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Year : 2011  |  Volume : 6  |  Issue : 3  |  Page : 159-183
Abstracts from Gulf Thoracic Conference in Dubai 2011

Date of Web Publication29-Jun-2011

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. Abstracts from Gulf Thoracic Conference in Dubai 2011. Ann Thorac Med 2011;6:159-83

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. Abstracts from Gulf Thoracic Conference in Dubai 2011. Ann Thorac Med [serial online] 2011 [cited 2019 Oct 15];6:159-83. Available from:

Lung hydatid cyst in a Sudanese patient treatment and molecular characterization

Abdelrahim M. I., Mohamed E. Ahmed, Omer R. A. 1

Deanship of scientific Research, Al-Neelain University, Khartoum, Sudan, 1 Parasitology Unit, University of Hohenheim, Stuttgart, Germany

Hydatid disease is an important, equally neglected disease of increasing burden in many regions around the world. We report a Sudanese male who was firstly presented with a neck swelling, then found to have a single cystic shadow on a chest radiograph and CT. The patients' history was unremarkable, except that he was a farmer and had contact with dogs and lived in rural community. Successful surgery (Posterolateral thoracotomy) was done and the diagnosis of cystic echinococcosis was later confirmed using PCR technique and DNA sequencing. We review the surgical procedure; molecular diagnosis and molecular epidemiology of pulmonary hydatidosis in sub-Saharan Africa, including Sudan.

Comparison of single chest tube and double chest tubes application after pulmonary surgery

Abdelwahed Taher Gdeedo

Department of Cardiothoracic Surgery, Tripoli Medical Center, Al Fornaj Street, PO Box 9503, Suk Guma, Tripoli, Libya

Presenter's biography : Dr. Abdelwahed Taher Gdeedo, M.D. was born in Libya in 1958. He graduated from Al Fateh University Faculty of Medicine in 1982 as MBBCh, and specialized in Belgium at the University of Antwerp from 1990 to 1996. He is an Associate Professor in Faculty of Medicine Department of Surgery Al Fateh University, and a Consultant Thoracic Surgeon and Head of the Department of Cardiothoracic Surgery in Tripoli Medical Center, Tripoli, Libya.

Objective: Draining of the chest cavity with two chest tubes after pulmonary lobar or sublobar surgery is a common practice. This study aimed to investigate whether using two tubes after pulmonary lobar or sublobar surgery is more effective than using a single tube.

Methods: We retrospectively analyzed 120 consecutive patients who underwent lobar or sublobar pulmonary resection for any pathological condition from January 2008 to December 2009. A new chest tube protocol was introduced on January 2009. This protocol included placement of a single chest tube instead of two chest tubes after lobar or sublobar pulmonary resection. In the first group consisting of 65 patients, only a single 32-Fr tube was inserted, while in the second group consisting of

55 patients, two tubes were inserted - a 28-Fr tube in the apical and a 32-Fr tube in the mid-axillary line in th e most dependent side of the hemithorax. Results: The pre- and post operative variables in both the groups were comparable. The mean amount of drainage from the chest tubes was 600±50 ml in the single group and 800±100 ml in the double tube group. In the single group, the tube was removed after 3±1 days, whereas in the double-tube group the second tube was removed after 5±2 days. The hospital stay was shorter for the single group which was just 1 or 2 days. Conclusion: Insertion of two chest tubes is not more effective than the insertion of a single chest tube after pulmonary lobar or sublobar surgery. Moreover, using a single tube is in fact more effective than using two tubes in that it could lessen pleural fluid loss and is more cost-effective.

Clinical audit of central venous catheter practice in intensive care setting in eastern province of Saudi Arabia


King Abdulaziz Hospital, Post Box: 2477, Alhassa 31982, Kingdom of Saudi Arabia

Presenter's name : Dr. Abdulsalam

Presenter's biography: Pulmonologist intensivist.

Background: Central venous catheterization is commonly used in critically ill patients and may cause various complications. The objective was to study the standard of practice of central venous catheters (CVCs) in adult intensive care unit (ICU) to identify the potential for improvement. Methods: This was a prospective audit conducted in an ICU of 300-bedded King Abdulaziz Hospital. All consecutive patients admitted during 18 months (April 1, 2007 to September 30, 2008) were included. Details of CVCs, indications, complications, and patients' demographic information were recorded daily until CVCs were removed. Results: Overall, 379 patients had 474 CVCs, which accounted for 3024 catheter days, with a mean duration of 6.35±4.7 days (95% CI 5.92-6.78). The most common site of insertion was the internal jugular vein [230 CVCs (48.5%)], 192 (40.5%) were subclavian catheters, and 52 (11%) were femoral. The CVC utilization ratio was 0.64. The catheter related local infection (CRLI) rate was 4.6 per 1000 catheter days, highest for the femoral site, and the catheter-related bloodstream infection (CRBSI) rate was 1.98 per 1000 catheter days, highest for the jugular route; however, the number of infections was insufficient to perform statistical analysis to reach a significant level. There were only few mechanical complications including two pneumothoraces, five arterial cannulations and single significant catheter dislodgement causing respiratory failure. Conclusion: Our results suggest that the compliance with ICU quality assurance program enabled us to keep the rate of complications low which is comparable to the international standards. There are opportunities to improve CVC management.

Sleep architecture of consolidated and split-sleep due to Fajr prayer and its impact on daytime sleepiness

Ahmed S. BaHammam, Almeneessiaer A., Munir M. Sharif

University Sleep Disorders Center, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia

Background : Muslims have five obligatory prayers per day. The first prayer (Fajr) is at dawn (about 1 hour before sunrise); so, Muslims are obliged to wake up early on weekdays and weekends. Summer nights have earlier dawn and shorter nights; so, some Muslims wake up to pray Fajr and then sleep until work time (split-sleep), while others sleep continuously (consolidated sleep) until work time and pray Fajr upon awakening. Objectives: We designed this study to objectively assess the sleep architecture and daytime sleepiness in consolidated and split-sleep due to Fajr prayer. Methods: This cross-over study was conducted on six healthy volunteers with a mean age of 32.0±2.4 years and a body mass index of 24.2±2.0 kg/m 2 . Sleep pattern of the participants was monitored for 1 week before starting the study using a sleep diary to make sure that they have a fixed sleep-wake schedule and that they slept for 7-8 hours per day to avoid the effect of prior sleep deprivation. Participants spent three nights in the sleep disorders center: 1) Medical checkup and adaptation night (not included in the analysis); 2) Consolidated sleep night; and 3) Split-sleep night. Type I attended sleep study (PSG) was conducted in the sleep disorders center as per the standard protocol. Participants went to bed at midnight and woke up at 7:30 AM in the consolidated sleep protocol. In the split-sleep protocol, participants went to bed at midnight, woke up at 4:00 AM for 30 min, went back to bed at 4:30 AM and woke up finally at 8 AM. PSG was followed by a multiple sleep latency test (MSLT) after both the nights as per the American Academy of Sleep Medicine (AASM) protocol. PSG and MSLT were scored according to the established AASM criteria. Results: There were no differences in the sleep efficiency and the distribution of sleep stages between the two protocols. However, during the consolidated protocol, the participants had higher wake after sleep onset (WASO) (48±28.9 min vs. 13.8±10.2 min, P=0.047). In a sub-analysis of the sleep architecture of the second part of the split-sleep protocol (sleep after praying Fajr), the following results were documented: Sleep latency 24.8±9.2 min, REM latency 32.2±29.9 min, sleep efficiency 85.2±4.5%, arousal index 13.54±9.63/hour, stage N1 4.9±3%, N2 49.7±15.3%, N3 11.5±9.6% and stage REM 34±7.7%. MSLT analysis revealed no significant differences in sleep latency of individual naps or their mean between the consolidated sleep and split-sleep protocols. Conclusion: No differences were detected in the sleep architecture or daytime sleepiness in the consolidated and split-sleep schedules when the total sleep duration was equal. Future studies should assess the effects of the two schedules on the neurobehavioral and cognitive function.

Validation of BodyMedia's SenseWear™ armband for determining sleep and wake in patients with obstructive sleep apnea

Ahmed S. BaHammam, Munir M. Sharif

University Sleep Disorders Center, College of Medicine,

King Saud University, Riyadh, Kingdom of Saudi Arabia

Background : The BodyMedia's SenseWear™ Armband (BSA) is a portable device that measures skin temperature, galvanic skin response, heat flux, and body acceleration (accelerometry). Accelerometry is measured using a two-axis micro-electronic mechanical sensor and the device has a built-in algorithm that can identify sleep and wakefulness based on arm movement. Wrist actigraphy that utilizes accelerometry techniques has been validated for detecting sleep and wake in humans; however, the algorithm of BSA is different from actigraphy and it is worn on the arm and not on the wrist. Patients with obstructive sleep apnea (OSA) form a special group with excessive movements during sleep, which may affect the accuracy of BSA algorithm in scoring sleep and wake. Objectives: To evaluate the validity of the BSA device in detecting sleep-wake pattern and sleep efficiency in patients with OSA. Methods: Simultaneous overnight recordings of in-laboratory polysomnography (PSG) (using EEG channels F3-F4, C3-C4, O1-CO 2 , and M1-M2) and BSA were performed on (1) 107 OSA patients [mean age of 45.2±14.3 years, body mass index (BMI) 34.6±8.5, mean apnea hypopnea index of 43 ±35.7/hr, and a mean recording time of 257.8±111.3 min) and (2) 30 controls matched with OSA patients for age and BMI. PSG was scored manually according to the American Academy of Sleep Medicine guidelines. The BSA device was placed over the triceps during the overnight sleep studies. The collected data were downloaded into a PC and an advanced analysis was used to extract and analyze the needed information. Bedtime and wake-up time were adjusted/synchronized for both recordings. BSA recoded sleep as 1 or 0. Sum of the sleep column was taken as total sleep time. Wake time was defined as time in bed minus total sleep time. Paired sample correlation was used to assess the strength of the relationship between sleep duration, wake duration and sleep efficiency using PSG and BSA. An agreement analysis between the PSG and BSA scoring results was performed using the Bland and Altman method. Results: There was no significant difference in OSA patients between BSA and PSG with regard to total sleep time (186.9±98.5 min vs. 184.9±99.5 min; P=0.71), total wake-up time (70.9±62.4 min vs. 72.9±62.5 min; P=0.71) and sleep efficiency (72.6±19 min, 71.3±22.7 min; P=0.52). There were strong correlations between BSA and PSG with regard to total sleep time (r=0.84; P<0.001), total wake-up time (r=0.61; P<0.001) and sleep efficiency (r=0.52; P<0.001). There was also no significant difference in the controls between BSA and PSG with regard to total sleep time (290.4±105.5 min vs. 301.1±96.5 min; P=0.32), total wake-up time (74±71.1 min vs. 63.2±61.5 min; P=0.32) and sleep efficiency (79.8±17.63 min vs. 83.3±14.6 min; P=0.23). In addition, there were strong correlations between BSA and PSG with regard to total sleep time (r=0.84; P<0.001), total wake-up time (r=0.63; P<0.001) and sleep efficiency (r=0.56; P<0.001). Bland Altman plots showed strong agreement between total sleep time, wake-up time and sleep efficiency for both OSA and the controls. Conclusion: Results suggest that BSA is a reliable method for determining sleep in patients with OSA when compared against the gold standard test (PSG). BSA can be a useful tool in determining sleep in patients with OSA and can be combined with portable sleep studies to determine total sleep time.

Objective assessment of sleep pattern and daytime sleepiness during Ramadan fasting in Muslims and non-Muslims

Ahmed S. Bahammam, Abdulrhman Alaseem, Abdulmajid Alzakri, Munir M. Sharif

University Sleep Disorders Center, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia

Background : Experimental fasting has been shown to alter the sleep-wakefulness pattern in various species. Since fasting during Ramadan is distinct from experimental fasting, the physiological and behavioral changes occurring during Ramadan fasting may differ from those occurring during experimental fasting. Studies using sleep diaries have shown a delay in bedtime and rise time during Ramadan. However, no objective study has assessed the sleep pattern continuously during Ramadan in a free-living environment. Objectives: To assess the effect of Ramadan and its attendant lifestyle changes on circadian changes in sleep, energy expenditure, skin temperature, daytime sleepiness and vigilance in Muslims and non-Muslims. Methods: In this descriptive study with repeated measures in a non-random sample of non-smoking healthy volunteers, we used the ArmBand to assess the 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 eight Muslim and eight non-Muslim volunteers during the last week of Shaaban and the first 2 weeks of Ramadan. The SenseWear ArmBand is a validated metabolic body monitoring system that records sleep efficiency, and duration and the circadian distribution over 24 hours. In addition, a self-administered questionnaire was completed by the participants three times: (1) BL, (2) R1, and (3) R2. Each questionnaire contained 29 questions concerning bedtime and wake-up time, naptime and duration, possible factors affecting bedtime, the pattern of meals, and daytime performance. Subjective sleepiness was assessed using the Epworth Sleepiness Scale (ESS). Data from the ArmBand were downloaded into the computer and data of each participant were extracted individually and entered into spreadsheet. In addition, Optalert was used to objectively assess daytime drowsiness using the John Drowsiness Scale (JDS) that utilizes infra-red reflectance oculography system to assess sleepiness and to assess mean reaction time (MRT). JDS is expressed as a scale from 0 to 10, where values >5 indicate a critical level of drowsiness. These tests were conducted at the same time of the day for each participant during BL, R1, and R2. Results: The mean age of Muslims was 36.25±4.46 years and the mean body mass index (BMI) was 26.27±2.38 kg/m 2 . For non-Muslims, the mean age was 34.75±3.33 years and BMI was 25.67±3.41 kg/m 2 . While the start of work had been delayed for Muslims from 7:30 AM to 10:00 AM, there was no change in the working hours for non-Muslims. When BL, R1 and R2 were compared in Muslims, there was a significant delay in bedtime and rise time and a significant reduction in total sleep time. On the other hand, there were no changes in bedtime, rise time and total sleep time in non-Muslims. No changes in ESS were found in Muslims and non-Muslims. JDS values in both Muslims and non-Muslims had normal readings at BL (1.70±1.16 vs. 1.68±1.07, respectively). There was no significant increase in both the groups during R1 and R2. MRT for Muslims was 684.50±127.75 ms and for non-Muslims it was 513.5±196.88 ms at BL. There was no significant increase at R1 and R2. Conclusion: The results of this study that utilizes an objective method to assess the sleep pattern confirms the findings of previous studies utilizing subjective assessment methods demonstrating a delay in bedtime and rise time in Muslims. There is no objective evidence of increased sleepiness during fasting. Changes in sleep pattern could be related to changes in lifestyle like the changes in working hours.

