: PMC2714564  PMID: 19641641
Gastroesophageal reflux disease; lungs; pulmonary

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