|Year : 2010 | Volume
| Issue : 3 | Page : 180-192
|Abstracts from the The Gulf Thoracic Congress
|Date of Web Publication||2-Jul-2010|
|How to cite this article:|
. Abstracts from the The Gulf Thoracic Congress. Ann Thorac Med 2010;5:180-92
The Gulf Thoracic Congress was conducted on 16 th to 19 th March 2010 at Abu Dhabi, United Arab Emeritus. The Congress was organized by the Saudi Thoracic Society and the Emirates Allergy and Respiratory Society, in collaboration with the American College of Chest Physicians (ACCP) and with the participation of the Cleveland Clinic Foundation
Impact of antibiotic resistance on clinical outcomes
Atef M. Shibl
King Saud University Hospital, Riyadh, Kingdom of Saudi Arabia
The emergence of drug resistance among community aquired pneumonia (CAP) pathogens has complicated empirical treatment of such infections. It is therefore imperative to know the susceptibility pattern of CAP pathogens when selecting an antimicrobial agent for empirical therapy. Since treatment of CAP is generally initiated empirically, it is imperative that the clinician be informed about the current local antibiotic resistance patterns and is familiar with the risk factors for typical infections among the population at risk. In a recent report from the Gulf Cooperation Council (GCC), CAP working group (CAPWG), Streptococcus pneumoniae, Hemophilus influenzae (including non-typable H. influenzae) and Moraxella More Details catarrhalis were the most predominant pathogens associated with CAP in the region. There are multiple published studies detailing the clinical impact of antibiotic resistance in the treatment of CAP and antibiotic susceptibility of CAP pathogens but only few are specific to our region. The Survey of Antibiotic Resistance (SOAR) 2007-2009 study presents the recent data on the antibiotic susceptibility of S. pneumoniae, H. influenzae, M. catarrhalis and S. pyogens in Saudi Arabia. (SOAR 2007-2009 Saudi Arabia data will be presented on 15 th March 2010.) We observed an in vitro-in vivo paradox which clearly explains why we do not encounter failure in the treatment of CAP although we observed resistance to β-lactam drugs. Based on new data for β-lactam PK/PD, new breakpoints were developed by CLSI for the interpretation of β-lactam susceptibility to S. pneumoniae. Efficient management requires several factors to be considered, including the selection of proper agents based on local resistance patterns.
Effect of Ramadan fasting on the circadian pattern of sleep after controlling for mealtime: An objective assessment
Ahmed S. BaHammam
University Sleep Disorders Center, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
Background: Conflicting data have been reported regarding the effects of Ramadan fasting on the circadian pattern of sleep and other physiological parameters. However, most data suggested a delay of circadian rhythm during Ramadan. The eating of meals exclusively at night has been proposed to increase metabolic rate and hence delay circadian rhythms. We hypothesize that lifestyle changes other than night-time eating may contribute to the delay in the circadian rhythm seen during Ramadan. Therefore, we designed this study to objectively assess the circadian changes in sleep, energy expenditure and body temperature in a highly selected group of healthy young adults who had delayed sleep phase syndrome (DSPS) (i.e., used to sleep in daytime and eat at night) and were on vacation during the study period. By controlling for mealtime, we aim to study the effects of other factors that may delay circadian rhythms. Method: We assessed circadian changes in sleep, energy expenditure and body temperature during a baseline period (BL, 1 week before Ramadan), the first week (R1) and the second week (R2) of Ramadan in 6 healthy Muslim young adults using portable armband physiological and activity sensor devices. The SenseWear Pro Armband?™ is a validated device that measures skin temperature, galvanic skin response, heat flux and body acceleration. All participants were in a free-living, unconstrained environment and showed delayed sleep phase syndrome, so that they normally slept during the day and ate at night. DSPS was documented using a translated and validated abridged version of the morningness-eveningness questionnaire. Data was downloaded into PC, and comparisons among BL, R1 and R2 were performed using repeated-measures ANOVA. A 24-hour cosinor model [f(t)=M+A*Cos(2πt/T+ø), where M=Mesor; A=Amplitude; Ζ=acrophase; T=24 hours] was developed to get the best estimates of the overall acrophase for skin temperature and energy expenditure. Results: The mean age of participants was 20.5 ± 2.9 years, and the mean body mass index (BMI) was 22.6 ± 2.7 kg/m 2 . Bedtime was delayed during R1 and R2 by 1.4-1.6 hours. Wake-up time was delayed during Ramadan (R1 and R2) compared to BL (10.42 ± 1.87 vs. 12.68 ± 1.41, P < .05). Total sleep time was comparable during the three periods. During Ramadan, there was a further delay in the acrophase of skin temperature, indicating a shift in the circadian pattern of body temperature. Additionally, there was a delay in the peak of energy expenditure during R1 and R2. Conclusion: These results support our hypothesis that in addition to sudden shift in mealtimes, other factors may affect the sleep pattern and circadian rhythms during Ramadan. Future research should explore factors that affect sleep pattern and circadian rhythms during Ramadan fasting.
- Adan A, Almirall H. Horne and Ostberg morningness-eveningness questionnaire: A reduced scale. Pers Individ Dif 1991;12:241-53.
- BaHammam A. Effect of fasting during Ramadan on sleep architecture, daytime sleepiness and sleep pattern. Sleep Biol Rhythms 2004;2:135-43.
- Bahammam A. Does Ramadan fasting affect sleep? Int J Clin Pract 2006;60:1631-7.
- Roky R, Chapotot F, Benchekroun MT, Benaji B, Hakkou F, Elkhalifi H, et al. Daytime sleepiness during Ramadan intermittent fasting: polysomnographic and quantitative waking EEG study. J Sleep Res 2003;12:95-101.
Compliance of DNR policy in a tertiary care center in Saudi Arabia
KAMC-Riyadh, Kingdom of Saudi Arabia
Background: DNR is an important aspect of medical practice, few studies from Arab, Muslim countries addressing this issue. KAMC-Riyadh, Kingdom of Saudi Arabia, has a clear policy (NOCODE policy) addressing all aspects of DNR. Objective: To assess the compliance to the current policy. Methods: Cohort study of a prospectively collected data through the period of 15/10/2008 to 15/01/2009 for patients where DNR was initiated. The patients' charts were followed prospectively to observe the DNR documentation completion. The data was analyzed in terms of frequencies and descriptive statistics, and the results are expressed as percentage. Result: DNR was initiated in 65 patients, 46.2% females and 53.8% males, with ages ranging from 19 to 93 years with a mean age of 66.14 + 16.07 SD. The DNR was initiated by ICU physician in 80% of the cases and MRP in 20% of the cases. There was a delay (more than 48 hours) in obtaining MRP signature in 8 (12.3%) patients, and there was no signature at all by the MRP in 13 (20%) patients. The documentation for explanation and discussion with the family was absent in 53.8% of cases. Conclusion: ICU physicians have a role in initiating DNR. Mostly this issue has not been addressed on admission. Documentation of DNR once initiated is still not up to the optimum level in 32.3% of cases, mainly by MRP. Discussion with family was not well documented in the chart in more than half of the cases. The main reason for poor communication between staff and patients and their families were cultural, educational and religious. This emphasizes the need to continuously evaluate DNR practice and the need for education of the medical staff and public in Arab Muslim countries. Abbreviations: ICU: intensive care unit, MRP: most responsible physician, DNR: do not resuscitate, HCW: health care workers, KAMC: King Abdulaziz Medical City.
Novel use of a PEG-tube fastener for securing silicone tracheal stents in patients with proximal benign tracheal stenosis
Ali I. Musani
National Jewish Health, Denver, Colorado, United States
Background: Benign tracheal stenosis occurs for a variety of reasons. Bronchoscopic therapies include silicone stent placement. Silicone stents are effective at maintaining airway patency. However, a common complication is stent migration, particularly when placed in the proximal trachea. To prevent migration of silicon stents, we utilized a novel technique of securing the stents in the trachea with the percutaneous placement of a PEG-tube fastener (PTF) through the neck and the silicone stent under bronchoscopic visualization. Objective: To determine the safety and effectiveness of securing silicone stents in the proximal trachea with a percutaneous PTF. Subjects: Four consecutive patients with surgically inaccessible benign proximal tracheal stenosis. Methods: The silicone stents were placed under general anesthesia via the rigid bronchoscope. The PEG-tube fasteners were placed under sterile conditions with direct bronchoscopic visualization. The needle was inserted through the neck and the silicone stent. The T-bar was deployed with a stylet, and the suture was tightened until the T-bar was flush with the wall of the stent. The external suture of the fastener was clamped with a metal clamp flush with a cotton pledget on the surface of the neck. A small amount of "play" was left in the suture for movement of the suture with the neck. Routine follow-up occurred as outpatients. Patients covered the external portion of the PTF with a waterproof dressing when showering. Results: All four PTFs were placed without complications. Late complications included a local cellulitis and a PTF suture breakage. No case of stent migration occurred while the fastener was in place. Two stents were removed due to patient intolerance at 1 week. Discussion: Placement of silicon stents is effective in treating benign tracheal stenosis. However, migration of silicone stents is noted. Securing the stent for a period of time allowing the studs to seat into the tracheal wall may help prevent this complication. Our experience with the PTF utilized for this purpose supports this idea. Modifications to the PTF may be required to allow for long-term use without late complications. Modifications could include a nonpermeable buttress such as a silicone bead and synthetic suture material less prone to breakage. Conclusions: In our small prospective sample, securing silicone stents in the proximal trachea was feasible, successful at preventing migration and safe to perform, but modifications to the PTF may be needed for long-term use.