Prevalence of thyroid disease in patients with obstructive sleep apnea

Salman A. Bahammam, Munir M. Sharif 1 , Anwar A. Jammah 2 , Ahmed S. BaHammam 1

King Saud bin Abdulaziz University, 1 University Sleep Disorders Center, 2 Edocrinology Unit, College of Edicine, King Saud University, Kingdom of Saudi Arabia

Background : It is common that hypothyroid patients suffer from sleep disordered breathing (SDB). However, previous studies have reported conflicting results and the majority have shown that hypothyroidism is relatively uncommon among obstructive sleep apnea (OSA) patients. Some of the previous studies defined hypothyroidism as a high serum thyroid stimulating hormone (TSH) level, without commenting on thyroxine hormone level, which means that some of the patients considered having hypothyroidism might have had subclinical hypothyroidism which carries different therapeutic and prognostic implications. Several studies have suggested an influence of both environmental factors and ethnicity on the prevalence of hypothyroidism. As a result, the prevalence of hypothyroidism in OSA patients may vary with race and geographical region. Objectives: To determine the prevalence of thyroid disease based on TSH and thyroxine levels among Saudi (Arab) patients with laboratory diagnosed OSA and try to identify the characteristics and predictors of thyroid disease in OSA patients. Methods: In this controlled prospective descriptive study, all consecutive patients who were referred to the sleep disorders center (SDC) for overnight sleep study in the period from January 2009 to June 2010 were included in the study. All patients underwent a standard in-lab type I polysomnography (PSG). Serum TSH and thyroxine (FT4) were measured in the morning within 4 weeks of sleep study using the electrochemiluminescence immunoassay (ECLIA) method. Clinical hypothyroidism was diagnosed: 1) if the patients had been diagnosed by the referring physician as a case of hypothyroidism and had been on thyroxine replacement based on chart documentation (will be called known clinical hypothyroidism) and 2) if the TSH was >5.0 mIU/mL and FT4 was <10.3 pmol/L (detected in SDC) (newly diagnosed clinical hypothyroidism). Subclinical hypothyroidism was defined as a serum TSH concentration above >5.0 mIU/mL when serum FT4 level was within the reference range. Hyperthyroidism was considered when TSH level was <0.25 mIU/mL and FT4 was >25.8 pmol/L. Subclinical hyperthyroidism was defined as TSH level <0.25 mIU/mL with normal FT4 level. To explore the associations between independent factors and clinical and subclinical hypothyroidism, a preliminary analysis used a univariate logistic regression model; one explanatory variable was tested in the model at a time. Subsequently, variables with significant P-values were evaluated further using a multivariate logistic regression model. Results: During the study period, 271 patients with OSA having a mean age of 48.7±14.1 years, body mass index (BMI) of 37.7±9.6 kg/m 2 and apnea hypopnea index (AHI) of 55.2±37/hr, and 76 non-OSA patients having a mean age of 40.8±14.9 years, BMI of 33.7±8.9 kg/m 2 and AHI of 3.8±3.1/hr underwent thyroid function test. Among the OSA patients, a total of 26 (9.6%) were known cases of clinical hypothyroidism. The prevalence of newly diagnosed clinical hypothyroidism was 0.4% and that of newly diagnosed subclinical hypothyroidism was 11.1% in the OSA patients. In the non-OSA patients, the prevalence of newly diagnosed clinical hypothyroidism was 1.4% and that of newly diagnosed subclinical hypothyroidism was 5%. There were no cases of clinical or subclinical hyperthyroidism in the studied group. Female gender was the only predictor of clinical hypothyroidism. Conclusion: The prevalence of newly diagnosed clinical hypothyroidism was very low in OSA patients to warrant routine testing for thyroid function. On the other hand, subclinical hypothyroidism was common among patients with OSA; however, the benefit of treating this condition is uncertain. Therefore, we do not recommend routine thyroid function testing in OSA patients unless hypothyroidism is suspected on the basis of symptoms and physical signs.

Recurrent catamenial pneumothorax with diaphragmatic defects association with Morgagni's hernia

Shadi Al-Shammary, Balsam Al-Awami, Yasser Al-Jehani, Yasser Al-Ghonimy

University of Dammam, Saudi Arabia

Catamenial pneumothorax is a rare type of spontaneous pneumothorax and occurs within 72 hours before or after the onset of menstruation, and was first described by Maurer in 1958. We report a case of recurrent pneumothorax in a middle-aged lady with history of pelvic endometriosis. Intraoperatively, it revealed a nodular liver lesion with diaphragmatic defects and holes. Closure of all defects and removal of nodules for biopsy was done, followed by apical parietal pleurectomy for pleurodesis. One year after surgery, the patient remains asymptomatic with no evidence of recurrence of pneumothorax. This case supports the recent reports that diaphragmatic defects are often present in patients with catamenial pneumothorax. Surgical intervention to inspect the diaphragm and close all defects should be done in patients with recurrent pneumothorax. A 40-year-old married lady presented with a history of spontaneous pneumothorax before 2 years and had undergone right oophero-salpengectomy 11 months before presentation for pelvic endometriosis. She came with the complaint of progressive shortness of breath for 5 days. Chest examination revealed diminished air entry to the right lung with dull percussion to all zones. A plain chest film was taken and it showed tension pneumothorax and complete collapse of the right lung with nodular lesion over the right copula of the diaphragm. Computed tomography showed collapsed lung with multiple septation in the pleural cavity and the diaphragmatic lesions. Right VATS with thoracotomy and exploration of the diaphragm and pleural cavity revealed the presence of a right diaphragmatic tear, Morgagni's hernia, and multiple purplish nodular lesions over the liver. The diaphragmatic hernia and tear were repaired, and the nodular lesions were sampled for pathology which later identified it as endometriosis. The patient was discharged after 1 week in a good condition and is undergoing regular follow-up with no recurrence for almost 1 year. Catamenial pneumothorax has a rare prevalence of 1-5% among menstruating women with spontaneous pneumothorax, with mean age between 32 and 37 years. It is the most common clinical manifestation of intrathoracic endometriosis presenting with recurrent spontaneous pneumothoraces, predominantly on the right side. Association with pelvic endometriosis has been reported in 20-70% of patients. As we can see, our patient presenting with catamenial pneumothorax and the diaphragmatic hernia implies Kirschner concept of the porous diaphragm syndrome in 1998, proposing pre-existing diaphragmatic defects allowing gas and fluids to go through this anatomic boundary. The incidence of diaphragmatic defects with catamenial pneumothorax ranges from around 29 to 66%. In regard of the management of similar cases, it has been found that surgery with postoperative hormonal therapy is the best plan for reducing recurrence. Catamenial pneumothorax should be suspected in any menstruating woman presenting with recurrent spontaneous pneumothorax. Given the systemic nature of the disease, surgical intervention should, in all cases, be followed by gonadotrophin releasing hormone (GnRH) analogue therapy to reduce the rate of recurrence.

Correlation of K-ras mutation with FDG uptake in lung cancer

Muhammad Chaudhry

Tawam Molecular Imaging Centre, Tawam Hospital Campus, Al Ain, PO Box 220323, Abu Dhabi, UAE

Presenter's biography : Dr. Chaudhry is a Clinical Assistant Professor from Radiology at Johns Hopkins Hospital and is the Medical Director at Tawam Molecular Imaging Center. Dr. Chaudhry's research interests focus on translational molecular imaging and clinical PET development in oncology, cardiology and neurology.

Background: Mutational status of K-ras, BRAF, PI3KCA and PTEN is routinely checked in many solid tumor malignancies. Several reports have suggested that these mutations may control the expression of transporters of glucose (particularly Glut-1) and proteins involved in the glycolytic pathways. We hypothesize that those tumors harboring these mutations may in fact be more FDG avid than those with the wild-type genes. This was a retrospective analysis of patients with lung cancer who underwent both k-ras mutation analysis and hybrid 18F-FDG PET/CT at our institution. Methods: All patients underwent hybrid 18F-FDG PET/CT imaging from May 2006 to March 2009. K-ras mutation status is reflected identically within the primary malignancy and its associated metastatic disease. The highest SUVmax (adjusted for lean body mass or lbm) within a volumetric ROI surrounding the tumor was measured on attenuation-corrected, iteratively reconstructed FDG PET images. In most of the cases, the lesion with the highest SUVmax underwent subsequent tissue sampling. Lesion size was also recorded on corresponding non-intravenous contrast non-diagnostic CT. Results: Twenty patients with lung cancer underwent screening for K-ras mutation. K-ras mutation was found in six patients, while no mutation was seen in 14 patients. In patients with mutations, the SUVmax (lbm) range was 1.5-13.1 (mean 7.8, median 7.8), compared to 1.3-29.1 (mean 9.6, median 8.3) in patients without mutations. One study was excluded from the analysis due to small size of the lesion at the time of PET/CT imaging. On CT images, average size of lesions with k-ras mutation was 3.5(AP) ΄ 3.0 (Transverse) cm, compared to 3 (AP) ΄ 3 cm (T) in patients with no mutations. However, these sizes may be under/overestimated due to non-breath-hold, non-diagnostic CT scan acquired for correlation and attenuation correction. Conclusion: In this retrospective analysis, the lung cancers without k-ras mutation had higher SUVmax (lbm) compared to the group of lung cancer patients with mutations; however, the difference is not significant possibly due to smaller sample size.

Safety of intradermal BCG vaccine in neonates

Ahmed H. Al-Salem

Maternity and Children Hospital, Dammam, Kingdom of Saudi Arabia

Presenter's biography : Consultant Pediatric and Thoracic Surgeon, Maternity and Children Hospital, Dammam, Kingdom of Saudi Arabia

Background and Objective: Bacillus Calmette-Guerin (BCG) is a live attenuated vaccine derived from Mycobacterium bovis. The BCG vaccine was first used to immunize humans in 1921 and since then, millions of children have been immunized with this vaccine. In Saudi Arabia, the BCG vaccine is administered to all newborns at birth. The use of BCG vaccine may be associated with a significant number of adverse effects. One of the rare complications of BCG vaccination is lymphadenitis. The exact incidence of BCG lymphadenitis is unknown, but it ranges from as low as 1:10,000 to as high as 38:1000. The aim of this study was to evaluate the safety of intradermal BCG vaccine administered to neonates in Eastern Province of Saudi Arabia. Methods: The medical records of all infants who developed BCG vaccine related complications were retrospectively reviewed for age at presentation, sex, duration of symptoms, birth weight, gestation, type of presentation, bacteriology, histopathology, method of treatment and outcome. The total number of vaccinated newborns was obtained from the vaccination register. Results: During the period from 15.04.1429 to 15.02.1432 , a total of 21,000 newborns received BCG immunization at our hospital, and during the same period, 70 infants developed BCG-related complications. This gives an incidence of 3.3/1000 newborns. There were 45 males and 25 females. Their age at presentation ranged from 2 months to 12 months (mean 4.8 months). Their presentation was as follows: left axillary lymphadenitis (53), supraclavicular lymphadenitis (7), local collection at the immunization site (6), left cervical lymphadenitis (1), bilateral axillary lymphadenitis (1), left arm abscess and left axillary lymphadenitis and local collection at the site of immunization (1). All were normal immunologically except two who were found to be immunocompromised (SCID and HIV). These two patients required treatment with anti-tuberculous drugs in addition to surgery. The six patients with localized collection at the site of immunization were treated with aspiration only while the patient with left arm abscess required incision and drainage. The remaining patients (63) were divided into two groups, those with simple lymphadenitis (6) and those with suppurative lymphadenitis (57). Those with simple lymphadenitis were treated expectantly and the nodes disappeared. The remaining patients with suppurative lymphadenitis were treated with total excision (54) or just incision and drainage (3) without anti-tuberculous treatment. Swabs for acid-fast bacilli were taken from 21 patients and were positive in 9 (43%) of them. Histology of the excised nodes was positive for granuolomatous lymphadenitis in all those who had excision. Conclusions: BCG vaccine is safe but is associated with a relatively high incidence of suppurative lymphadenitis. The reason for the high incidence of suppurative lymphadenitis in our patients is not known but is probably attributed to a more immunogenic vaccine. Whereas non-suppurative lymphadenitis can be treated conservatively and regresses without treatment, suppurative lymphadenitis should be treated with total excision. This is safe, well tolerated and shortens the recovery period without the need for anti-tuberculous treatment. Although the use of BCG vaccine may be associated with side effects, the potential morbidity and mortality from tuberculosis outweighs that from BCG-related complications.