Pilot study of a novel bronchoscope with a built-in miniature video screen, camera and light
Ali I. Musani
National Jewish Health, Denver, Colorado, United States
Objectives: To evaluate the performance of a mobile bronchoscope with miniature video screen, light source and a digital camera. Design: Prospective study. Setting: Inpatient and outpatient tertiary care center. Interventions: None. Patients: Twenty patients who were undergoing diagnostic or therapeutic bronchoscopies from May 2009 to July 2009. Results : Thirteen of the patients underwent bronchoscopy via the oral and nasal approach; 2, via a tracheostomy; and 5, via an endotracheal tube or laryngeal mask airway. The scope was also used in the placement of a percutaneous tracheostomy tube and in the operating room for a procedural intubation. The overall performance of mobile bronchoscope was satisfactory. The majority of difficulties encountered by the bronchoscopists came from the performance of the monitor. The main issue was the need to turn the screen in order to view the image in an upright position. Conclusions: The airway mobile scope is well suited for rapid airway examination and interventions often needed in emergency rooms, intensive car units, operating rooms and in office settings. The ease of use of the bronchoscope could be enhanced with small changes to the display of the image on the LCD screen.
A pilot study of the feasibility of confocal endomicroscopy for examination of the human airway
National Jewish Health, Denver, Colorado, United States
Background: Traditional methods of evaluating human airway histology, such as surgical biopsy or endobronchial biopsy, are limited by risks associated with these tissue-sampling procedures. Objective: To develop and evaluate the first confocal endomicroscope for real-time, in vivo imaging of human respiratory mucosa in a clinical setting. Methods: A confocal endomicroscope prototype was designed using Pentax bronchoscope parts (EB1970K). Airways of adult subjects (n=5) undergoing rigid bronchoscopy for various clinical indications were imaged with the confocal endomicroscope following IV administration of fluorescein sodium. The device was introduced into the airways via the rigid bronchoscope. Images were collected from the trachea, primary and secondary carinae, and any endobronchial mass. The images were compared to those obtained from histologic sections from conventional endobronchial biopsies. Results: Confocal endomicroscopy provided real-time images of cellular and subcellular structures of the respiratory mucosa and submucosa in vivo. The pseudostratified columnar epithelium (including columnar cells and goblet cells) could be visualized. Images obtained at increasing depth revealed the lamina propria and microvasculature. Longitudinal folds in the mucosa enabled imaging in cross section, showing alignment of epithelial cells along the basement membrane and cilia on the surface of cells. Below the epithelium, smooth muscle could be identified. In images from a subject with an endobronchial adenocarcinoma, confocal imaging could distinguish between normal airway epithelium and malignant tissue. Conclusions: Confocal endomicroscopy is a feasible method for analyzing human airway wall architecture and endobronchial abnormalities in histologic detail in vivo.
Management of malignant pleural effusion with small-bore indwelling pleural catheters
National Jewish Health, Denver, Colorado, United States
Objective: 1) To ascertain if long-term alleviation of symptoms and spontaneous pleurodesis can be achieved in malignant pleural effusions (MPEs) by using a small-bore pleural catheter (PC) without using sclerosing agents in outpatient and inpatient settings. Design: Retrospective chart analysis of both inpatients and outpatients having PCs placed for recurrent, symptomatic MPEs. Setting: Tertiary urban hospital pulmonary outpatient practice. Patients: A total of 102 patients with recurrent and symptomatic MPEs. Interventions: Placement of PCs under local anesthesia in a bronchoscopy suite followed by frequent drainage of pleural fluid of up to 1.5 L on every other day. Measurements: Percentage of patients and the time required for achieving pleural symphysis by alternate-day drainage of MPE via the PC, and complications related to the placement and maintenance of the PC. Results: A total 102 patients with PCs were studied from January 2002 to August 2005. Based on previous studies, our arbitrary cut off time for achieving pleurodesis was 60 days. Forty out of 51 outpatients reached 60 days or beyond mark. Seventeen (42.5%) of these 40 patients achieved partial or complete pleurodesis in a mean time of 28 days (range, 7-55 days). Ten more pleurodesis occurred after 60 days cut off period. With a similar cut off period of 60 days, 33 out of 51 inpatients reached or passed that mark. Seventeen (51.5%) patients developed partial or complete pleurodesis in a mean time of 30.29 days (range, 7-59 days)
Predictors and outcome of unplanned extubation in COPD patients
Amany Esmail Zeidan
Faculty of Medicine, Mansoura University Hospital, Mansoura, Egypt
Background: Unplanned extubation (UE) is one of the major complications in mechanically ventilated patients; however, its impact on mortality, duration of mechanical ventilation (MV), length of stay in intensive care unit (ICU) and length of hospital stay, as well as predictors for its incidence and need for ongoing hospital care, had not been adequately defined. Aim: The aim of this study was to identify the predictors and the outcome of unplanned extubation in COPD patients. Study Design: Case-control retrospective study in which retrieved data of UE COPD patients were compared to those of planned extubation COPD patients. Patients and Methods: A retrospective, case-control study included screening database of ventilated COPD patients in pulmonary critical care unit, Pulmonary Medicine Department, Mansoura University Hospital, in the period between June 2006 and June 2008. The data of 40 UE COPD patients were compared to those of control group consisting of 40 planned extubated matched COPD patients. The variables collected on each patient included patient demographics, admission APACHE II score (acute physiology and chronic health evaluation score II), major comorbidities, multiple-organ dysfunction score (MODS) and ventilation parameters. Result: Unplanned extubated COPD patients were associated with a statistically significant prolonged duration of MV, ICU stay and hospital stay (10.2, 13.4, 19.3 days) compared to 7.1, 10, 14 days in planned extubated COPD patients, respectively. No significant difference in mortality rate was found in planned (22.5%) compared to unplanned (27.5%) extubation COPD patients. However, statistically it was significantly higher in those who needed reintubation in the unplanned group. The odds ratio was 3.34 for agitation; its P value was .03; its P value was .001 for PaCO 2 as a predictor for UE in COPD patients. Hyponatremia, hypoalbuminemia and hypocalcemia were statistically significantly lower in those who needed re-ventilation in the UE group, but creatinine and APACHE II were higher. Conclusion: Increasing agitation and rising PaCO 2 can predict UE in COPD patients. Ventilating COPD patients using dual mode may ameliorate the chances of VAP, etc comorbidity, MODS, hypoalbuminemia, higher APACHE II score and older age were associated with the need for reintubation in UE COPD patients.
In vivo transformation of lung cells with apoprotein E-derived peptide conjugated to polylysine (apoEdp-PLL): A non-viral vector for gene therapy
Isfahan University of Medical Sciences, Isfahan, Iran
Gene therapy is defined as the technology by which genes, small DNA or RNA molecules, are delivered to human cells, tissues or organs to correct a genetic defect or to provide new therapeutic functions for the ultimate purpose of preventing or treating diseases. It is an exciting field of biomedicine that has the potential to benefit patients affected by particularly complex diseases like cancers. A wide range of viral and non-viral vectors have so far been used, each with specific strengths and weaknesses, and numerous attempts have been made to overcome these hurdles in order to optimize gene therapy protocols. For diseases with challenging current line of treatment, the innovative strategies like gene therapy are highly demanded. Two diseases, viz., cystic fibrosis (CF) and α1-antitrypsin (α1-AT) deficiency, are relatively common single-gene disorders for which the genetic basis is known and for which current treatment strategies are not curative. On the other hand, lung cancers with multifactorial nature are an interaction between complex genetic and environmental factors. Attempts have been made to treat both categories by gene therapy. For any sort of gene therapy, we need to develop a nontoxic, nonimmunogenic, cost-effective approach with good transformation/ expression efficiency for target organ. Here we report the development of a non-viral vector using LDL receptor-mediated pathway for transporting genetic materials to the lung tissue. A tandem dimmer sequence of apoprotein-E conjugated to polylysine was used as DNA delivery vector for in vivo transformation of lung. pCDNA3.1 plasmid complexed with apoEdp-PLL harboring beta-galactosidase reporter gene was injected to the tail vein of 5 male Balb/c mice. Frozen sections were prepared 2 days after injection from lung tissue and stained with X-gal for transgene activity assay. Beta-galactosidase reporter gene activity detection kit (Sigma, USA) was used for quantitative assessment of gene expression. The beta-galactosidase activity level of 180 ng/mg of protein was detected, which is indicative of acceptable transformation and activity of the transgene in the lung tissue. In all control tissues tested, the value was 0.05 ng/mg. The results are very encouraging for in vivo-targeted transformation using the constructed vector for gene delivery to the lung. Using specific promoter for exclusive gene expression in lung tissue, virtually any gene, for cancer or monogenic diseases, could be targeted to the lung tissue.
Evaluation of difficulties in diagnosis and treatment of pneumococcal infections
Oskoui M., Nobari S., Rahmati ghezelgeh F., Farrokh P.
Department of Bacteriology, Pasteur Institute of Iran
Background: Pneumonia is caused by microbial infection in the lung. Streptococcus pneumoniae is the most important bacterial pathogen of the respiratory tract, especially for pneumonia. The emergence and spread of resistance to commonly used antibiotics has now challenged the treatment of pneumococcal infections. The evolution of strains of S. pneumoniae resistant to penicillin has created difficulties worldwide in selecting an appropriate chemotherapeutic agent. Accurate identification is crucial for correct diagnosis and treatment of patients with pneumonia; however, because of the emerging of optochin resistance, misidentification of pneumococcal strains can occur in laboratories, and it can cause an overestimate of antimicrobial resistance. Methods: A total of 300 samples were collected from patients of clinical centers in Iran, during the period 1998 to 2009. All isolates were tested by biochemical tests such as alpha-hemolysis on chocolate agar, catalase test, optochin susceptibility and bile solubility. pbp2b, psaA and atpC genes were amplified with pneumococcal specific primers by PCR and then sequenced. Susceptibility testing was done by disc-diffusion method for antibiotics, which included oxacillin, erythromycin, cefotaxime, cotrimoxazole, vancomycin and tetracycline; discs and MIC were determined by broth micro-dilution method for penicillin. PFGE was done for all isolates. Results: From a total of 300 collected isolates, 68 isolates were identified as Streptococcus pneumoniae after using biochemical tests and molecular methods. Of these 68 isolates, 57 (83.8%) were optochin susceptible and bile soluble, 7 (10.3%) were optochin resistant (zone was less than 14 mm) and bile soluble and 4 (5.8%) were optochin resistant and bile insoluble; these equivocal strains were determined as Streptococcus pneumoniae by PCR and sequencing of pbp2b, atpC and psaA genes. We have seen an increasing level of penicillin resistance (MIC ≥3.2 μg/mL) in the newest isolates. After PFGE, resistant isolates showed different patterns. Conclusion: The results showed that the profiles of antibiotic resistances in S. pneumoniae have been changing in recent years in Iran, and antibiotic resistance has become a major concern. Optochin-resistant strains of Streptococcus pneumoniae in Iran have been increasing in parallel to other countries. A-hemolytic streptococci resistant to optochin should be checked for bile solubility in clinical laboratories. We showed that molecular methods have higher sensitivity and specificity than phenotypic tests for identification of Streptococcus pneumoniae. We predict that emergence of resistance will prove to be a major drawback with increased use, as has been seen for other antibacterial agents.
Knowledge and use of, and attitude towards, inhaled steroids among asthmatics attending the outpatient clinic in Alshaab Hospital, Khartoum, Sudan
Omer Elgaili Yusuf
Shaab Teaching Hospital, Khartoum, Sudan
Background: Asthma is a chronic inflammatory disease of the airways that needs chronic treatment with inhaled steroids and long-acting beta agonists. With such medications, patient education is essential for successful management. We examined the knowledge and use of, and attitude towards, inhaled steroids as chronic treatment of bronchial asthma among asthmatic patients. Methodology: Data was collected by interviewing a randomly selected group of patients attending the Alshaab Hospital for chest medicine in Khartoum, Sudan, in a period of 1 month (20 th August to 20 th September 2009), and the data was descriptively analyzed. Results: A total of 210 patients were included, with 100% response rate. Almost 95.1% of the patients knew inhaled steroids as asthma treatment, but less than half (46.4%) knew the difference between the "reliever" and "preventer" inhalers, and 54.5% could mention one possible side effect of inhaled steroids. Although 89.1% of the patients knew that inhaled steroids are useful, yet only 35.5% of the patients knew the exact role of inhaled steroids in asthma treatment; and 62.7% of the patients thought that inhaled steroids might be harmful. However, 93.6% of the patients consented to the continuous use of inhaled steroids, but still, 44.5% of the patients were afraid of becoming dependent on inhaled steroids. Strangely, 18.2% of the patients thought that inhaled steroids may exacerbate asthma; consequently, 45.5% of the patients stopped their inhaled steroids and 95% of the patients do use their inhaled steroids in acute attacks of asthma. Forty-five percent of the patients were not aware of the need for gargling after inhaled steroid use, and 48.2% of the patients increased the dose frequency themselves. About half (56.4%) of the patients knew the spacer, and 11.8% of them are using it. Conclusion: There is a lack of essential information among asthmatic patients about inhaled steroids, such as the difference between the "reliever" and the "preventer" inhaler and the side effects and how to minimize them. The fear of becoming dependent on inhaled steroids and the rumors that inhaled steroids might be harmful are widespread. But in spite of the previously stated facts, there is clear abuse of inhaled steroids, like using them for treating asthma exacerbations and increasing the dose without referring to the treating doctor. Therefore, intensive patient education, counseling and continuous monitoring of patients' knowledge, attitude and practices regarding inhaled steroids are highly recommended.
Idiopathic pulmonary fibrosis in Iran
Mohammad Reza Masjedi, Neda Hashemi, Atefe Fakharian, Mehran Marashian
Iranian National Research Institute of Tuberculosis and Lung Diseases (NRITLD)
Background: More patients have been diagnosed with Idiopathic pulmonary fibrosis (IPF) in the last two decades than in the past; however, there is still no effective therapeutic intervention discovered, and patients continue to progress to respiratory failure. Since there is scarce documented data on IPF in Iran, we decided to collect information from registered patients to find out the epidemiological, clinical and radiological features, as well as the course and outcomes, of the disease. Materials and Methods: This is a retrospective analysis of symptoms, signs, radiology, lung biopsy, course and outcome in IPF patients in the National Research Institute of Tuberculosis and Lung Diseases (NRITLD) and the Respiratory Clinic between 1988 and 2008. Results: A total of 132 patients were included in this study. Their mean age was 56.56 ± 16.1 years, and 67 (50.8%) were male and 31 (23.4%) had smoked sometimes throughout their lives. Dyspnea (68.2%) and cough (60.6%) were the most common presenting symptoms, and crackles and finger clubbing were found in 85.6% and 55.3% of the patients, respectively. HRCT was performed in 47.7% of the cases, with reticular and reticulonodular opacities being the most common patterns. HRCT was not used in some cases because it was not a routine test in IPF diagnosis earlier. In terms of percentage, 59.1% of the patients had a lung biopsy, which was reported to be diffuse interstitial fibrosis in 91.1% of them. Sixteen patients died within a mean time of 10.44 ± 14.8 months from their first visit, at a mean age of 56.8 ± 20.8 years, which was significantly lower than the life expectancy in Iran (P=.017). The mean survival time was 13.7 years, and the 1- and 3-year survival rates were 88% and 79%, respectively. Conclusion: IPF is now diagnosed more commonly in Iran, with similarities in clinical patterns to cases elsewhere, but Iranian patients may be developing the disease a decade earlier and with a higher survival rate than the patients in western countries.
Awake anesthesia for major thoracic surgical procedures: An observational study
KAMC-Riyadh, Kingdom of Saudi Arabia
Objective: Major thoracic surgical procedures are rarely performed under awake anesthesia. The purpose of this study was to review the experience of a tertiary center in major thoracic surgical procedures done under awake anesthesia. Methods: This single-center, single-operator, retrospective review of cases of thoracic surgery done under awake anesthesia included all patients operated upon in the period from September 2002 to September 2006. Thoracic epidural anesthesia was done either between T1-T3 or T4-T6 depending on the type of procedure. The block level was verified using warm-cold discrimination. In addition, stellate ganglion block was performed in some patients to achieve cough control. The following data were documented: patients' demographics, the type and approach of procedure, operative time, intraoperative complications, conversion to general anesthesia, mortality, the need for intensive care unit (ICU) admission and postoperative hospital length of stay. Results: A total of 79 surgical procedures were performed over the study period. The mean age of the patients was 37 ± 18 years (males, 59%). Twenty-five (32%) of the patients underwent thymectomy; 11 (13%) patients, lung resection; and 8 (11%) patients, symphathectomy. The most common approach was thoracoscopy in 61 (77%) patients, followed by thoracotomy in 11 (14%) patients and median sternotomy in 3 (4%) patients. The median postoperative hospital stay was 1.5 days, with 33% of patients discharged on the same day of operation (day surgery). Only 5 (6%) patients were admitted to the ICU; of these, 3 patients (in 2002) did not need ICU admission, but epidural policy at that time mandated ICU admission; only 2/79 (2.5%) required ICU stay. One patient died as a result of his underlying metastatic hepatocellular carcinoma 9 days postoperatively. One other patient was converted early to general anesthesia prior to pneumonectomy after discovery of left upper lobe involvement, and he died 3 months later. There was no anesthesia-related mortality. Conclusions: We conclude that major thoracic procedures can be safely performed under awake anesthesia. The technique avoids general anesthesia and endotracheal intubation, reduces postoperative hospital stay and minimizes intensive care unit admission. This study strongly suggests awake anesthesia can improve outcomes and reduce cost. A proper multi-center trial to further evaluate this technique is needed.