Role of tumor necrosis factor alpha gene polymorphism in childhood asthma and wheezy infant

Abla Saleh Mostafa

Faculty of Medicine Cairo University, Dubai 33977, Sharjah Uae, Sharjah, United Arab Emirates

Background: 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 also 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. Results: Genotype frequencies for the TNF-alpha 308 G/A OR were significantly more in asthmatic children than in controls (OR 0.4; 95% CI 0.1-1.9). Conclusions: Our results suggest that genetic variation, G/A 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.

24-hours ambulatory ECG's response to transcutaneous electrical nerve stimulation in refractory angina pectoris

Abeer Ahmed Abdelhamed, Hala Mohammed Ezz El Din Hamed 1

Department of Physiotherapy, College of Health Science, University of Sharjah, 1 Physical Therapy for Cardiopulmonary Disorders and Geriatrics, Faculty of Physical Therapy, Cairo University

The aim of this work was to investigate the effect of Transcutaneous Electrical Nerve Stimulation (TENS) application on the clinical parameters in refractory angina patients including: severity of symptoms and 24-hour ambulatory ECG reports. Forty male patients, with age ranging between 42 and 66 years, suffering from chronic refractory angina participated in the study. They were divided into two equal groups, the TENS group which received routine medications plus TENS for 1 hour 3 times a day, and the control group which received regular medical treatment only. The period of study was 2 weeks and a further follow-up period of 2 weeks. The results of this study showed a significant reduction in the intensity of chest pain, frequency of anginal attacks, and rate of short-acting nitrate consumption in the TENS group. Concerning the episodes of ST depression there was also a reduction in the TENS group, over the control group.

Immunological assessment of acquired immunodeficiency syndrome patients with and without pulmonary tuberculosis

Essam S. A. Badawy, Mervat Shafik Y. 1 , Sanna S. Abdel-shafy 2

Department of Internal Medicine, Minia University, 1 Department of Clinical Pathology, Ain-shams, 2 Cairo University

Presenter's biography : Consultant Internist, Hera G. Hospital, Makkah. Assisstant Professor, Internal Medicine, Minia University.

Background: Tuberculosis and HIV play off each other's weaknesses. HIV weakens the immune system and makes it more vulnerable to infection and disease, encouraging TB to develop. In assessing the degree of immune deficiency in HIV-positive patients of a particular region, knowledge of reference range of T-cell subset counts of healthy individuals of that particular region is essential. The enumeration of CD4- and CD8-positive cells, surrogate markers for HIV disease progression, is helpful in the management and follow-up of immunocompromised HIV positive patients. Objectives: The present study was undertaken to determine the reference range of T-cell subsets in healthy individuals and to compare the values with those in HIV positives with and without pulmonary tuberculosis. Methods: Blood samples from 32 HIV seronegative healthy volunteers comprising group I (22 males, 10 females) and 114 HIV-positive patients, divided into group II of asymptomatic (n=35; 24 males, 11 females) and group III of AIDS patients (n=79; 63 males, 16 females, subdivided into IIIA consisting of 35 patients with TB and IIIB consisting of 44 patients without TB), in the age group of 17-60 years, were analyzed for enumeration of CD4+, CD8+ cells/ΞΌ l by flowcytometry. The study workup was carried out in BHG-Jaddah region after taking informed consent from subjects of the study. Results: In group I, the CD4 and CD8 levels were 685±201 and 589±270 Ξcells/ml 3 , respectively, in males and 743±262 and 551±254 Ξcells/ml 3 , respectively, in females. Overall, a significant depressed level of CD4 (519±187 Ξcells/ml 3 ) and an elevated level of CD8 (1169±493 Ξcells/ml 3 ) in group II and 173±119 and 1062±593 Ξcells/ml 3 , respectively, in group III were observed. Group II patients had the highest level of CD8 cells. Among the HIV positives, the CD8 mean level was notably lower in symptomatic patients (group III) (1062±593) than the asymptomatic ones (group II) (1169±493), and in the former group, the level was notably lower in patients with TB (group IIIA) (1005±569) than in patients without TB (group IIIB) (1076±597). No asymptomatic women had CD4 count of less than 500 Ξcells/ml 3 .

Inhaled iloprost for pulmonary hypertension: Clinical effects of adding inhaled iloprost to existing sildanafil therapy

Hadil Al-Otair

Department of Critical Care, College of Medicine, King Khalid University Hospital, PO Box 2925, Riyadh - 11461, Kingdom of Saudi Arabia

Presenter's biography: Graduate of Jordan University 1992 Arab board and Saudi Board in Internal Medicine1998. Membership of Royal College of Physicians and Surgeons of UK in 2003. King Saud University Fellowship in Pulmonary Medicine in 2004. Member of American College of Chest Physicians and Society of Critical Care Medicine. Currently working as Assistant Professor in Medicine and Consultant in Pulmonology and Intensive Care at King Khalid University Hospital, Riyadh.

Background/Aim: Pulmonary hypertension (PH) is a serious condition with progressive course where patients may continue to be symptomatic despite monotherapy or they do not reach treatment goals. This study was conducted to evaluate the long-term effects of adding inhaled iloprost to PH patients who were on existing sildanafil therapy in terms of functional class, 6-minute walk distance (6MWD) and quality of life. Methods: PH patients who were referred to the pulmonary service of King Khalid University Hospital, Riyadh, Saudi Arabia, were recruited. PAH was defined as systolic Pulmonary Artery Pressure of >40 mmHg or mean pulmonary artery pressure >25 mmHg at rest or >30 mmHg with exercise. Patients were on sildanafil for least 3 months. Those who were on prostanoids or endothelin receptor antagonists were excluded. Patients were assessed using NYHA classification and were subjected to 6MWD, pulmonary function tests, transthoracic echocardiogram, right-side catheterization, arterial blood gases and brain natriuretic peptide measurements. Quality of life was assessed using SF-36 validated Arabic version. Patients were instructed for iloprost inhalation therapy, 20 mcg six times during the day with a break during sleep. At the end of the study period, the patients who completed 6 months were reassessed for their NYHA class, 6MWD, BNP and HRQOL. Results: Thirty-one patients with mean age of 48.3±14.5 years were studied. The underlying cause for PH was connective tissue disease in 19 (61.3%) patients, sarcoidosis in 5 (16.2%), interstitial pulmonary fibrosis in 5 (16.2%) and chronic venous thrombo-embolism in 2 (6.5%) patients. Mean duration of symptoms was 12.9±3.2 months. The mean pulmonary artery pressure was 32.6±11.7 mmHg and mean pulmonary vascular resistance was 4.0±2.3 wu. In 25 patients who completed the study, NYHA class and 6MWD significantly improved. There was a trend toward better quality of life with significant improvement in general health and role limitation after the addition of iloprost. Conclusion: The use of iloprost therapy as an adjuvant to existing sildenafil therapy may result in significant improvement in NHYA functional class, 6MWD and quality of life in patients with PH.

Treatment of elderly (>75 years) with lung cancer:

A 4-year material in clinical practice from Karolinska University Hospital at Sweden

Hirsh Koyi, Eva Brand, Gunnar Hillerdal 1

Department of Respiratory Medicine, Karolinska Institutet, and 1 Department of Respiratory and Allergy, Karolinska University Hospital - Solna, Stockholm, Sweden

Presenter's biography: MD, PhD, Senior Consultant, Researching about lung cancer both clinical and experimental.

Background: Sixty percent of all neoplasms and two-thirds of all deaths due to cancer occur in persons older than 65 years. More than 50% of patients with lung cancer are older than 65 years and 30% are older than 70 years. With more persons surviving to older age, treatment of the elderly with lung cancer has become an important issue. Methods: All patients 75 years or older with lung cancer seen at the Department of Respiratory Medicine and Allergy, Karolinska Hospital, from 2003 to 2006 were retrospectively reviewed. In all, 438 patients were analyzed. Results: The mean age was 80 years, and 250 (57.1%) were men. 94.8% of the males and 81.4% of the females were smokers or former smokers. 328 (74.9%) had PS 0-2. 7.8% had SCLC, 37% had adenocarcinoma, and 21.2% had squamous cell carcinoma. 18.9% had clinical lung cancer and the others had broncheoalveolar cell carcinoma or low differentiated carcinoma. 10% underwent radical surgery, 23.7% received chemotherapy only, 19.9% received radiotherapy against the tumor (thereof stereotactic 5.7%), and 3.2% received concomitant chemo-radiotherapy. 6.6% received radiotherapy against metastases, and 36.5% had no therapy. Only 6.7% were given second-line chemotherapy. Survival was 219 and 190 days for patients of 75-80 years and >80 years, respectively. Patients with PS=0 survived for 533 days, those with PS=4 survived for only 20 days. Survival among smokers or former smokers and never smokers were 212 and 132 days, respectively. Survival among those who received chemotherapy was 573 days, while for the others it was 181 days. Conclusions: Significant survival among patients given second-line chemotherapy complete was observed in patients less then 80 years old.

Surgical management of thymoma

Imthiaz Manoly

Wessex Cardiothoracic Centre, Southampton University Hospital NHS Trust

Presenter's biography : Cardiothoracic Registrar working at Wessex Cardiothoracic Centre, UK MBBS, MRCS.

Objective: To describe a single-center experience on the surgical management of thymoma. Study Design: A retrospective study on 63 consecutive patients who had thymectomy for presumed thymoma over a 7-year period in a University hospital in the Wessex region, United Kingdom, was conducted. Outcome Measures: Age, sex, association of myasthenia gravis or paraneoplastic syndrome, surgical approach, extent of surgical resection, tumor size, histological features of the tumor, clinical staging of the thymoma and short- and long-term outcome after surgery. Results: The mean age of the patients was 62.8 years. There were 26 female and 27 male patients. Myasthenia gravis was associated with 26 patients while 27 patients were detected incidentally on CT chest. Thirty-two patients had thymectomy by sternotomy while 28 patients had thoracoscopic approach. There were three conversions of thoracoscopy to sternotomy due to technical difficulty. The average length of stay after the surgery was 4.8 days. According to WHO staging, 18 patients were Type A, 14 patients were Type AB, 9 patients were Type B1, 9 patients were Type B2, and 3 patients were Type B3. There were 10 other patients who presented with local symptoms and had a pre-surgery diagnosis of thymoma on CT Chest. However, they were histologically diagnosed as other anterior mediastinal tumors. Radiotherapy was used as an adjunct to surgical treatment in 84% of patients with stage II and III disease. The actuarial 3-year survival rate was 98%. Only one patient died of metastatic thymoma. Mixed cellular histological features were more commonly seen with stage I disease. Conclusions: Thymomas are slow-growing tumors which can be often missed in the absence of symptoms. A multidisciplinary approach is necessary for prolonged survival even in patients with invasive disease. Complete resection of the tumor followed by adjunct radiotherapy has improved the survival rate significantly.

VATS systematic mediastinal nodal dissection and stage migration: Impact on clinical pathway

Khalid Amer

Southampton General Hospital, 204 Hill Lane, Southampton SO15 7NQ, UK

Presenter's biography: Consultant Thoracic Surgeon with special interest in VATS major pulmonary resections and Systematic Nodal Dissection.

Objectives: The aim of this study was to investigate the role of routine Systematic Mediastinal Nodal Dissection (SND) performed during video assissted thoracoscopic surgery Major Pulmonary Resections (VMPR) as a staging strategy for non-small cell lung cancer (NSCLC), compared to preoperative staging by conventional positron emission tomography (PET) and computed tomography (CT) imaging. Methods: All patients suspected of having early lung cancer (T1-2, N0-1, M0) were staged preoperatively by CT/PET. During VMPR, all lymph nodes on the right side at stations 2-4, 7, 8, 9, 10 and 11 and on the left stations 4-6, 7, 8, 9, 10, 11 and 3 when indicated were dissected en bloc. Histology was done on the paraffin-embedded nodes and patients were staged accordingly. Preoperative and postoperative staging were compared. Stage migration and impact on clinical pathway were noted. Stage IIa and higher were referred for adjuvant chemotherapy. Results: Between April 2007 and January 2011, 106 consecutive patients with suspected primary NSCLC proceeded to VMPR+SND. Histology confirmed NSCLC in 96 patients; 45 were men and 51 were women. Median age was 68.6 (range 42.8 84.7) years. Ninety-one (94.8%) underwent lobectomy, 3 (3.1%) underwent bilobectomy and 2 (2.1%) underwent pneumonectomy. PET accurately correlated with SND histological diagnosis in 42 (43.8%) patients. The unexpected N2 disease in cN0-1 was 9/86 (10.5%). SND resulted in 25 stage migrations, upstaged in 16 (16.6%) and downstaged in 9 (9.4%) patients. All upstagings were adenocarcinomas. Four (4.2%) PET negative patients had multi-station N2 disease. SND resulted in changing the clinical pathway for 19 (20%) patients. Fourteen (14.6%) patients upstaged to qualify for chemotherapy and 5/9 (5.2%) downstaged patients were saved the chemotherapy. There was no morbidity or mortality attributable to this added procedure. Conclusions: SND during VMPR is safe and should be routinely performed even when nodal metastasis is considered unlikely. VATS-SND is more accurate than PET in staging the mediastinum for NSCLC. PET sensitivity is significantly reduced in adenocarcinoma and might result in stage migration. Adjuvant multidisciplinary treatment should be based on SND staging.