Sodium oxybate in patients with refractory cataplexy: A university center experience
Mashael K. Alshaikh
University Sleep Disorders Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
Background: Narcolepsy with cataplexy is a disabling sleep disorder affecting around 40/100,000 Saudis. It is characterized by severe irresistible attacks of sleep and sudden loss of muscle tone (cataplexy) and can be associated with sleep-onset or sleep-offset paralysis and hallucinations, as well as weight gain. (1) Some patients continue to have frequent attacks of cataplexy despite using standard treatment. Sodium oxybate (Xyrem) has been approved recently to treat patients with refractory cataplexy. (2) Nevertheless, the clinical experience with this medication is still limited, especially in children, elderly and patients with concomitant obstructive sleep apnea (OSA). (3) In this report, we describe the response of 4 Saudi patients who had intractable cataplexy despite high dose of standard first line treatment with sodium oxybate. Methods: In this observational study, we describe 4 patients with intractable cataplexy who were started on sodium oxybate. Patient 1 was 23 years old, patient 2 was 17 years old, patient 3 was 11 years old and patient 4 was 70 years old with concomitant severe OSA. Sodium oxybate was initiated for all patients in the sleep disorders center (SDC) under polysomnography monitoring. The dose was built up every month until symptoms were controlled, side effect appeared or we reached the maximum dose of 9 g. Patients were followed up monthly in the first 6 months of starting the treatment. Complete history was obtained and physical checkup done during each visit. Our follow-up team was composed of a sleep medicine specialist, clinical pharmacist, a nurse and sleep technologist. Patients had a 24-hour telephonic access to a member of the team. Results: On an average, each patient underwent 4 sleep studies during sodium oxybate titration and was followed up for around 2 years after starting treatment. The dose needed to control symptoms ranged from 5 to 9 g. Cataplexy and sleep-onset hallucinations disappeared in all patients. Additionally, daytime sleepiness decreased in all patients - subjectively, using the Epworth Sleepiness Scale; and objectively, using the Multiple Sleep Latency Test. Polysomnography demonstrated clear reduction in sleep latency, arousal index and stages N1 and N2. Slow-wave sleep (N3) and sleep efficiency improved on sodium oxybate. Of particular interest is the demonstration of the safety of sodium oxybate in a child and an elderly patient with documented severe OSA. CPAP was titrated initially to eliminate all sleep-disordered breathing events, and then sodium oxybate was introduced. Side effects included nausea, snoring, confusion and enuresis. Nevertheless, all side effects disappeared after reducing the dose. Conclusions: Sodium oxybate is an effective and well-tolerated medication for patients with cataplexy. Nevertheless, it needs special monitoring and follow-up by a specialized center.
- Dauvilliers Y, Arnulf I, Mignot E. Narcolepsy with cataplexy. Lancet 2007;369:499-511.
- Mohsenin V. Narcolepsy-master of disguise: evidence-based recommendations for management. Postgrad Med 2009;121:99-104.
Co-culture with eosinophils enhances airway smooth muscle cell proliferation
Rabih Halwani 1 , Saleh Al-Muhsen 1,2 , Hamdan Al-Jahdali1 3 , Yuki Sumi 4 , Qutayba Hamid 1,4
1 Asthma Research Chair and Prince Naif , Center for Immunology Research, King Saud University; 2 College of Science, King Saud University, 2 Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia; 3 King Abdulaziz Medical City, Riyadh, Saudi Arabia; 4 Meakins-Christie, Laboratories, Faculty of Medicine, McGill University, Montreal, Quebec, Canada;
Background: Asthma is a chronic inflammatory disorder of the lung airways that is associated with airway remodeling and hyper-responsiveness. It is well documented that the smooth muscle mass in asthmatic airways is increased due to hypertrophy and hyperplasia of the airway smooth muscle (ASM) cells. Moreover, eosinophils have been proposed in different studies to play a major role in airway remodeling. Here, we hypothesized that eosinophils modulate the airways through enhancement of ASM cell proliferation. Objective: The aim of this study was to examine the effect of eosinophils on ASM cell proliferation using eosinophils isolated from asthmatic patients and normal control subjects. Methods: Eosinophils were isolated from peripheral blood of 6 mild asthmatics and 6 normal control subjects. ASM cells were incubated with eosinophils or eosinophil membranes, and ASM proliferation was estimated using thymidine incorporation. The mRNA expression of extracellular matrix (ECM) in ASM cells was measured using quantitative real-time PCR. Results: Co-culture with eosinophils significantly increased ASM cell proliferation. However, there was no significant difference in ASM proliferation following incubation with eosinophils between asthmatic patients and normal control subjects. Co-culture with eosinophil membranes had no effect on ASM proliferation. Moreover, there was no significant change in the mRNA expression of ECM proteins in ASM cells following co-culture with eosinophils when compared with medium alone. Conclusion: Eosinophils induce ASM cell proliferation independent of ECM synthesis.
IL-17 enhances B-cell migration towards basal membrane in severely asthmatic airways
Rabih Halwani 1 , Saleh Al-Muhsen 1,2 , Qutayba Hamid 1,3
1 Asthma Research Chair and 2 Prince Naif Center for Immunology Research; 3 King Saud University, Riyadh, Saudi Arabia
Background: The increase in ASMC mass is a major structural change described in asthma. This increase has been attributed to ASMC hyperplasia and hypertrophy. Recent studies have suggested a role of chemokines in SMC migration towards the epithelium. B-cells play an important role in asthma development, mostly via the production of IgE, which contributes ultimately to the pathology of allergic asthma. Although few reports have indicated the local production of IgE in lung tissues, B-cell infiltration into the inflamed lung tissue has not been thoroughly investigated. B-cells have been reported to form germinal centers in inflamed tissues in many chronic diseases. Objective: To determine the level of infiltration of B-cells into inflamed lung tissue in severe compared to mild asthma patients, as well as COPD patients. The mechanism behind this infiltration will also be investigated. Methods and Results: Lung tissues from severe and mild asthmatic patients, as well as COPD patients, were stained for B-cells using immunohistochemistry. Interestingly, B-cell germinal centers were observed in lung tissue from severe but not mild asthmatic patients. The mechanism behind this phenomenon was then explored. Role of IL-17 in triggering B-cell migration was investigated. Migration towards IL-17 gradient was determined using Boyden chamber. Although B-cells were shown to migrate towards both IL-17A and IL-17F, much lower concentrations of IL-17F, compared to IL-17A, were sufficient to induce migration. Moreover, B-cells within germinal centers in the lung tissue of severe asthmatic as well as COPD patients were shown to express higher level of IL-17R compared to those of mild asthmatic patients, using immunohistochemistry as well as qPCR. Conclusions: IL-17 drives the migration of B-cells in the lung tissue and plays a critical role in the formation of germinal centers in the airways of severe asthmatic patients.
An unusual endobronchial presentation of a common disease
R. Narasimhan, A. R. Gayathri
Department of Respiratory Medicine, Apollo Hospitals, Chennai, India
Tuberculosis is a common infectious disease in humans, caused by Mycobacterium tuberculosis. One third of the world's population has been infected with tuberculosis. Endobronchial tuberculosis is tuberculous infection of the tracheabronchial tree, with microbiological and histopathological evidence. It is seen in 10% to 40% of patients with active tuberculosis. We describe a case of a 47-year-old nonsmoker, HIV negative, who presented with dry cough, breathlessness, hoarseness of voice and low-grade fever of 6 months' duration. His chest x-ray was normal. CT scan of the chest revealed irregularity of the anterior tracheal mucosa. Bronchoscopy was done, and it showed ulcerated vocal cords and pseudomembrane formation of the lining mucosa of the trachea and bronchi. BAL revealed presence of many AFB. Endobronchial biopsy showed granulomatous inflammation consistent with tuberculosis. The presentation of endobronchial tuberculosis with pseudo-membrane formation of the mucosa of trachea and bronchi is unusual. The patient was started on anti-tuberculosis therapy with 2 months of Isoniazid, Rifampicin, Ethambutol and Pyrazinamide, followed by 7 months of Isoniazid, Rifampicin and Ethambutol. A short-duration course (4 weeks) of oral steroids was also initiated. At the end of 9 months of anti-tuberculosis therapy, the patient's repeat bronchoscopy revealed residual tracheal stenosis in lower one third of trachea, which was managed conservatively.
The role of thoracic surgery in the management of complicated swine flu
King Fahd University Hospital, University of Dammam, Al Khobar, Saudi Arabia
Background: After the first reported case of H1N1 in Mexico on March 18, 2009, the outbreak was subsequently confirmed worldwide. H1N1 pandemic has reached the Kingdom of Saudi Arabia after the first case reported in June 2009, and so far around 14,500 cases have been reported, with mortality of about 0.9%. The role of infectious disease team and intensive care is very well reported in the literature in the management of fatal complication of H1N1 infection, such as acute respiratory distress syndrome (ARDS), with variable outcome. There is no mention about the role of thoracic surgery in the management of other pleuropulmonary complications associated with this infection. We report 5 cases of such surgical complications which were managed successfully by the thoracic surgeon in our university hospital. Methods: Proven cases of H1N1 that developed pleuropulmonary complications and necessitated thoracic surgery intervention in Eastern Province University Hospital in the Kingdom of Saudi Arabia were reviewed. Results: Out of a total of 97 proven cases of H1N1 in our hospital, 5 (4.8%) patients, 4 female and 1 male, developed pleuropulmonary complications and underwent surgical interventions. The mean age was 27 ± 16.6 (SD) years (range, 6-48 years). One (20%) patient out of 5 underwent right middle lobe lobectomy for necrotizing pneumonia complicated by lung abscess and persistent bronchopleural fistula. Two (40%) patients developed pneumothorax and required chest tube insertion. One (20%) patient developed massive pleural effusion with respiratory compromise and required thoracoscopic drainage. One (20%) patient developed empyema and underwent thoracoscopic drainage and decortications. All the patients recovered well postoperatively except one patient of pneumothorax, who died because of severe ARDS and myocarditis, and mortality was not related to the surgical intervention. The risk factors related to surgical complications were not different from the usual risk factors for the infection itself, viz., pregnancy, co-medical morbidities and the patient being a child. Conclusion: It is very important to increase awareness among the medical fraternity about the surgical complications of H1N1 infection, and timely interventions helped in improving patient care and overall outcome.
Elevated exhaled nitric oxide in asymptomatic asthmatics taking bronchodilators on demand with controlled body composition
Syed Shahid Habib
Department of Physiology, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia
Objectives: Fractional exhaled nitric oxide (FENO) is a recently introduced noninvasive marker to measure inflammation and oxidative stress in the lung. This study aimed to measure FENO in Saudi asthmatic adult patients who had mild-to-moderate persistent asthma and in whom symptoms were controlled by inhaled short-acting β-2 agonists on demand only, and compare them with healthy individuals matched for body composition without any evidence of obstructive airway disease. Methods: As per selection criteria, 61 subjects were finally selected. Of these, 30 subjects were known asthmatic patients, and 31 were healthy individuals matched for age, height, weight, BMI and body composition. Forced expiratory volume in 1 second (FEV1), FVC, FEV1/ FVC, PEF, FEF25, FEF50 and FEF75 were measured by standard methods. FENO measurements were performed by chemiluminescence procedure using single-breath technique according to the recent guidelines of ATS (American Thoracic Society). Results: Ventilatory function parameters - FEV1 (P= .0020), FVC (P=.0030), PEF (P=.0121), FEF25 (P=.0241), FEF50 (P=.0240) and FEF75 (P=.1824) - were significantly lower in asthmatic subjects compared to matched healthy controls. FENO was significantly higher (82.51 ± 39.26 ppb) in asthmatic subjects compared to controls (23.03 ± 8.56 ppb) (P < .0001). Conclusion: FENO levels are increased in patients with bronchial asthma with mild-to-moderate symptoms with patients taking bronchodilators on demand only. It may be suggestive of the need for more accurate evaluation and early intervention with anti-inflammatory drugs in a significant proportion of these patients.
Coal dust impact and the presence of pulmonary chronic obstructive disease in workers exposed in Kosovo power plant
Sanije, Xhevdet 1 , Xhemajli 2
Institute of Public Health of Kosova, Peja, Kosova; 1 KSA-KFMC-Riyadh; 2 QDT "Galaxy" , Prishtinw, Kosova
Chronic obstructive pulmonary disease (COPD) is a condition that is characterized by airflow limitation that is not fully reversible and worsens with time. Worldwide, cigarette smoking is the most commonly encountered risk factor for COPD; although in many countries, air pollution resulting from coal dust or from the burning of wood and other biomass fuels has also been identified as a COPD risk factor. The purpose of this study was to determine the role of coal dust air pollution as a risk factor for COPD, as well as the associated presence of COPD in exposed workers. This study was done in the Institute of Occupational Medicine in Obiliq, Kosovo. The group exposed to coal dust comprised of workers in the maintenance department, while the control group comprised of workers from another department with a lower level of coal dust air pollution. Both groups together included 192 workers. We tested the coefficient and the correlation parameters 'a' and 'b' for regression. Differences between variables were tested with t test and X 2 test. The average value of FVC (forced vital capacity) for all examined workers was 4.62, with variability from minimum 2.41 to maximum 7.13, without significant changes between groups. Differences were found within each group, among workers with exposure up to 19 years and those with exposure of over 20 years. Thus-obtained values of average FVC were lower in workers with longer exposure. High negative coefficient of linear correlation was found in both groups. In the exposed group, r = −0.35; whereas in the control group, r = −0.46. The average value of FEV1 (forced expiratory volume in 1 second) for all workers was 3.69, with variability from minimum 1.99 to maximum 5.68, without significant changes between groups. In the control group, the difference was 3.53 for exposure of more than 20 years, as compared to 3.94 for those with exposure up to 19 years. In general FEV1/FVC ratio for all workers showed lower obtained values than predicted values, and the average difference was −0.36, with variability from −25.00 to +20.00. Workers with longer exposure and older age are more affected by coal dust than those with shorter exposure and younger age. Coal dust along with smoking affects the reduction of values of the FVC parameters.
The use of thoracoscopy to improve medical students' interest and understanding of thoracic anatomy: A pilot study
Sami A. Alnassar
College of Medicine, King Saud University, Riyadh, Saudi Arabia
Objective: The evolution of minimally invasive surgery (MIS) has a great potential for improving both health care and medical education. MIS thoracoscopy can be a useful teaching tool offering a link between clinical medicine and basic science. Our objective was to develop a video-based educational tool designed for learning thoracic anatomy and to examine whether this tool would increase students' stimulation and motivation for learning anatomy. Methods: Our video-based tool was developed by recording different thoracoscopic procedures focusing on intraoperative live thoracic anatomy. The tool was then integrated into a preexisting program for first year medical students (n= 150), and it included cadaver dissection of the thorax and review of clinical problem scenarios of the respiratory system. Students were guided through a viewing of the videotape which demonstrated live anatomy of the thorax (15 minutes) and then asked to complete a 5-point Likert type questionnaire assessing the video's usefulness. Results: Questionnaires were completed by 119 medical students. Most students were satisfied with the thoracoscopic video as a teaching tool (mean score, 4.39 ± 0.65) and thought that it increased their interest in learning (mean score, 4.63 ± 0.58) and their understanding of thoracic anatomy (4.10 ± 0.89). The majority would like to see this new teaching tool incorporated into the anatomy curriculum (mean score, 4.60 ± 0.66). The video presentation also increased students' interest in surgery as a future career (mean score, 4.19 ± 0.83). Conclusion: Incorporating live surgery via thoracoscopic video presentation in the gross anatomy teaching curriculum had high acceptance and satisfaction scores among first year medical students. The video increased students' interest in learning, in clinically applying anatomic facts and in surgery as a future career. Future studies will include a randomized controlled trial to evaluate the objective gain in knowledge associated with this teaching tool.
The emergence of Beijing genotype of Mycobacterium tuberculosis in the Kingdom of Saudi Arabia
King Faisal Specialist Hospital and Research Centre. Tuberculosis Research Unit-Research Centre, Riyadh, Saudi Arabia
Objective: To investigate the prevalence of Beijing genotype strains of Mycobacterium tuberculosis in the Kingdom of Saudi Arabia. Materials and Methods: We analyzed available data on a total of 1505 strains isolated during 2002-2005. Results: Spoligotyping revealed that Beijing family isolates represented 4.5% of all isolates. Conclusion: The occurrence of Beijing genotype was associated with young age and drug resistance. It affected both Saudi nationals and migrants originating from Asia. Our data argues in favor of both ongoing transmission and imported cases of the disease due to the Beijing genotype. Further studies covering the period 2006-2008 are needed to reveal the real impact of Beijing genotype on prevailing tuberculosis epidemiology in Saudi Arabia.
Effects of some CC and CXC chemokines on airway smooth muscle cell proliferation and survival
Al-Muhsen, Saleh Zaid
Asthma Research Chair and Prince, Naif Center for Immunology Research, King Saud University, Riyadh, Saudi Arabia
Background: The increase in airway smooth muscle cell (ASMC) mass is a major structural change described in asthma. This increase has been attributed to ASMC hyperplasia and hypertrophy. Recent studies have suggested a role of chemokines in SMC migration towards the epithelium. Objectives: The objective of the current study was to test the hypothesis that chemokines (eotaxin, RANTES, IL-8 and MIP-1a) can increase the rate of proliferation and enhance the survival of ASM cells. Methods : ASMCs were exposed to different concentrations of eotaxin, RANTES, IL-8 or MIP-1α. To test for proliferation, stimulated ASMCs were pulsed with 3H-thymidine or ASMCs were stained with BrdU and then analyzed with flow cytometry. Apoptosis was measured using Annexin-V and flow cytometry. Results: In a concentration-dependent manner, chemokines such as eotaxin, RANTES, IL-8 and MIP-1α increased ASMCs'' 3H-thymidine incorporation and DNA synthesis. IL-8, eotaxin and MIP-1α decreased the number of apoptotic ASMCs compared to the matched controls. Conclusions: We conclude that chemokines might contribute to airway remodeling seen in asthma by increasing ASM mass through enhancement of ASMC proliferation and survival.