Video-assisted thoracic surgery major pulmonary resections for lung cancer: The southampton experience

Khalid Amer

Southampton General Hospital, 204 Hill Lane, Southampton SO15 7NQ, United Kingdom

Presenter's biography : Consultant Thoracic Surgeon with special interest in VATS major pulmonary resections and Systematic Nodal Dissection.

Objectives: Despite the proven safety and long-term results of video-assisted thoracic surgery (VATS) lobectomy, the technique is not widely adopted in the UK. We set out to start a VATS lobectomy program against financial and time constraints to meet cancer waiting times. We present the clinical outcomes of patients undergoing VATS Major Pulmonary Resections (VMPR), with an emphasis on postoperative events. Methods: Patients were deemed suitable for VMPR if on CT/PET the lesion was suspected to represent lung cancer T1-2, N0-1 and M0. VMPR involved individual hilar structure dissection without rib spreading. Systematic Mediastinal Nodal Dissection (SND) was added in the last 106 cases. Results: Between April 2005 and January 2011, 197 patients were considered suitable for first time VMPR for suspected lung cancer; 85 were men and 112 were women. Median age was 68.4 (range 34.9-85.5) years. Eleven patients were not suitable after initial videoscopic assessment and 186 proceeded to VMPR (179 lobectomy, 3 bilobectomy, 2 pneumonectomy and 2 patients with poor lung function underwent segmentectomy). There were 24 (12.2%) conversions to thoracotomy. The median operative time for VATS lobectomy was 3:30 (h:mm) including SND. The median length of hospital stay for the completed VMPR-SND was 4.0 days (range 1-25 days, mode 3 days). There were no in-hospital deaths and 3 (1.5%) out of hospital deaths, median duration of air leak was 10 (range 3-20) days, Intensive Care Unit admission 19 (10.2%), pneumothorax 31 (16.7%), respiratory complications 31(16.7%), bronchial complications 6 (3.2%) and bleeding requiring exploration 1 (0.5%). The median follow-up was 12.9 months (range 0.1-54.4 months). The actuarial survival at 1, 2 and 3 years for all stages was 85.0±3.8%, 82.2±4.2% and 73.5±7.0%, respectively. Conclusion: High postoperative events are to be expected when starting a VATS lobectomy program. Nevertheless, VATS major pulmonary resections are safe and long-term results are not compromised. They should be considered as the first choice for cT1-2, N0-1, and M0 lung lesions. Aggressive approach to postoperative complications reduced the length of hospital stay to a median of 4 days. Air leak remains the most important cause for prolonged hospital stay.

Validity of multidimensional body mass index (B), airflow obstruction (O), dyspnea (D) and exercise capacity (E) (BODE index) as a predictor of hospitalization for COPD

Mahmoud Elprince

Faculty of Medicine, Suez Canal University, PO Box 1123, Ismailia, Egypt

Presenter's biography: Professor of Chest Medicine, Chief of Chest Unit, Suez Canal University, Vice Dean Faculty of Nursing, Suez Canal University.

Background: Systemic manifestations of chronic obstructive pulmonary disease (COPD) often correlate with increased risk of mortality and may be considered surrogates of disease severity. Objectives: To test how well a multidimensional grading system that assessed the respiratory and systemic expressions of COPD would better predict the outcome in these patients. Methods: A total of 150 patients with COPD (age 45-83 years; 89% males) were enrolled in a 32-month prospective study and followed up for a mean period of 12 months. The BODE index was calculated; the main outcome measure was the number of hospital admissions for COPD during follow-up. The following variables were assessed for each patient: age, sex, pack years of smoking, FVC%, FEV1%, the best of two 6-minute walk tests done 30 minutes apart, degree of dyspnea, and body mass index (BMI). Results: 126 patients were available for the follow-up examination (follow-up rate, 84%); 85 (67%) patients required at least one hospital admission and 6 (4.8%) died. In multivariate analyses, a significant effect of BODE score on the number of hospital admissions was found [95% confidence interval (CI) 0.36-0.61; P<0.000]. In comparison, there was a significant but smaller effect of the pack years of smoking and BMI on the number of hospital admissions (95% CI 0.03-0.05; P<0.000) and (95% CI −0.32 to −0.09; P<0.03).

Meta-analysis of the efficacy of sodium oxybate (Xyrem® ) in patients with narcolepsy-cataplexy

Mashael K. Alshaikh, Andrea C. Tricco 1 , Mariam Tashkandi 2 , Muhammad Mamdani 1,2 , Ahmed S. BaHammam,

Sharon E. Straus 1,3

University Sleep Disorders Center, King Saud University, Riyadh, Kingdom of Saudi Arabia, 1 Li Ka Shing Knowledge Institute of St Michael's Hospital, 2 Applied Health Research Centre, St. Michael's Hospital, 3 Division of Geriatrics, University of Toronto, Toronto, Ontario, Canada

Background : Narcolepsy is a sleep disorder characterized by excessive daytime sleepiness associated with sudden loss of muscle tone (cataplexy). Sodium oxybate (Xyrem® ) is a recently approved drug for the treatment of refractory cataplexy and excessive daytime sleepiness in patients with narcolepsy. However, the clinical experience with sodium oxybate in patients with narcolepsy-cataplexy is still limited. Objectives: To assess the efficacy and safety of sodium oxybate in patients with narcolepsy-cataplexy. Methods: Electronic databases (e.g., MEDLINE) and references of retrieved articles were searched to identify potentially relevant material. Randomized controlled trials (RCTs) assessing the efficacy and safety of sodium oxybate for patients with narcolepsy and cataplexy were included. Two reviewers independently abstracted data and appraised the study quality using the Cochrane risk of bias tool. Disagreements were resolved by discussion. The summary measures were the relative risk (RR) and the mean difference (MD). The studies were plotted in a forest plot to examine heterogeneity visually. Random effects meta-analyses were calculated and heterogeneity was assessed using the I2 statistic. Pooled estimates were derived using a random-effects model and 95% confidence interval (CI) was derived based on a normal distribution. All analyses were conducted in Review Manager Version 5. Results: Six RCTs and five companion reports were included after screening 14 full-text articles and 483 citations. None of the included RCTs were assessed as having adequate sequence generation or allocation concealment and all were funded by private industry. Sodium oxybate (usually at 9 g) was superior to placebo on reducing cataplexy attacks [two studies, mean difference (MD): −8.5, 95% CI: −15.3,−1.6], increasing Maintenance Wakefulness Test (two studies, MD: 5.18, 95% CI: 2.59-7.78), reducing sleep attacks (two studies, MD: −9.65, 95% CI: −17.72, −1.59), and increasing Clinical Global Impression scores (three studies, RR: 2.42, 95% CI: 1.77-3.32). Sodium oxybate did not significantly increase rapid eye movement sleep versus placebo (two studies, MD: −0.49, 95% CI: −3.90, 2.92). Patients receiving sodium oxybate had statistically more adverse events versus placebo, including gastrointestinal/nausea, vomiting, and dizziness; yet, enuresis was not significantly different from placebo. All meta-analyses had minimal statistical heterogeneity (I 2 ranging from 0 to 13%). Conclusions: Sodium oxybate provided clinical relief across most outcomes; yet, harms occurred more frequently compared with placebo. Further research is warranted examining sodium oxybate at lower doses (e.g., 6 g) and the effects on quality of life. These results should be interpreted with caution due to few included studies and the potential risk of bias.

Endoscopic ultrasound-guided fine needle aspiration of the left and right adrenal glands combined with immunostains discloses the nature of metastasis from thoracic and other malignancies

Mohamad Eloubeidi

American University of Beirut, PO Box 11-0236, Riad El Solh 110 72020, Beirut, Lebanon

Presenter's biography : Dr. Eloubeidi is considered a world renowned authority in endoscopic ultrasound-guided fine needle aspiration. He has authored more than 300 peer reviewed publications, abstracts and book chapters. He has lectured internationally on the role of EUS-FNA in staging lung cancer patients in sampling lymph nodes and adrenal glands.

Background: Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) can sample both the left and the right adrenals. Identifying the appropriate origin of metastasis can help determine the type of therapy that a patient might receive. We assessed the utility of EUS-FNA and immunostains in determining the origin of metastasis to the adrenals glands. Methods: The records of all patients who underwent EUS-FNA of either the left or the right adrenal gland were reviewed. Data were collected on the size of the adrenal gland, shape of adrenal gland by EUS, history of prior, concomitant or suspicion of new cancer diagnosis. Onsite cytopathology was performed in all patients. At the discretion of the pathologists, additional passes were requested to acquire additional lesional material for immunostains Results: Over a 10-year period, EUS-FNA was performed in 102 patients by a single endosographer. Sixty-six percent were males and 77% were Caucasians. The median age was 64 years (range 42-85 years). The left adrenal was sampled in 95 patients and the right adrenal in 7 patients. The median size of the lesions was 24΄16 mm. A median of three passes were performed (range 1-8).Thirty-nine patients (38%) were ultimately diagnosed with metastatic disease to the adrenals as follows: non small lung cancer n=27, small cell lung cancer n=4, breast cancer n=2, esophageal cancer n=2, colon cancer n=1, melanoma n=2, lymphoma n=1. One patient was diagnosed with bilateral histoplasmosis. Univariate analysis shows that adrenal gland lesions that are malignant are significantly associated with rounded shape (OR 8.33; 95% CI 1.81, 38.46), sharp edges (OR 14.49; 95% CI 1.83, 114.94) or altered shape of gland (OR 12.04; 95% CI 3.93, 36.63). Only 51% of lesions >30 mm were malignant, while 33% of lesions less than 30 mm were proven malignant. The adrenal gland lesions were more likely to be malignant if the PET standard uptake value (SUV) was >4 [OR=19.8 (4.62, 84.82); P<0.0001]. No complications were encountered. Multivariate logistic regression shows that both altered shape (adj. OR=16.24; P<0.0001) and round shape (adj. OR=13.20; P=0.0056) of adrenal glands are significant predictors of malignancy of adrenal lesions when adjusted for shape, edges, age, sex, race, number of passes, size of lesions and SUV. In 14 patients, EUS-FNA of the adrenal glands was the first and only test used to diagnose metastatic lung cancer. Conclusions: This large study confirms that EUS-guided FNA with immunostains is capable of safely and reliably diagnosing metastatic disease to the adrenal glands from various primary sites. EUS-FNA in appropriately selected patients can be the first and sole diagnostic test to diagnose metastatic stage IV lung cancer without the need of any additional testing.

Minimally invasive sampling of abnormal positron emission tomography targets by endoscopic ultrasound-guided fine needle aspiration improves clinical staging of patients with suspected non-small cell lung cancer

Mohamad Eloubeidi

American University of Beirut School of Medicine, PO Box 11-0236, Riad El Solh 110 72020, Beirut, Lebanon

Presenter's biography : Dr. Eloubeidi is considered a world renowned authority in endoscopic ultrasound-guided fine needle aspiration. He has authored more than 300 peer reviewed publications, abstracts and book chapters. He has lectured throughout the world and participated in courses and live demonstrations at prestigious institutions such as Harvard and Mayo courses in EUS-guided fine needle aspiration in staging lung cancer patients.