Genetic mutations in Turkish patients with pulmonary embolism and deep venous thrombosis: A preliminary study
Baskent University, School of Medicine
Background: Venous thromboembolism (VTE) is a common clinical challenge, being recognized with increased frequency. The importance of genetic thrombophilic factors in the development of VTE has been increasingly recognized. The Factor V Leiden (FVL) and prothrombin 20210A (PT 20210A) mutations are most frequently associated with inherited thrombophilia. Objective: Our aim was to study genetic mutations involving Factor V Leiden (FVL), prothrombin (PT) 20210A, methylene-tetrahydro-folate-reductase (MTHFR), Factor V Cambridge (FVC); and plasminogen activator inhibitor (PAI)-1 (4g4g, 5g5g, 4g5g), alpha-fibrinogen Thr312Ala (H1/H2) polymorphisms in the Turkish population with pulmonary embolism (PE) and deep venous thrombosis (DVT). Methods: Medical records were reviewed for genetic and acquired risk factors, chest X-ray reports, d-dimer levels and computed tomogram (CT) angiography results in patients who were diagnosed to have DVT by bilateral deep venous compression Doppler ultrasonography. Pulmonary embolism was confirmed graded by a CT angiography. (Control group was created from the patients suspected to have DVT but with negative Doppler studies and agreeing to participate in the study.) All venous blood samples were collected before the anticoagulant treatment. FVL, FVC, PT 20210A, MC677T mutations; and PAI-1, alpha-fibrinogen Thr312Ala (H1/H2) polymorphisms were investigated by PCR-RFLP method. Results: A total of 104 patients were included in the study, 68 with PE (M: F= 31:37) and 36 in the control group (M: F= 16:12). The mean age of patients with PE and control group was 54.0 + 19.7 and 48.4 + 14.1 years, respectively. There was no significant difference in the number of subjects with regard to age and gender between the two groups. Gene mutations were found in 59.5% and 61.3% of males and females, respectively. In the control group, gene mutations were present in 75% (n= 15) of males and 62.5% (n= 10) of females. There was no significant difference in the gene mutations between the genders in both groups (P > .05). There was no statistically significant difference in the incidence of most gene mutations between the PE and control groups except for FVL. There was no significant difference between any gene mutation and the extent of PE (P > .05). Thirty (73.1%) patients had only 1 gene mutation, 10 (24.3%) had 2 and 1 patient had 3 different gene mutations. Of the 29 non-massive PE patients, 20 had 1 gene mutation, 1 had 3 gene mutations and 8 had 2 gene mutations. Of the 9 sub-massive PE patients, 4 had 1 gene mutation and 1 had 2 gene mutations. Of the 7 massive PE patients, 6 had 1 gene mutation (3 MTHFR/HTRZ, 1 MTHFR/HMZM, 1 PT20210A/HTRZ and 1 FVC/HMZM) and 1 had 2 gene mutations (FVL/HTRZ + MTHFR/HTRZ). Twenty-four percent of patients with DVT had both lower extremities involved. There was no relationship between the age of the patients (above and below 45 years) and incidence of any of the gene mutations (P > .05). Sixty percent of the patients with PE had risk factors for DVT. In terms of percentage, 8.9% of the patients with risk factors for PE were FVL/ heterozygote (HTRZ); 2.2%, FVC/HTRZ; 4.4%, FVC/homozygote mutant (HMZM); 17.8%, MC677T/HTRZ; 13.3%, MC677T/HMZM; and 13.3%, with PT20210A/HTRZ; and 31.1% of them were 4g4g; 51.1%, 4g5g; 17.8%, 5g5g mutant; and 13.3% were H1H2/HTRZ (for all:P > .05). Conclusion: Mutations only involving FVL genetic thrombophilic factor seem to be associated with increased risk of DVT and PE. Unlike prior studies, we did not find any correlation.
Role of tumor necrosis factor alpha gene polymorphism in childhood asthma and wheezy infant
Abla Saleh Mostafa
Cairo University, Dubai
Background: Bronchial asthma is a common complex disease with multiple determinants that include genetic variation, environmental exposures and gene-environment interactions. Tumor necrosis factor (TNF)-alpha has a recognized role in asthma pathophysiology and childhood wheezing, and variation in the locus that affects expression of this cytokine may contribute to asthma occurrence. A genetic predisposition to increased TNF-alpha production, influenced by single-nucleotide gene polymorphisms, may be important. Objective: Our goal was to investigate whether genetic variation in TNF-alpha is associated with asthma and infant wheezing and whether the association is related to the severity of the disease or modified by parental smoking, atopy and other epidemiological factors. Frequencies of TNF-alpha 308G/A polymorphism were compared in 25 asthmatic children, 25 wheezy infants and 15 control school children. Result: For genotype frequencies for the TNF-alpha 308 G/A, ORs were significantly more in asthmatic children as compared to controls (OR, 0.4; 95% CI, 0.1 to 1.9) (P < .001). Also a significantly higher frequency of the GA polymorphism was found in wheezy infants as compared to the control group (OR, 0.2; 95% CI, 0.04 to 0.9) (P < .001). No association was found between the polymorphism and severity of the disease. Exposure to passive parental smoking wasn't a risk factor for the polymorphism, nor did the polymorphism have an effect on the total eosinophil count and total IgE in both groups. Conclusion: Our results suggest that genetic variation, GA polymorphism in TNF-alpha may contribute to childhood asthma and wheezing. These findings may have implications for future early-intervention studies by helping to identify infants and children at increased risk for wheezing and childhood asthma.
Extrapleural pneumonectomy with adjuvant chemo-radiotherapy for treatment of malignant pleural mesothelioma
Abdel Rahman M. Abdel Rahman, Rabab M. Gaafar, Fatma A. Kasem, Hoda A. Baki, Hisham A. Hoseiny
Background: The incidence of malignant pleural mesothelioma (MPM) has been steadily increasing over the past 30 years. It is expected to continue until 2020 all over the world (due to long latency period, 15-40 years). Surgical resection has been considered the mainstay of treatment for malignant pleural mesothelioma by some. However, it is impossible to achieve microscopically complete resection with surgery alone. Methods: Between 2002 and 2006, 52 patients with MPM were operated upon by extrapleural pneumonectomy. Only 36 of these patients completed the assigned tri-modality treatment protocol. Preoperative workup included computed tomography, pulmonary function tests, pleural biopsy, fiber-optic bronchoscopy, full laboratory investigations, echocardiography in patients over 50 years of age. Other investigations such as MRI chest, bone scan, brain CT and ventilation perfusion scan were done when indicated. IMIG staging system was used to stage our patients. Extrapleural pneumonectomy with mediastinal nodal dissection or sampling was done for all patients. We routinely performed bronchial stump coverage for all right-sided lesions using intercostal muscle or azygos vein for safe pulmonary resection. Adjuvant chemotherapy was started within 6 weeks after surgery for every 3 weeks for 6 cycles in the form of Holoxan 1500 mg/m 2 on days 1, 2, 3 and carboplatin (area under curve= 5) on day 1. Radiation therapy was given with 2 parallel opposing fields using linear accelerator, including the entire hemithorax, the ipsilateral mediastinal pleura, the ipsilateral pericardial surface, ipsilateral bronchial stump and the full thickness of the thorax at the site of the thoracotomy incisions and sites of chest drains; a margin of 1 cm was used, with an added separate electron beam field for the operative scar or drain sites in a dose of 45 to 60 Gy. Results: There were 17 males and 19 females; age range was 23-65 years. All patients had asbestos exposure, with duration of exposure ranging between 12 and 46 years. Five patients had positive family history of the disease. Twenty-three patients had right-sided disease and 13 had left-sided disease. By CT scan, 20 patients had unilateral pleural effusion, 13 had diffuse pleural thickening and 3 patients had a combination of pleural thickening and effusion. Preoperative staging revealed 12 patients with stage I and 24 with stage II disease. Postoperative staging showed 5 patients with stage I, 14 with stage II and 17 with stage III disease. Major morbidity developed in 2 patients, while minor complications occurred in 7 patients. Two patients died after surgery. Epithelial histology was found in 27 patients, 7 with mixed histology and 2 with sarcomatiod type. There were 5 patients with N2 disease, 1 with both N1 and N2 disease and 2 with N1 disease only. Recurrent disease developed in 28 patients, 13 with local recurrence, 9 with peritoneal, contralateral hemithorax in 3, contralateral axilla in 1 and bone metastases in 1 and bone and soft tissue metastases in 1 patient. The overall 1-year survival was 83.3%, overall 2-year survival was 52.7%, overall 3-year survival was 19.4% and overall 4-year survival was 14%. Conclusion: Multimodality treatment appears to benefit a subgroup of highly selected patients with MPM.
Pericardial window: Is video-assisted thoracoscopy?
Magdi Ibrahim Ahmad Muhammad
Department of Thoracic Surgery, King Fahd Hospital, Almadinah Almunawarah, Saudi Arabia
Background: The approach to pericardial window in patients with pericardial effusion remains undefined - whether surgical (transthoracic or subxiphoid) or thoracoscopic pericardial "window" is the optimal operative approach to pericardial effusion. We hypothesized that the window into the pleural space created by thoracoscopy might improve outcomes. Methods: Between September 2007 and October 2009, 30 patients (18 men, 12 women; mean age, 44 years) at our department with echocardiographically diagnosed pericardial effusion were studied. Group (A) comprising 15 patients underwent the surgical (transthoracic or subxiphoid) procedure, and 15 patients (Group B) underwent the video-assisted thoracoscopy procedure. Preoperative, intraoperative and postoperative variables, morbidity, recurrence and survival were compared between the both groups. Results: Preoperative variables were more or less the same between the two groups. Operative time and lengths of stay in hospital or intensive care unit were more in the surgical group (A). No differences were observed between the 2 approaches in terms of recurrence of effusion. Conclusions: Pericardial window by video-assisted thoracoscopy is an effective technique for pericardial drainage and biopsy. Apart from its diagnostic value, it allows the physician to fashion a pleuropericardial window for effective drainage while avoiding the complications of classic surgical procedures.
Predicting the appropriate adjustment of mechanical ventilator
H. M. Al-Otaibi, N. M. Bedforth 1 , R. P. Mahajan,
J. G. Hardman
Division of Anaesthesia and Intensive Care, University of Nottingham, U.K.; 1 Department of Anaesthesia, Nottingham, University Hospitals NHS Trust, Nottingham, UK
Background: The main objective of mechanical ventilator (MV) adjustment is to attain desirable pH and arterial blood gases values (ABGs). The purpose of the present study was to evaluate clinicians' accuracy of adjusting MV to achieve desired ABGs. Materials and Methods: Thirty-one sets of data were collected from 16 mechanically ventilated patients in the critical care unit. Each dataset comprised fractional inspired oxygen (F I O 2 ), respiratory rate (RR: breath/minute), tidal volume (V T : mL), minute ventilation (liter/minute), body temperature (°C), hemoglobin (g/dL), pH and ABGs. Data were collected before and 10 minutes after MV adjustment (adjustment of F I O 2 , RR and/ or V T ). Thirty-three clinicians (11 respiratory therapists, 11 nurses and 11 medical staff) were shown all the data except the MV settings after adjustment (F I O 2 , RR and V T ). They were asked to predict the changes in MV that had occurred. All data are presented as a mean (SD) unless stated otherwise. Results: F I O 2 increased in 12 subjects by 0.19 (0.04) and decreased in 19 subjects by 0.13 (0.04). RR and V T increased by 3.6 (2.1) and 26 (18), respectively, and decreased by 2.6 (1.2) and 77 (81), respectively. The magnitudes of changes for PaO 2 and PaCO 2 (absolute, signless values) were 5.91 (3.4) kPa and 0.61 (0.54) kPa, respectively. The 95% limits of agreement (LA 95% ) between measured and predicted magnitudes of changes for F I O 2 , RR and V T are displayed in [Table 1]. Conclusion: Clinicians show considerable variation in estimating the appropriate size of changes for MV parameters. Respiratory therapists overestimate the size of changes for F I O 2 whereas medical staff and nurses underestimate it. All clinicians underestimated the magnitude of changes for RR and V T , implying an expectation of greater changes in patients in response to changes in RR and V T than actually occurs. Our results imply that educational intervention may improve the management of MV in health care staff.
A comparison of methods of predicting arterial partial pressure of oxygen following adjustment of inspired oxygen fraction during mechanical ventilation
H. M. Al-Otaibi, R. P. Mahajan, J. G. Hardman
Division of Anaesthesia and Intensive Care, University of Nottingham, UK
Background: There are many tools to predict the patient's arterial partial pressure of oxygen (PaO 2 ) after adjustment of inspired oxygen fraction (F I O 2 ). However, these tools may be awkward to use in the clinical situation and may be inaccurate. We aimed to assess clinicians' ability to predict PaO 2 using the current "gold-standard" isoshunt diagram and a newly derived formula. Materials and Methods: Following approval by local ethics committee, 15 randomly selected patients whose lungs were mechanically ventilated in the critical care unit were enrolled. A total of 20 datasets were collected before and after adjustment of F I O 2 ; each dataset comprised F I O 2 , minute ventilation (liter/minute), positive end-expiratory pressure (cm H 2 O), hemoglobin (g/dL), pH and arterial blood gas values (ABGs). Twenty randomly selected respiratory therapists predicted PaO 2 after adjustment of F I O 2 using the isoshunt diagram and a newly derived formula: new PaO 2 = new FIO 2 x old PaO 2 / old FIO 2 x k; where k = 1 - ( old FIO 2 - new FIO 2 ) / 2. All data are presented as a mean (SD) unless stated otherwise. Results: F I O 2 decreased, on an average, from 0.6 (0.18) to 0.5 (0.13) units. PaO 2 decreased, on an average, from 21.5 (14.1) to 15.5 (8.3) kPa. The 95% limits of agreement (LA 95% ) between measured and predicted values of PaO 2 were ?2.71 ± 4.54 kPa (isoshunt group) and 0.55 ± 2.6 kPa (new formula group). Predicted and measured changes in PaO 2 . Conclusion: Clinicians achieved poorer accuracy in predicting PaO 2 when using the isoshunt diagram than when using our newly derived formula. The new formula combines ease of use and sufficient accuracy for use in clinical settings.
Genetic markers for asthmatic Saudi population
King Saud University, Riyadh, Saudi Arabia
Background: Asthma is classified as a multifactorial disease with both genetic and environmental factors contributing to its development. Many studies have been carried out to determine the role of genetic susceptibility in the development of asthma. They found heritability risk for asthma is up to 60%. The number of genes contributing to asthma may exceed 100. Most of the genes found are associated with asthma inflammation process. Polymorphisms contributing to innate immune molecules were investigated for their association with asthma. Novel polymorphisms associated with asthma have been identified in multiple populations. Objectives: This study aimed to screen 5 common variants (IL13 Arg144Gln A>G rs20541, IL13 C1111T C>T rs1800925, IL4Ra Ile50Val A>G rs1805010, IL4Ra Gln551Arg A>G rs1801275 and MS4A2 Glu237Gly A>G rs569108) in 3 different genes (IL13, MS4A2 and IL4Ra) which specifically associate with asthma in both adult and pediatric subjects; to determine the common variants in the asthmatic Saudis and allele frequencies of each variant in both asthmatic and normal Saudi individuals and to compare frequency of alleles in the asthmatic Saudis with that in other populations; and, in addition, to identify genetic markers for asthma in the Saudi population. Materials and Methods: The study was approved by the ethics committee at the College of Medicine and King Khalid University Hospital (KKUH), King Saud University, Riyadh, Saudi Arabia. Informed consent was obtained from all study patients; or in case of children, from their guardians. Each subject completed a general questionnaire on respiratory health and family history of asthma. Blood samples were collected from 50 asthmatic adults and 50 asthmatic children attending clinics of the KKUH. The diagnosis was based on routine diagnostic parameters. As controls, blood was also collected from 50 normal, healthy adults attending the blood bank and 50 healthy children not suffering from asthma and attending the hospital for minor illnesses. DNA extraction and genotyping: DNA was extracted using the Illustra blood GenomicPrep Mini Spin kit from GE Healthcare Amersham, UK, according to the manufacturer's instructions. Subjects were genotyped for each polymorphism by direct PCR-sequencing method or real-time PCR for allelic discrimination. Results: Allele associations: We compared the genotype frequencies and allelic to all of the study single nucleotide polymorphisms (SNPs) among asthma patients with those among controls. P value was not significant for all variants except one SNP show association with asthmatic pediatric comparing to their control, although statistically not significant (0.0537). This SNP (rs1801275) in IL4R gene which was located in exon 11. This study polymorphisms Arg144Gln G>A and C1111T C>T effecting IL-13 plasma level in the presence of homozygous mutant allele. Therefore, finding this relationship need to be investigated that had been failed due to absence of the mutant allele but there was a significant difference between the two groups. Population analysis of study SNPs: Our data was compared with that of other populations. There was extreme difference in some populations, which was not the case in other populations. Conclusion: The lack of replication of this association study could be due to the different SNPs tested, to different ethnicity-specific effects of particular SNPs, or to the relatively small number of subjects analyzed in this study. This can be seen clearly with asthmatic pediatric population's result for IL4Rα variant. Larger sample size may reveal strong association.
Screening for genetic variants of IL-4 and ADAM33 genes in a sample from Saudi asthmatic children in Riyadh
Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
Background: There is accumulating evidence that asthma is considered a polygenic disease induced by environmental factors. The studies regarding the association have demonstrated that over 100 variants in candidate genes are associated with asthma in different ethnic groups, including IL-13, IL-5, IL-4R, IL-4, TNF, NOS1 and ADAM33. However, this has never been validated in the Saudi population, and a very limited number of studies have been performed in populations of Arabic descents. Objectives: To examine the frequency of single-nucleotide polymorphisms (SNPs) of selected asthma-related genes (IL-4 and ADAM33) using different genotyping methods in asthmatic Saudi children. Methods: Six SNPs in IL-4 and ADAM33 genes were genotyped in 100 patients with asthma and 100 healthy controls from KKHU in Riyadh. Genotypes were determined by the RT-PCR, RCP-sequencing, multiplex ARMS and RFLP. Data were analyzed using the SPSS software. Results: The allele frequency of all SNPs was determined. Our preliminary results indicated a significant association of ADAM33 and IL-4 polymorphisms with asthma susceptibility in Saudi asthmatic population compared to controls. The association of ADAM33 and IL-4 polymorphisms with asthma phenotype is now being investigated. Conclusion: These preliminary results indicate a significant association between selective single-nucleotide polymorphisms (SNPs) of IL-4 and ADAM33 and asthma susceptibility in asthmatic children as compared to controls.