Background: Current guidelines recommend that all abnormal lesions by positron emission tomography (PET) scan should be sampled prior to thoracotomy in patients with lung cancer. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has been demonstrated to be safe and minimally invasive in diagnosing N2/N3 and metastatic disease to the adrenal glands. We currently report our updated large experience to determine the role of EUS-FNA in identifying abnormal PET scan lesions. The secondary objective was to determine the predictors of lymph node malignancy. Methods: Consecutive patients (N=282) who underwent both PET and EUS-FNA between June 2003 and June 2009 at a tertiary care teaching hospital were evaluated. Targets sampled by EUS included: the adrenal glands and/or (N2/N3) stations 9, 8, 7, 5, 4L, or 2. All EUS examinations were performed by a single endosonographer. The reference standard included surgery or clinical follow-up (6 month). Abnormal PET targets were defined by a maximum standardized uptake value (SUV) of >2.5. Results: Mean age was 66 years and 66% of the patients were men. Mediastinal lymph nodes were solely sampled in 243 patients, while only Stage IV lesions were sampled in 18 and both were sampled in 21 patients. In the 264 patients who underwent EUS-FNA of lymph nodes, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EUS-FNA were 76%, 100%, 100%, 81%, and 88%, respectively, and for PET, the values were 84%, 53%, 64%, 78%, and 69%, respectively, for confirming N2/N3 disease. EUS-FNA confirmed PET staging in 168 patients, while 63 were "downstaged" (25.8%) and 11 were "upstaged" (4.1%); 22 patients were falsely downstaged by EUS-FNA. In 11 patients with false-negative FNA results, the node was not routinely accessible by EUS. In multivariable analysis, the short axis of the lymph node by EUS (OR adjusted 1.25; 95% CI: 1.09-1.44; P=0.002) and SUV of the lymph node (OR adjusted 1.38; 95% CI: 1.12-1.69; P=0.002) were significant predictors of malignancy when adjusted for age, race, sex, lymph node long axis, primary mass SUV and location, and prior chemotherapy. EUS-FNA confirmed Stage IV lung cancer in 19 patients (1 gastrohepatic node, 1 perigastric node, 1 pancreas, 3 right adrenals and 13 left adrenals) and in 1 patient who had left adrenal involvement without PET uptake. Conclusions: EUS-FNA improved clinical staging in patients with suspected non-small cell lung cancer (NSCLC). Its ability to accurately confirm the nature of abnormal PET scan targets, along with the ability to upstage and downstage false-positive and false-negative PETs, makes it an ideal choice for initial minimally invasive sampling. Lymph node short axis and lymph node SUV were the significant predictors of malignancy and may help guide endosonographers as to which lymph node needs to be sampled first during EUS.

Empyema thoracic in Sudan: A series of 100 cases

Mohamed Elamin Ahmed, Abdelrahim MI 1 , Talal Mohammed Geregandi 2

Consultant Cardiothoracic Surgeon, Dean of Scientific Research, Alneelain University; 1 Research Fellow, Deanship of Scientific Research, Alneelain University; 2 Registrar of Surgery, Alshaab Teaching Hospital

Background : Pleural empyema is the collection of pus between the lungs and the chest wall; and it is treated with a multitude of therapeutic options. Optimal therapy and cost containment requires selection of the most appropriate initial intervention.Decortication for empyema thoracic is the commonest thoracic operation in Sudan. The surgical outcome has improved greatly over the last 5 years. Aim: To analyze the epidemiology, etiology and clinical presentation of empyema, and to correlate between these factors and the morbidity and mortality of decortication. Methods: In this retrospective study, a total of 100 patients of empyema thoracic, who underwent posterolateral thoracotomy and decortications during the period June 2002-2007, were included. Patients were referred from all parts of Sudan. Posterolateral thoracotomy and decortication for empyema thoracic were done at Alshaab and Khartoum Teaching Hospitals, the only place in Sudan where thoracic surgery is carried out regularly. Study variables included age, gender, residence, presenting symptoms, underlying pathology, causative organisms and postoperative outcomes. The collected data were analyzed with the help of a computer using Statistical Package for Social Science (SPSS) software and the results were presented in tables and graphs. Results: A total of 100 patients were included in the study: males 57 (57%), females 43 (43%). Male-to-female ratio was 1.3:1.0. The mean age was 33.12 years. Majority of the patients (i.e., 42%) were in the age group 21-40 years. 35% of patients were from the northern states. Most of these patients presented with more than 1 year history; and most of them (48%) had post-pulmonary tuberculosis. The commonest symptoms at presentation were cough (80%); dyspnea (78%), fever (35%) and chest pain (32%). Gram-negative bacilli were isolated from empyema fluid in 11 patients (11%), while mycobacteria were cultured in 6 (6%) and Staphylococcus in 5 (5%) patients. In 68 patients (68%), the pus was sterile. The most common complications were bleeding, air leak and recollection, and all were treated conservatively. Thirty percent of the patients developed wound infections; all were gram-negative bacilli, except one patient who developed wound infection due to Pseudomonas. All were minor skin infections treated by regular dressing and antibiotics according to sensitivity. One-third of the patients showed re-expansion of the chest 2 weeks after surgery, and all patients seen later were symptom free. The mortality rate was 5%; 80% of them had post-pulmonary TB and 80% of the deaths were due to respiratory problems. Conclusion: Decortication is safe as a modality of management, putting in mind proper selection of patients. There is near equality in the early postoperative morbidity and mortality results from this study and the literature results; this may denote the natural reflection to the improved surgical and anesthetic care. These results provide the basic data for further work to substantiate the role of all the mentioned factors. More control studies are needed comparing other modalities of management (tube thoracotomy, fibrinolytic therapy and VAST).

Prevalence and predictors of arrhythmia in patients with obstructive sleep apnea

Nader Alasousi, Munir Sharif 1 , Ahmed Hersi,Ahmed BaHammam 1

Department of Cardiac Sciences, 1 University Sleep Disorders Center, College of Medicine, King Saud University, PO Box 220941, Riyadh, Kingdom of Saudi Arabia

Background : Based on our practice, cardiac arrhythmias appear to be common among patients with obstructive sleep apnea (OSA), although the true prevalence of cardiac arrhythmias remains to be determined. It may influence morbidity, mortality and quality of life for patients with OSA. Very limited number of studies has addressed this issue in the literature; therefore, we designed this study to assess the prevalence and types of arrhythmias in OSA patients and to try to detect predictors for arrhythmia in this group of patients. Methods: In this case-control study, overnight sleep studies of all patients who underwent type I attended all-night polysomnography in the University Sleep Disorders Center (SDC) at King Khalid University Hospital, between 2001 and 2008, were reviewed. Sleep studies were scored manually according to the established criteria and OSA was diagnosed according to the American Academy of Sleep Medicine diagnostic criteria. Sleep studies of patients with and without OSA were reviewed by two physicians (one of them is a cardiologist) who were blinded to the existing sleep disorder and the comorbid conditions for the presence of arrhythmia in both the groups, [e.g. premature atrial contraction (PAC), premature ventricular contraction (PVC) and atrial fibrillation (AF)]. To explore the associations between independent factors and arrhythmia in OSA patients, a preliminary analysis used a univariate logistic regression model; one explanatory variable was tested in the model at a time. Subsequently, variables with significant P-values were evaluated further using a multivariate logistic regression model. Results: The study comprised 257 OSA patients and 99 non-OSA patients (control group). OSA patients had a mean age of 47.9±13.5 years, body mass index of 35.7±9.5 kg/m 2 , apnea hypopnea index (AHI) of 42.4±36.9/hour, and males represented 60.7% of the group. In addition, they had the following comorbidities: hypertension (42.2%), diabetes mellitus (35.3%), ischemic heart disease (10.2%) and dyslipidemia (39.4%). Some patients showed multiple arrhythmias within a single study. The prevalence of arrhythmia in OSA patients was higher than that in the non-OSA group (24.5% vs. 12.1%; P=0.01). Among the OSA patients, PAC was present in 26 patients (10.1%), PVC in 42 patients (16.3%) and AF in 4 patients (1.6%). OSA patients with arrhythmias were significantly older (53.5±15.3 years vs. 46±12.4 years; P<0.05). Conclusions: Patients with OSA had a higher prevalence of arrhythmia compared to controls. Arrhythmia was more prevalent among OSA patients with longer periods of hypoxemia and those with ischemic heart disease. Future studies should examine the impact of co-existing arrhythmia on morbidity and mortality and the effect of positive airway pressure therapy on arrhythmias in this group of patients.

Comparison of tracheal reconstructions with PTFE and Dacron grafts in rabbits

Murat Oncle, Fahrett

Konya State Hospital, PO Box 42110, Konya, Turkey

Objective : To compare the success of tracheal reconstruction techniques using Dacron and PTFE graft interpositions following long tracheal segment resection. Methods: Three different groups, each consisting 10 rabbits, were studied. Group A was the control group and primary anastomosis was performed after resection of eight tracheal rings. Dacron graft interposition in group B and polytetrafluoroethylene graft interposition in group C were used for the same tracheal resection as in group A. The groups were compared on the basis of clinical observations, macroscopic and morphometric studies, and histopathologic examination. Results: No tracheal stenosis was seen in group A. In group B, mild stenosis was found which was considerably less stenotic than in group C. Dacron graft interpositions after tracheal resection resulted in greater epithelialization and neovascularization compared with reconstruction using PTFE grafts. Conclusions: Primary anastomosis is still the preferred technique for tracheal reconstruction. If long segment tracheal resection is needed and primary anastomosis is impossible, Dacron graft interposition is preferable to PTFE.

The effect of laparoscopic paraesophageal hernia repair on pulmonary function test

S. Alnassar, J. Kondra, J. Clifton, R. J. Finley

College of Medicine, King Saud University, P.O. Box 7805 Surgery (37) Riyadh 11427, Kingdom of Saudi Arabia

Objective : A retrospective cohort study was conducted to examine the impact of laparoscopic paraesophageal hernia repair on the pulmonary function test (PFT). Methods: Between 2001 and 2005, there were 39 patients diagnosed with paraesophageal hernia. Patients were evaluated based on history, physical examination, CXR, barium swallow and upper endoscopy. Preoperative PFT was done within 3 months prior to surgery and postoperative PFT was done at least 1 month after surgery. Results: Thirty-four patients (87%; 8 males and 26 females) were included in the study with a mean age of 71 years (±12 years). Presenting symptoms included GERD (47.0%), dysphagia (35.2%), anemia (20.5%), dyspnea (32.4%), chest pain (61%), and cough (6%). Six patients had type II hernia, 22 had type III and 6 had type IV. The mean ASA was 2.5 (±0.7). Significant improvement was noted in mean FEVI (10.0%, pre: 2.17±0.78 L, post: 2.38±0.92 L, P=0.002); FVC (9.3%, pre: 3.01±1.05 L, post: 3.27±1.22L, P=0.001) and TLC (8.3%, pre: 5.95±1.59 L, post: 6.43±1.49 L, P=0.002). Improvements were also seen in FEV1/FVC% (2.0%, pre: 71.57±8.5%, post: 72.87±9.04%, P=0.166) and RV (7.8%, pre: 2.34±0.68 L, post: 2.51±0.45 L, P=0.123); however, they were not statistically significant. The mean length of stay was 2.6 days (±1.9). Minor postoperative complications occurred in five patients (14.7%). There was no in-hospital or 30-day mortality.Conclusion: Laparoscopic repair of paraesophageal hernia results in a significant improvement of PFT and is well tolerated by elderly patients with other comorbid diseases.

Sleepiness among road traffic accident drivers: Reason to worry

Siraj Omar Wali

King Abdulaziz University, Post Box: 4377, Jeddah - 21491, Kingdom of Saudi Arabia

Presenter's Biography: Roah Merdad is a graduate of King Abdulaziz University, Faculty of Medicine. She graduated with an (A) average and first degree honors. She is currently doing her internship year at King Abdulaziz University Hospital, and plans to specialize in Public Health and Community Medicine. She is a member of many volunteer groups and is actively involved in a few research projects.

Background: Road traffic accidents (RTAs) pose a serious health burden internationally as they cause significant morbidity and mortality. They are the ninth leading cause of death worldwide. Estimates suggest an annual global loss of around US$ 520 billion as a result of RTAs. Human error has been labeled the major underlying cause in up to 40% of car crashes. According to a new study by the AAA Foundation for Traffic Safety from the USA, two out of five drivers (40%) admit to falling asleep at the wheel. Published estimates on the number of road traffic accidents caused by sleepiness range from 1 to 3% in the USA to 10% in France and over 30% in Australia. Reports from Saudi Arabia in 2007 estimate road traffic fatalities to be around 6300 and non-fatal road traffic injuries to be around 36,000 for that year alone. Between 1971 and 1997, 564,762 people were injured or died from RTAs in Saudi Arabia, representing around 3.5% of the population. In the Ministry of Health hospitals, 20% of bed occupants and about 80% of deaths are due to RTAs. There is limited local information on the prevalence of sleepiness among drivers in Saudi Arabia and its impact on the high numbers of RTAs. Objectives: The aim of this study was to determine the prevalence of sleepiness as a possible cause contributing to RTAs. Methods: All drivers who presented to the Emergency Room (ER) and were admitted to King Khaled National Guard Hospital, in Jeddah, Saudi Arabia, post RTA from January to June 2008 were interviewed using a questionnaire within 24 hours from admission. This questionnaire was in Arabic and included in addition to demographic questions, inquiry about the possible cause of this accident from the driver's perspective, history of previous accidents, snoring, and the usual timing and duration of sleep. Sleepiness was estimated using both the Epworth Sleepiness Scale (ESS) and Stanford Sleepiness Scale (SSS). Results: The total number of interviewed drivers was 68. The mean age of the studied population was 28.35±11.66 SD. The proportion of Saudis was 95.6% (n=65). Around half (54.4%) had a previous RTA. The proportion of drivers that said the cause of the accident was sleepiness was 10.3% (n=7). The majority attributed their accident to other peoples' mistakes, speed and negligence. Regarding the drivers' sleeping habits, about a quarter (27.9%) reported snoring at night; close to half (47%) sleep at 12 a.m. or later; more than two thirds (72.1%) sleep 6 hours or less a night. A quarter of drivers (25%) had an SSS score of 4-8. A score of 10 or higher based on ESS was found in 14.7% of participants. Of all the drivers with an SSS score of 4-8, 41.1% answered sleepiness as the cause of the accident. Similarly, for all the drivers with an ESS score of more than 10, the majority (70%) attributed their accident to factors other than sleepiness. Conclusion: The study revealed poor sleep hygiene among RTA drivers. Sleepiness among drivers was prevalent as one-quarter of drivers were classified as sleepy/not alert by the SSS and about 15% were considered chronically sleepy by the ESS. A good number of sleepy drivers did not attribute their accident to sleepiness. Future studies need to be carried out on a larger scale to explore the exact prevalence and impact of sleepiness among RTA drivers in Saudi Arabia as well as the etiology of such sleepiness.