Prevalence of restless legs syndrome and its correlates in a large sample of Saudis
Ahmed S. BaHammam
University Sleep Disorders Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
Background: Restless legs syndrome (RLS) is a common sensory-motor disorder that disrupts a patient's ability to stay at rest during the late evening and early night hours, resulting in delayed sleep onset and sleep fragmentation. Although recent studies have suggested a high prevalence of RLS even in the subclinical and general population and its close relationship with sleep, few epidemiological studies on the prevalence and correlates of RLS have been performed in a large sample of a general population in different countries; however, none have been conducted among Arabs. Therefore, this study was conducted using a validated questionnaire to determine the prevalence of RLS and its correlates in Saudis attending primacy care centers. Methods: In this cross-sectional study, trained medical students administered the International RLS Study Group (IRLSSG) and the IRLSSG severity scale for RLS (IRLS) questionnaire to a consecutive random sample of Saudi patients (>18 years of age) attending primary health care centers in Riyadh, Albaha and Makkah. The used questionnaire had been translated into Arabic, and the Arabic translation had been validated. Additionally, demographic data and data regarding comorbid conditions known to affect RLS were collected. Data were expressed as mean ± SD. To assess predictors of RLS, a univariate analysis was performed initially. Variables which were significant in the univariate analysis were entered into a multivariate regression model. Sample size was calculated to detect a prevalence of 6%. SPSS software was used in the analysis. Results: The study group comprised 1419 participants. There were 675 males with a mean age of 35.75 ± 13.20 years and a mean body mass index (BMI) of 27.59 ± 7.06. There were 744 females with a mean age of 34.87 ± 14.04 years and a mean BMI of 26.73 ± 5.52. The prevalence of RLS was 9%. RLS was more prevalent in males than in females (12.4% vs. 6.2%, respectively). The prevalence in different age groups was as follows: 17-29 years (8%), 30-44 (11%) and 45-59 (13%). Multivariate regression analysis revealed the following predictors: male gender (OR, 2.2; P < .001; CI, 1.5-3.3), diabetes mellitus (OR, 2.3; P = .002; CI, 1.4-3.8), anemia (OR, 1.8; P = .04; CI, 1.0-3.2), age > 60 years (OR, 2.8; P = .03; CI, 1.1-7.1). Conclusion: RLS is common among Saudi adults. It is significantly associated with diabetes mellitus, anemia and increased age. Chest physicians who practice sleep medicine need to be able to identify and manage RLS, which is prevalent and is associated with considerable morbidity.
The effect of one-night CPAP therapy on oxidative stress and antioxidant defense in patients with severe OSA
Mohammaed Alzoghaibi, Ahmed S. BaHammam
University Sleep Disorders Center, King Saud University, College of Medicine, King Saud University, Riyadh, Saudi Arabia
Background and Objectives: Obstructive sleep apnea (OSA) is a common disorder that results in increased cardiovascular morbidity and mortality and many other physiological and immunological disorders. An increase in hypoxia due to OSA may cause generation of reactive oxygen species (ROS). ROS are toxic to biomembranes and may lead to peroxidation of lipids. An increase in systemic biomarkers of inflammation and oxidative stress has been found in patients with OSA. Several epidemiological studies have identified OSA as a risk factor for systemic hypertension, and a direct etiologic link between the two disorders has been shown. Continuous positive airway pressure (CPAP) therapy has been shown to decrease cardiovascular morbidity and mortality in OSA patients. However, contradictory results have been reported with regard to its effects on oxidative stress. This study aimed to systematically examine the effects of one-night CPAP therapy on oxidative stress (lipid peroxidation) and antioxidant defense [superoxide dismutase (SOD)] in patients with severe OSA. Methods: The study group comprised of 34 hypertensive, nonsmoking patients with a mean age of 45.1 ± 11.8 years, body mass index of 37.4 ± 8.4 kg/m 2 , apnea hypopnea index (AHI) of 80.2 ± 30.9/h and desaturation index of 55.1 ± 3.1/h. Included patients were not on medications that may affect the antioxidant activity. Patients spent four nights in the sleep disorders center; night 1: an adaptation night; night 2: a diagnostic night; night 3: CPAP titration night; and night 4: a therapeutic night for CPAP treatment. Studies were separated by 1-2 weeks. Blood samples were collected first thing in the morning after awakening on nights 2 and 4 and were immediately transferred to the laboratory for SOD, lipid peroxidation measurements. Oxidative stress level was quantified by measurement of thiobarbituric acid-reactive substances. SOD enzymatic activity was measured by a purely chemical system based on NAD(P)H oxidation. Results: Mean SOD concentrations were not significantly different at pre- and post-CPAP treatment (0.22 ± 0.086 vs. 0.22 ± 0.01 U/mL, respectively). However, CPAP treatment significantly inhibited lipid peroxidation levels (2.81 ± 0.27 vs. 2.47 ± 0.35 mmol/mL, respectively, P < .005). Conclusion: The present study supports the theory that CPAP therapy decreases the levels of oxidative stress in OSA patients but may not affect the antioxidant defense.
- Lavie L. Oxidative stress--a unifying paradigm in obstructive sleep apnea and comorbidities. Prog Cardiovasc Dis 2009;51:303-12.
- Alonso-Fernαndez A, Garcνa-Rνo F, Arias MA, Hernanz A, de la Peρa M, Piιrola J, et al. Effects of CPAP on oxidative stress and nitrate efficiency in sleep apnoea: a randomised trial. Thorax 2009;64:581-6.
- Alzoghaibi MA, Bahammam AS. Lipid peroxides, superoxide dismutase and circulating IL-8 and GCP-2 in patients with severe obstructive sleep apnea: a pilot study. Sleep Breath 2005;9:119-26.
A comparative study of the treatment outcomes in sputum smear-positive HIV-positive and HIV-negative pulmonary tuberculosis patients on DOTS therapy in a tertiary hospital in Nigeria between December 2006 and June 2008
Osagie Kingsley Sunday
Department of Medicine, National Hospital, Abuja, Nigeria
Background: This study was done to compare the treatment outcomes of pulmonary tuberculosis in HIV-positive patients and HIV-negative patients on DOTS therapy at the National Hospital, Abuja, between October 2006 and April 2008. Methodology: A total of 390 smear-positive pulmonary tuberculosis patients were studied. Only patients with acid-fast bacilli on stained smears of expectorated sputum were considered to have PTB. Only samples seropositive with both stat-pak and determine were considered HIV positive. Genie was used as tiebreaker. They were placed on the standard combined anti-TB drugs. The treatment outcome measures (bacteriologic cure, treatment completed, defaulted, failed, death and transferred out) were determined at the end of the continuation phase. The results were analyzed using SPSS version 13.8. Results: The demographic characteristics were similar in the HIV-positive and HIV-negative patients. All the 390 patients studied had cough of greater than 3 weeks' duration, and all were productive of sputum. Hemoptysis was found in 68 (36.9%) of the HIV-positive patients as against 144 (75%) in the HIV-negative patients. This difference is statistically significant (P = .001). There was an observed significant difference in the sputum AAFB density between the HIV-positive and the HIV-negative patients. Seventeen (7.2%) of the HIV-positive patients and 12 (5.7%) of the HIV-negative patients had + sputum density (P = .03). The treatment outcomes were as follows: The HIV-positive patients comprised of patients as follows - cured, 128 (69.6%); treatment completed, 44 (23.9%); died, 10 (5.4%); treatment failure, 1 (0.5%); and defaulted, 1 (0.5%); as against cured, 150 (72.8%); treatment completed, 50 (24.7%); died, 5 (2.4%); and 0 (0%), treatment failure; and 0 (0%), defaulted in the HIV-negative patients. The differences were not statistically significant (P = .469). There was higher death rate in the HIV-positive patients [10 (5.4%)] than in the HIV-negative patients [5 (2.4%)]; this difference is not statistically significant (P = .469). Conclusion: In this study, the cure rates in the HIV-positive and HIV-negative patients were similar. The rates were lower than the 85% recommended targets of the WHO by 2005. The mortality rate in the TB/ HIV-positive patients was higher than that in the TB/ HIV-negative patients. This study showed that DOTS therapy is an effective strategy in the treatment of pulmonary tuberculosis irrespective of the HIV status of the patients. Setting: The chest clinic, National Hospital, Abuja, Nigeria.
- Kochi A. The global tuberculosis situation and the new control strategy of the World Health Organisation. Tubercle 1999;72:1-6.
- World Health Organization. Global tuberculosis control; surveillance, planning, financing, Geneva, Switzerland: WHO 2006, WHO Report No WHO/HTM/TB; 2006. p. 89-90.
- Treatment of tuberculosis. Guidelines for national programme. 3 rd ed. Geneva, World Health Organisation. WHO/CDS/TB/2003:313; 2003.
- Aaron L, Saadoun D, Calatroni I, Launay O, Mιmain N, Vincent V, et al. Tuberculosis in HIV infected patients; a comprehensive review. Clin Microbiol Infect 2004;10:386-98.
- Erhabor GE, Adewole O, Adisa AO, Olajolo OA. Directly observed Short-course Therapy for tuberculosis. A three-year experience in a teaching hospital. J Natl Med Assoc 2003;95:1082-8.
- Treatment of tuberculosis. Guidelines for national programme. 3 rd ed. Geneva: World Health Organisation. WHO/CDS/TB/2003:313; 2003.
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