Public knowledge of pulmonary tuberculosis

Osama Samergandi, Ahmad Abulaban, Siraj Wali

King Abulaziz University, PO Box : 4377, Jeddah - 21491, Kingdom of Saudi Arabia

Presenter's biography: 1- Final Year Med Student 2- Internist and Neuro Fellow 3- Con Chest And Sleep Med.

Background: Pulmonary tuberculosis is a common and current health problem in Saudi Arabia. Public education and awareness is essential for the prevention of tuberculosis. The aim of this study was to assess the level of public general knowledge regarding this highly infectious but preventable disease. Method: A cross-sectional, questionnaire-based study was conducted at three main shopping centers in Jeddah city. A structured questionnaire was developed to assess the basic knowledge about pulmonary tuberculosis. The questionnaire included demographic data, level of education, source and level of knowledge using 11 multiple choice questions focused on basic facts about pulmonary tuberculosis. Results: 463 subjects were randomly recruited and completed the questionnaire. 256 (55.3%) were females. Their age ranged between 12 and 72 years, with a mean of 28.7 years (SD±11.2). About one-third [166 (35.9%)] of them were students and another third [163 (35.2%)] were employees. The majority (73%) of the candidates were relatively well educated, had completed at least the high school. Half (50.3%) of the candidates thought that they had sufficient knowledge regarding tuberculosis. However, 34.8% did not know that lungs are the primary organ affected; more than half (52.9%) denied that it is an infectious disease, and more than 50% were not aware that there is an effective treatment. The mean score of the level of knowledge for the whole group was 5.15 out of 11 (SD±2.95) and 39.5% scored less than 4. Females had a higher score (5.55) than males (4.69) out of 11 (P=0.003). Conclusion: Our data shows that public awareness regarding pulmonary tuberculosis was very much under expectation. Essential information was lacking even among well-educated people. Clinical Implementation: More efforts to address this problem are crucial in order to help prevent this killer infectious disease worldwide.

Smoking habits among medical students in the western region of Saudi Arabia

Siraj Wali

King Abulaziz University, PO Box: 4377, Jeddah - 21491,Kingdome of Saudi Arabia

Presenter's biography: Siraj Wali, Ass: Prof. of Med. All others were med students at the time of the collection of data and currently they are all house officers.

Background: Tobacco consumption, a prevalent public health problem worldwide, is increasing in Saudi Arabia. Physicians could play an important role in helping patients refrain from smoking. Objectives: We attempted to estimate the prevalence of tobacco smoking and understand the attitude, practice, and knowledge thereof, among medical students at the main medical school in the western region. Methods: We performed a cross-sectional study using anonymous, self-administered, Global Adult Tobacco Survey based questionnaires on students from the main medical college in Jeddah, Saudi Arabia. Results: Of the 643 students in the study, 90 (14%) indicated that they smoked tobacco at the time of the study; the prevalence of smoking was 25% and 9% in males and females, respectively. Smoking was more common among males (P=0.003), but there were more ex-smokers among females (P<0.001). Friends and parents were considered the primary influence for initiating the smoking habit, followed by the media. Ninety percent thought that doctors should set a good example by not smoking. Most of the study population indicated that smoking is related to serious illnesses; however, non-smokers were better aware of such illnesses than smokers were. Although the majority thought that smoking tobacco is harmful, about 20% believed that smoking a water pipe is not. Conclusion: Despite good knowledge of tobacco consumption hazards, 25% male medical students and 9% female medical students in Jeddah continue to smoke. Factors contributing to the initiation, continuation, and spread of this devastating habit should be addressed urgently by policy makers.

Relationship of fractional exhaled nitric oxide with asthma control test scoring in adult asthmatics

Syed Shahid Habib

King Saud University, Post Box: 2925, Department of Physiology (29), KKUH King Saud University, Riyadh, Kingdom of Saudi Arabia

Presenter's Biography : Dr. Shahid is Associate Professor of Physiology and Consultant at Clinical Physiology Division of College of Medicine and King Khalid University Hospital at King Saud University, Riyadh, Saudi Arabia. He graduated from Khyber Medical College, Pakistan, in 1994 and completed his Fellowship in Physiology from College of Physicians and Surgeons, Pakistan. His main contributions have been to study biomarkers in cardiovascular and respiratory diseases. At present, he is keenly interested in studying the effects of metabolic diseases on exhaled nitric oxide. He has published more than 45 research papers and about 23 abstracts.

Background: Fractional exhaled nitric oxide (FENO) is a recently introduced non-invasive marker to measure inflammation and oxidative stress in the lung. Conventional measures of asthma severity have combined assessments of symptoms, amounts of B2 agonist used to treat symptoms, and lung function. Asthma Control Test (ACT) score was devised by Nathan et al. in 2004 and is recommended by National Heart Lung and Blood Institute (NHLBI) in Asthma Guidelines 2007. There is paucity of data on correlation between ACT score and FENO levels in asthmatics. Objective: To study ACT score and FENO levels in adults patients with asthma and to see correlation between these tests of asthma control. Methods: This study was carried out at Department of Physiology College of Medicine and pulmonary division of Medicine Department of King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia. We recruited 59 diagnosed cases of asthma, out of which 54 subjects completed the study. History and clinical examination details were recorded in a predesigned proforma. FENO levels were measured using NIOX MINO (Aerocrine, Sweden), taking into consideration all precautions recommended by American Thoracic Society (ATS guidelines 2005). After FENO measurements, ventilatory functions were recorded by the standard techniques. Forced expiratory volume in first second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, peak expiratory flow (PEF), forced expiratory flow 25% (FEF25), forced expiratory flow 50% (FEF50) and forced expiratory flow 75% (FEF75) were measured by the Vitallograph (ALPHA, Ireland). All recordings were made in sitting position. At least three readings were obtained and the best of three was taken as the final result. Results: The mean age was 36.08±14.28 years, height was 167.30±8.65 cm, weight 80.25±11.01 kg, FEV1 3.16±0.76 L, FVC 3.77±0.73 L and FEV1% 83.77±7.74%, FENO 48.93±33.31 and ACT score was 17.58±4.93. Mean FENO values were significantly higher in patients with ACT score‚ 20 (65.46±35.42) compared to those patients with ACT score 20 (27.36±10.48, P<0.001). There was a significant negative correlation between FENO and ACT score in asthmatic subjects (r=−0.581, P<0.0001). However, there was no significant correlation of FENO with age, height, weight, asthma duration, FVC, FEV1 and FEV1%. Conclusions: FENO levels correlate negatively with ACT score. Patients with low ACT score have significantly higher levels of FENO compared to those with higher ACT score. This indicates an ongoing inflammatory state in patients with poor asthma control. Both ACT score and FENO are useful tools to assess asthma severity and control.

Left lower lobectomy for endobronchial metastasis of uterine cervix cancer

Aysun Misirlioglu

Department of Thoracic Surgery, Chest Diseases and Thoracic Surgery Hospital, PO Box: 34840, Istanbul, Turkey

Presenter's biography : Thoracic surgeon.

Objectives: Endobronchial metastasis is not common in patients with cervix carcinoma and is frequently seen in renal, breast, and colorectal carcinomas. Here, we report a case of left lobar lobectomy performed on cervix carcinoma with endobronchial metastasis. Methods: A 38-year-old woman presented with cervix carcinoma with distance metastasis, 10 months after the treatment of primary tumor. Patient had only radical hysterectomy for cervix carcinoma and the pathological stage was Stage IB2. Dyspnea was the main symptom. Thorax computerized tomography of the patient obtained at the level of the left lower bronchi demonstrated a mass. Flexible bronchoscopy showed lesion in the left lower lobar bronchi. Histopathologic examination of bronchial biopsies and brushing confirmed endobronchial metastasis of the cervix carcinoma as squamous cell carcinoma. There was no distance metastasis on PET/CT. Results: Left lower lobectomy was performed on the patient. According to frozen examination, surgical limits were clean. We have followed our case since 3 months after surgery and there has been no complication. Conclusions: After initial treatment (radical hysterectomy), pulmonary metastasectomy and even lobectomy for uterine malignancies is a useful and acceptable treatment for long-term, disease-free survival.

Polysomnographic and clinical characteristics and predictors of obesity hypoventilation syndrome in Saudis

Ahmed S. BaHammam, Almeneessier A., Munir M. Sharif

Background: Obesity hypoventilation syndrome (OHS) is one of the sleep disordered breathing (SDB) that is confused with obstructive sleep apnea (OSA) since most patients with OHS display repeated upper airway obstruction during sleep. Despite its major impact on health, this disorder is under-recognized and underdiagnosed. Objectives: To assess the prevalence, clinical characteristics and predictors of OHS in a large sample of Saudi patients with moderate to severe OSA. Methods: Subjects comprised 766 patients who were referred to the sleep disorders center with a clinical suspicion of SDB and were diagnosed using type I attended polysomnography (PSG) to have moderate to severe OSA. OSA and OHS were diagnosed according to the American Academy of Sleep Medicine guidelines. Baseline characteristics, daytime sleepiness, polysomnographic data, arterial blood gases, pulmonary function testing, and pulmonary artery pressure were compared between OHS patients and pure OSA patients. To explore the predictors of OHS, a preliminary analysis used a univariate logistic regression model; one explanatory variable was tested in the model at a time. Subsequently, variables with significant P-values were evaluated further using a multivariate logistic regression model. Correlation between PaCO 2 and anthropometric, respiratory and polysomnographic parameters was found using Pearson correlation coefficient. Results: OHS was identified in 64 out of 766 patients with OSA (8.4%). Compared with pure OSA patients, OHS patients were significantly older (59.9±12.0 years vs. 46.3±12.9 years), had higher proportion of females (80% vs. 32%), higher body mass index (BMI; 44.5±11.0 vs. 35.4±9.0), higher daytime PaCO 2 (56.0±11.9 mmHg vs. 45.1±27.4 mmHg), lower paCO 2 (59.2±14.3 mmHg vs. 77.5±22.8 mmHg), higher apnea hypopnea index (AHI) (72.9±45.9/hour vs. 45.5±35.5/hour), lower average SaCO 2 during sleep (83.7±8.1% vs. 93.7±4.6%), and a higher pulmonary artery pressure (56.5±16.3 mmHg vs. 41.0±17.0 mmHg). Among the OHS patients, 4.7% had pure hypoventilation and 95.3% had mixed hypoventilation and obstructive SDB. Univariate regression analysis revealed that female sex (OR=5.4), BMI ≥ 30 kg/m 2 (OR = 5.5), AHI ≥ 30/hour (OR=2.0), desaturation ≤80% (0.45 ), and PaCO 2 ≥ 45 mmHg (OR=6.7) were predictors of OHS. Subsequent multivariate logistic regression analysis adjusting for other variables showed that female sex (OR=2.7, P=0.03, CI=1.13-6.65) and PaCO 2≥45 mmHg (OR=6.5, P<0.001, CI=2.73-15.37). Daytime hypercapnia represents a key feature of OHS; correlation coefficients between daytime PaCO 2 and other variables were examined to determine the factors underlying development of hypercapnia in OHS. BMI, nocturnal average SaCO 2 , and lowest recorded SaO2 during sleep significantly correlated with PaCO 2 . In particular, BMI (r=0.44, P<0.001) and average SaCO 2 (r=−0.58, P<0.001) exhibited the closest correlation with PaCO 2 . Conclusion: OHS is common among Saudi patients referred to the sleep disorders center, with OSA. In contrast to previous studies, OHS among Saudis is more common among women. Female gender and daytime hypercapnia are independent predictors of OHS among patients with OSA.

Prevalence and characteristics of cigarette smoking among 16- to 18-year-old boys and girls in Saudi Arabia

Mohamed A. Al Ghobain, Mohamed S. Al Moamary, Sulieman N. Al Shehri 1 , Mohamed S. AL-Hajjaj

College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, 1 Department School Health, Ministry of Education, Riyadh, Kingdom of Saudi Arabia

Objective: To study the prevalence and characteristics of cigarette smoking among secondary (high) school students (16- to 18-year-old boys and girls) in Riyadh city, Saudi Arabia.Methods: We applied the standard 2-stages cross-section study design. Secondary (high) schools for both boys and girls in Riyadh city were selected randomly from cluster sample method; we used the global youth tobacco survey (GYTS) to achieve our objectives. Results: Among 1272 students (606 boys and 666 girls), the total prevalence of those who ever smoked cigarette was 42.87%, while the prevalence was 55.63% among boys and 31.41% among girls. Total prevalence of current cigarette smokers was 19.50%, while the prevalence was 31.26% among boys and 8.91% among girls. In spite of the fact that the majority of students think that smoking is harmful, most of them neither want to stop smoking now nor tried to stop smoking in the last year. Cigarette smoking is significantly associated with male gender, smoker friends, and smoker parent, while it is not significantly associated with the type of school. Conclusion: Smoking prevalence among secondary (high) schools students in Saudi Arabia is high and alarming. There is a need to implement an education program about smoking for the students, addressing the importance of parents and friends to serve as models for the students not to initiate smoking.

Prevalence of chronic obstructive pulmonary disease among smokers attending primary healthcare clinics in Saudi Arabia

Mohammed Al Ghobain, Mohamed S. Al-Hajjaj 1 ,Siraj Omar Wali 2

College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia, 1 Department of Pulmonary Medicine, King Saud University, King Khalid University Hospital, 2 Department of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia

Background and Objectives : The prevalence of chronic obstructive pulmonary disease (COPD) in Saudi Arabia is unknown. The aim of this study was to estimate the prevalence of COPD among smokers, more than 40 years of age, attending primary healthcare clinics in Saudi Arabia. Setting and Design: A questionnaire was used in a cross-sectional collection of demographic data and other items related to diagnosis of COPD in patients visiting primary healthcare clinics. Methods: Eligible subjects were current or ex-smokers and aged 40 years or above. Spirometry was performed according to American Thoracic Society criteria. Airflow obstruction was classified according to the 2003 update of the World Health Organization and Global Initiative for Chronic Obstructive Lung Disease criteria. COPD was defined as a ratio less than 0.70 of post-bronchodilator-predicted forced expiratory volume in the first second to forced vital capacity (FEV1/FVC < 0.70). Results: Five hundred and one subjects were eligible for data analysis. Seventy-one patients had an FEV1/FVC ratio <0.70, comprising 14.2% of the study population, of which 95.8% were males. Current smokers comprised 57 (80.3%) subjects. Of the 71 subjects who fulfilled the criteria for COPD diagnosis, none were found to be in COPD stage I; 40 (56.3%) were in stage II and 31 (43.6%) were in stage III of the disease. Conclusion: Underdiagnosis of COPD in primary healthcare clinics in Saudi Arabia is common, but its exͼtent is not different from the corresponding data available in the literature for other countries. Use of spirometry as a routine test for all patients older than 40 years of age and with a smoking history can help in early detection and proper diagnosis of COPD, which subsequently will help in implementation of preventive measures.

A comparative study of FVC, FEV 1 , and TLC in non-smoking Saudi students at Eastern Province, Saudi Arabia, with Caucasian reference values

Amr El-Noueam, Stephanie Enright, Noor AL-Khathlan

University Of Dammam, Cardiff University

Aim : This cross-sectional study was designed with the following aims:

  • Measure forced vital capacity (FVC), forced expiratory volume in 1 second (FEV 1 ) and total lung capacity (TLC) in a population of Saudi adults
  • Investigate the existence of any differences between Saudi measured lung function values and Caucasian reference values, taking into consideration height, age and sex similarities between the two groups
  • Produce prediction equations for FVC, FEV 1 and TLC for adult student population in the Eastern Province of Saudi Arabia

Methods: These specific parameters of lung function were measured using techniques and equipment that meet American Thoracic Society (ATS) recommendations in 112 non-smoking university students (52 males and 60 females). The median age for males was 22.9 years and for females was 19.4 years. The inclusion criteria were the following:

  • Age 18-22 years
  • Male and female subjects with an average height
  • Non-smoker healthy subjects
  • Saudi Arabian origin (born and grown up in Eastern Province)

The exclusion criteria were the following:

  • Age <18 or >22 years
  • Pregnant
  • Obese
  • BMI > 25
  • Highly trained athletes
  • Poor spirometry quality or unable to perform spirometry according to ATS guidelines
  • Smoker or having prior history of smoking cigarettes, pipe or cigars
  • Having upper respiratory tract infection within the past 3 weeks
  • History of asthma or allergy
  • Presence of chronic cough
  • Having chest surgery

The procedure was as follows

  • Ethical approval was taken
  • Invitations were sent to the students at University of Dammam
  • Questionnaires were distributed to determine student's suitability
  • Baseline characteristics were taken and pulmonary function tests were performed
  • Measured values were compared with the reference values

Results: Statistically significant differences (P<0.01) were identified between the mean of the measured values of lung function for Saudis and the mean of Caucasian reference values. Saudi males and females had lower mean values and standard deviations for FVC, FEV 1 and TLC than Caucasian males and females. Conclusions: The most clinically relevant finding is the significant differences found between the means of the measured lung functions (FVC, FEV1 and TLC) in Saudi population and Caucasian reference values derived from the commonly used European prediction equations. The observed mean values for FVC, FEV 1 and TLC for Saudis were found to be lower than the mean predicted values for Caucasians by about 10%, 5% and 8%, respectively, for males, and by 16%, 12% and 5%, respectively, for females. This difference may be explained in terms of environmental and lifestyle factors such as:

Long-term exposure to high levels of air pollution from the Gulf War (August 1990);

  • the petroleum industries in the Eastern Province;
  • the sudden increase in traffic pollution;
  • changes in dietary pattern; and
  • the sedentary lifestyle.

The first published set of prediction equations for FVC, FEV 1 and TLC in "healthy" Saudi adults living in the Eastern Province of Saudi Arabia has been established. Recommendations: This study recommends the performance of further and considerably larger studies:

  • To develop prediction equations for all regions of Saudi Arabia, since the Kingdom covers an area of more than 2,000,000 km2 and consists of several regions, each of which differs geographically from others (some of them are located at the sea level while others are located at an altitude of 3200 m above the sea level).
  • On a wider age range of Saudi population: from childhood to geriatric, to cover all the age groups in the Saudi community.
  • On a wider height and weight ranges.
  • To measure all lung functions: lung volumes, flow rates and the diffusing capacity of the lungs (DLCO).
  • To compare the lung functions of Saudi population to those of other Gulf and Middle Eastern countries, as well as other ethnic groups, to understand the relative roles of genetic constitution and exogenous influence on lung function development.

Abrupt withdrawal of inhaled corticosteroids in COPD does not produce spirometric deterioration: Role of phenotyping

Feisal A. Al-Kassimi, Mohammed S. Al-Hajjaj, Esam H. Alhamad, Abdullah A. Abba Emad Raddaoui, Shafi A. Shaikh

Background: It is still controversial whether the abrupt withdrawal of inhaled corticosteroids (ICS) in chronic obstructive pulmonary disease (COPD) results in spirometric worsening. [1-4] Corticosteroids were found to have no effect on inflammatory cells or markers. We suggested in 2004 that the studies which demonstrated a bronchodilator effect by ICS in COPD were biased by the inclusion of irreversible asthma. [5] To test our hypothesis, we excluded cases of irreversible asthma from a group of COPD patients. The change of spirometry after withdrawal of Budesonide was measured. Methods: This was a prospective descriptive study conducted at King Saud University, Riyadh, between April and May 2009. COPD was diagnosed in smokers (≥10 years/pack), aged 40 or more, with chronic symptoms and FEV 1 < 80% predicted with FEV 1 /FVC ≤ 70% in spite of having received Budesonide 320 ΅cg/Formeterol 9 ΅cg bid. A total of 32 patients with ''COPD'' were subdivided into the following phenotypes: 1) Irreversible asthma: Bronchial biopsy diagnostic of asthma with normal diffusion coefficient (KCO) (n=8 patients). 2) Airflow limitation (AFL) likely to be irreversible asthma: Patients who refused bronchial biopsy but had normal KCO (n=5). 3) COPD: (a) PaCO 2 ≤ 60 mmHg, PaCO 2 > 45 mmHg, and serum bicarbonate > 28 mmol/L (n=5); (b) HRCT scan showing panlobular emyphysema with bullae larger than 2 cm (n=6); or (c) Bronchial biopsy diagnostic of chronic bronchitis (n=5). 4) AFL likely to be COPD: Patients who do not fit in group 3 but who have low KCO (n=3). Patients in phenotypes 3 and 4 (n=19) were subjected to Budesonide withdrawal while continuing with Formeterol. Spirometry was performed before and 4 weeks after Budesonide withdrawal. It is the standard clinical practice in the first author's clinic to withdraw ICS in the summer. The change of FEV 1 was below 200 mL in all patients. Results: COPD phenotypes display different responses. Patients with emphysema (E phenotype) on HRCT scan showed low DLCO and absent response to b2-agonists and ICS. Mixed emphysema/bronchitis (M phenotype) showed only reduced response to b2-agonists. Phenotype A (without emphysema) is associated with higher DLCO and greater responsiveness to b2-agonists. These phenotypes correspond to emphysema, mixed COPD, and asthma (with some overlap). Phenotyping by bronchial biopsy into irreversible asthma and COPD showed 100% correlation with response to oral Prednisolone and ICS. [6-7] Two studies found a significant but modest decline of FEV 1 at 4.1%, 1 month after withdrawal of ICS. [3-4] Neither study had strict criteria for exclusion of irreversible asthma. Two other studies reported no significant decline of FEV 1 , 6-minutes walk test or the St George's respiratory questionnaire. [1-2] Conclusion: In conclusion, abrupt withdrawal of Budesonide for 4 weeks produced no significant drop of FEV 1 or FVC. This may be explained by phenotypying to exclude asthma.


  1. Choudhury AB, Dayson CM, Kilvington HE, Eldridge S, James WY, Wedzicha JA, et al. Withdrawal of inhaled corticosteroids in people with COPD in primary care: A randomized controlled trial. Respir Res 2007;8:93.
  2. van der Valk P, Monninkhof E, van der Palen J, Zielhuis G, van Herwaarden C. Effect of discontinuation of inhaled corticosteroids in patients with chronic obstructive pulmonary disease: The COPE study. Am J Respir Crit Care Med 2002;166:1358-63.
  3. Wouters EF, Postma DS, Fokkens B, Hop WC, Prins J, Kuipers AF, et al. Withdrawal of fluticasone propionate from combined salmeterol/fluticasone treatment in patients with COPD causes immediate and sustained disease deterioration: A randomized controlled trial. Thorax 2005;60:480-7.
  4. O'Brien A, Russo-Magno P, Karki A, Hiranniramol S, Hardin M, Kaszuba M, et al. Effects of withdrawal of inhaled steroids in men with severe irreversible airflow obstruction. Am J Respir Crit Care Med 2001;164:365-71.
  5. El-Kassimi FA. Differentiating asthma and COPD patients. Chest 2004;126:653-4: author reply 654-5.
  6. Chanez P, Vignola AM, O'Shaugnessy T, Enander I, Li D, Jeffery PK, et al. Corticosteroid reversibility in COPD is related to features of asthma. Am J Respir Crit Care Med 1997;155:1529-34.
  7. Al-Kassimi FA, Abba AA, Al-Hajjaj MS, Alhamad EH, Raddaoui E, Shaikh SA. Asthma masquerading as chronic obstructive pulmonary disease: A study of smokers fulfilling the GOLD Definition of chronic obstructive pulmonary disease. Respiration 2011; Jan 29. [Epub ahead of print].

Adjuvant chemotherapy in a real-life setting

Brandιn E, Koyi H, Lamberg K 1

Department of Respiratory Medicine Gδvle Hospital, Gδvle, and Karolinska institutet Stockholm, 1 Department of Respiratory Medicine and Allergology, Uppsala Akademiska Hospital, Uppsala, Sweden

Background: Adjuvant chemotherapy has become a standard of care for patients with resected non-small cell lung cancer (NSCLC) stage IB-IIIA. The benefit is seen mainly in patients with stage II and IIIA disease. The aim of this work was to study the implementation of the therapy in our region with one university hospital and three other hospitals. We wanted to evaluate the choice of chemotherapy, when it was started after surgery, how many cycles were given, and if not given, wh y? Study of survival after surgery is included in our analysis comparing the different hospitals. Methods: Retrospective study of patient files of all patients who underwent surgery because of lung cancer from 2004 to 2008 was carried out. Thirty-four patients were excluded because of the following reasons: neoadjuvant chemo was given in 27, 2 were inoperable patients who underwent exploratory thoracotomy and 5 patients were found to have metastasis a short time after surgery. Results: Of the 200 patients, 105 were females. Median age was 68 (range 40-85) years. 106 were current smokers and 65 were former smokers. Lobectomy was performed in 155, pneumonectomy in 30 (12 right, 18 left) and wedge resection in 15 patients. Stage based on surgery outcome was as follows: IA in 73 (36.5%), IB in 60 (30%), IIA in 2 (1%), IIB in 18 (9%), IIIA in 25 (12.5%), IIIB in 7 (3.5%), and unknown in 15 (7.5%). Dominating histology was adenocarcinoma in 50% and squamous cell carcinoma in 31%. Sixty-seven percent of the patients with stage IB-IIIB received chemotherapy. 33% (37 patients) did not receive chemo because of factors like age, presence of comorbidities, bad performance postop or the patient's own wish. In 6 patients, no reason was given. Thirty percent of patients with stage IA received chemotherapy. In all, 67% started chemotherapy within 8 weeks postop, 15% started it 9-10 weeks postop, and 18% had it 11 or more weeks postop. The choice of chemotherapy was according to local traditions. Cisplatin/Vinorelbine, Carboplatin/Gemcitabine or Carboplatin/Vinorelbine was used in 92.9% of the patients, and three or four cycles were given. In 5 patients, radiation therapy was added. In total, 33% (66/200) of the patients relapsed until August 2010. Among those with stage IA, 17.8% (13/73), and among those with IB-IIIB, 43% (48/112) relapsed. A curve showing the survival in the different hospitals will be presented. Conclusions: Adjuvant chemotherapy after resection of NSCLC is implemented in our region. The benefit within patients with stage IA is not yet proven. The goal to start within 6-8 weeks after operation was fulfilled in 67% of patients. Platinum-based chemotherapy is the standard with a few exceptions. With accurate use of PET CT, futile thoracotomies can be avoided and the staging becomes better. In this study, only a few patients underwent PET CT. The relapse rate was discouraging although adjuvant chemotherapy was given. Surprisingly, we found that the relapse rate was greater in patients who were adjuvant treated in both IA (22.7% compared with 15.7%) and IB-IIIB (46.7% compared with 35.1%). The number of patients is small; so, we plan to extend this study to include 2009 in a future presentation. The survival data will then also be updated.

Assessment of respiratory care educational environment using DREEM inventory

Ghazi Alotaibi, Amal Alamer, Esraa Makhdom

Department of Respiratory Care, College of Applied Medical Sciences, University of Dammam, Dammam, Kingdom of Saudi Arabia

Background : Medical and health-related education has undergone major innovations over the last two decades. Among the most important innovations are outcome-based education and student-centered learning approach. In student-centered teaching, a great emphasis is placed on how and where students learn. The climate at which learning occurs has been the scope of interest for many medical educationalists. Educationalenvironment is defined as the climate of the institution as experienced by students, which has direct or indirect influence on the learning process. Research studies have shown that a positive and supportive environment is an essential requirement for successful learning. Roff et al. (2001) found that the educational environment makes an impact on students' learning experiences and outcomes. It has been also reported that students who perceived their learning environment as positive are more likely to develop effective learning strategies and adopt deep learning approach (Shreemathi and Roff, 2004). Study objective: To measure students' perception of educational environment of Respiratory Care program at the University of Dammam. Methods: Dundee Ready Educational Assessment Measure (DREEM) was used to assess the educational environment. DREEM is intended to measure and diagnose the environment of educational institutions in the healthcare professions. DREEM was designed in such a way that it is not culturally specific and can be used in a wide range of health-related disciplines. It consists of 50 statements related to learning environment, where students are requested to indicate level agreement with each statement using a 5-point Likert scale (strongly agree, agree, uncertain, disagree, and strongly disagree). The validated Arabic version of DREEM was revised for clarity of lack and ambiguity and administered to all male and female undergraduate Respiratory Care students in years 2, 3, and 4. Response rate was 95.5%. Results: The Arabic version of DREEM used in this study was found to be reliable, with excellent internal consistency (a=0.905) as measured by Cronbach's alpha coefficient. There were no statistical significant differences in males' and females' perceptions of RC educational climate, reflecting consistency of the educational environment in RC department. Analysis of the five subscales of DREEM indicates a tendency toward positive environment. The overall learning environment score was 125.68 out of 200 (63%). Students' perception of social environment was the least among the five domains. There were statistically significant differences in students' perceptions of some educational environment's domains between year 2 as compared to year 4 students, and year 3 as compared to year 4 students. This may be because students who enrolled in the program longer become overloaded and stressed. This study revealed nine areas in the RC department that are not contributing to a good educational environment. Conclusions: DREEM questionnaire is a useful and practical tool to diagnose educational environment. The overall educational environment in the RC department is more positive than negative and consistent in male and female teaching areas. There are great opportunities to enhance the educational environment of the RC department. One important change is to implement effective supportive system for students who get stressed. A student-centered approach of teaching should be adopted to promote active learning. RC curriculum should be modified to reduce content overload. A follow-up qualitative study is needed to get insight about weaknesses and strengths of the learning environment.

Causes of pediatric pulmonary hypertension (PAH) and its management in a tertiary care center in Saudi Arabia

Hanaa Banjar

Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, KSA

Background : Pulmonary arterial hypertension (PAH) has been described frequently in the pediatric population. Approximately 40% of cases of PAH are idiopathic and 6% are heritable in nature, with the remaining mainly associated with congenital heart disease (CHD) and a few associated with connective tissue diseases, HIV or portal hypertension. Mortality associated with PAH is extremely high. The mean survival after confirmation of diagnosis is 2.8 years among adults and less than 1 year among children. Objective: To identify the different causes of PAH and treatment modalities in referred cases to the Pediatric Pulmonary clinic in a tertiary care center in Saudi Arabia and the course of their management and outcomes. Methods: Retrospective chart review of all patients referred to the pulmonary clinic with documented PAH based on cardiac catheterization and or echocardiogram during 1-year period (March 2009-February 2010) was carried out. Results: A total of 114 patients with confirmed PAH were analyzed. Mean age at diagnosis was 3.1±3.8 years. 55 (48%) were males and 59 were (52%) females. The most common cause of PAH was found to be CHD in 100 (87.7%) patients. The most common CHDs that caused PH were: ASD in 76 patients (76%), VSD in 63 patients (63%), common AV canal in 39 patients (39%), PDA in 45 patients (45%), Tetr alogy of Fallot in 10 patients (10%), and total anomalous pulmonary venous return (TAPVR) in 10 patients (10%). Other causes of PAH were the congenital anomalies in 100 patients (87.7%) and Down syndrome in 44 patients (28%). Other congenital anomalies were CHARGE association, skeletal dysplasia, and demyelinating diseases. Eleven patients (10%) had PAH due to congenital lung anomalies such as diaphragmatic hernia in association with lung hypoplasia, and congenital lobar emphysema; 11 patients (10%) had PAH due to chronic lung disease (CLD); in 2 patients it was due to livin g in high altitude; in 2 patients it was associated with obesity; 2 patients had PAH associated with Alagile syndrome; and 2 patients had idiopathic PAH. Obstructive sleep apnea (OSA) was detected in 31 patients (27%), asthma in 33 (30%), and recurrent chest infection in 41 (36%). Thirty-two patients (28%) required CO 2 , 36 (32%) required gastroesophageal reflux (GER) Factors that were related to development of PAH were found to be: common A-V canal (P=0.05), OSA (P=0.02), and female sex (P=0.05). Sixty of 114 patients (53%) were started on vasodilators. Sildenafil (Revatio) was the most common drug used in 35 patients (30%), alone or in combination with Bosentan (Tracleer) or inhaled Ventavis (Iloprost). Bosentan alone or in combination was used in 21 patients (18%) and inhaled Ventavis alone or in combination was used in 8 patients (4%). Seventy-five patients (66%) continued to have PAH at follow-up, and the factors that contributed to persistence of PAH at follow-up were the presence of CHD (P=0.05) and unclosed ASD (P=0.03). Conclusions: Pulmonary hypertension is a common disease and should be diagnosed and treated early before it becomes irreversible and resistant to vasodilators. Early closure of ASD and CHD defect repair improves PAH.

Clinical characteristics and outcomes of hospitalized patients with influenza A (H 1 N 1 ) infection in

Al-Amiri Hospital, Kuwait

Al-Tamimi K, Al-Mutairi S, Alazemi S, Ekrouf K, Al-Ghimlas F

Background: In 2009, influenza A (H 1 N 1 ) infection was announced to be a pandemic disease. The clinical characteristics and outcomes of patients suffering from this disease in Kuwait and the Middle East area are unknown. Methods: In our secondary hospital, a specialized consulting team evaluated and aided in the management of all reported, hospitalized patients with influenza A (H 1 N 1 ) infection. We are reviewing the medical reports of patients with influenza A (H 1 N 1 ) infection, hospitalized during the period August 2009-December 2010. Results: We reviewed 130 charts of hospitalized patients documented to have the disease. Fifty-four percent were females. The mean age was 30.5 years, with 40% below 18 years and 10% above 65 years of age. The mean weight was 46.2 kg. Sixty-nine percent of them had at least one co-morbidity. 128 patients survived (mortality was 0.02%). Coryzal symptoms (45%), easy fatigability (41%), abdominal complaints (39%), and dyspnea (38%) were amongst the most common presentations. Patients also suffered from cough (32%) and sputum (39%). Hemoptysis was reported in one patient. Other symptoms reported were fever (11%) and neurological complaints (10%). The complete blood profile showed mean white blood cell count of 10.0Χ10 9 /L), mean hemoglobin of 120.0 g/dL, and platelet count of 292.0Χ10 6 /mL. Only fifty-five percent of these patients had their chest X-rays reported, and among these, 81% were abnormal (68% consistent with pneumonia). All those patients whose medical records were available for review (114) received the antiviral oseltamivir. Dose and duration were variable according to the patients' age, presence of renal impairment, and/or disease severity, but were consistent with the international guidelines. Conclusions: Our data are similar to other reports [1,2] indicating that influenza A (H 1 N 1 ) infection is a mild disease with low mortality risk. The protocol used for treatment follows the international guidelines. This might be due to adopting a specialized consulting team for documented cases.


  1. Jain S, Kamimoto L, Bramley AM, Schmitz AM, Benoit SR, Louie J, et al. Hospitalized patients with 2009 H1N1 influenza in the United States, April-June 2009. N Engl J Med 2009;361:1935-44.
  2. Cao B, Li XW, Mao Y, Wang J, Lu HZ, Chen YS, et al. Clinical features of the initial cases of 2009 pandemic influenza A (H 1 N 1 ) virus infection in China. N Engl J Med 2009;361:2571-2.

Compliance with 6-hour sepsis resuscitation bundle in a Saudi hospital

Rifat S. Rehmani, Javed I. Memon, Talib M. Lone, A. S. Abdulbasir

Departments of Emergency Medicine and Internal Medicine, King Abdulaziz Hospital, Al-Ahsa, Kingdom of Saudi Arabia

Background : Severe sepsis and septic shock are associated with significant morbidity and mortality. Protocol-driven early goal-directed therapy (EGDT) has been shown to reduce mortality in patients with severe sepsis and septic shock. The initial 6-hour "resuscitation bundle" focuses on the identification of high-risk patients as well as administering early aggressive resuscitation with specific end points. To improve the initial severe sepsis management, it is important to understand the current practices. The aim of this study was to determine the rate of compliance with 6-hour sepsis bundle and its outcome in terms of mortality in patients with severe sepsis or septic shock in our hospital. Methods: We conducted a retrospective cohort study on all consecutive adult patients with severe sepsis or septic shock who were admitted to the Intensive Care Unit at King Abdulaziz Hospital in Saudi Arabia from January 2008 to March 2009. Special datasheet was made to collect data on demographics, initial vital signs, baseline laboratory values, severity of illness scores by acute physiology and chronic health evaluation II (APACHE II), co-morbid conditions, requirement of vasopressors and mechanical ventilation, compliance to sepsis resuscitation bundles and the 30-day mortality. The outcome measures were the rate of compliance with 6-hour sepsis care bundles adapted from the Surviving Sepsis Campaign guidelines on patients' clinical care. The items evaluated were: (1) measurement of blood lactate; (2) obtaining blood samples for culture before use of antibiotics; (3) first dose of an appropriate antibiotic to be given within 3 hours of admission to ED (1 hour after the onset of sepsis in ward setting); (4) fluid bolus of 20 mL/kg of crystalloids, if there is hypotension or blood lactate is >4 mmol/L, and apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) to ≥65 mm Hg; (5) in the event of persistent arterial hypotension despite volume resuscitation (septic shock) and/or initial lactate >4 mmol/L, central venous pressure (CVP) of ≥8 mm Hg and central venous oxygen saturation (ScvCO 2 ) ≥70% has to be achieved. Results: There were ninety-five patients included in the study. The mean (SD) age was 68.6 (18.3) years; the mean (SD) APACHE II score was 21.5 (7.4); 56% were males, 63% had septic shock and 54 patients (55%) required mechanical ventilation. The ICU mortality was 25 (26.3%; 95% CI 17.5-35.2%) and 30-day hospital mortality was 26 (27.4%; 95% CI 18.7-36.5%). Urine was the most common source (27%), followed by the chest (25%).The rates of compliance with the 6-hour sepsis bundle for the elements evaluated were the following: 83% of patients had determinations of blood lactate; 17% of septic patients had no blood cultures drawn; 41% had received their first dose of antibiotics in the recommended timeframe; 81% of the cases of severe sepsis or shock received a fluid aggressive therapy; 87% of the patients had central venous catheter placement; targeted CVP and MAP were achieved in 54% and 86%, respectively; 24% of the patients had central venous oxygen saturation measured and targeted ScvCO 2 was achieved in only 9.5% of the 95 cases. Conclusion: The compliance to 6-hour sepsis resuscitation bundle is variable in our hospital and the mortality rate is within the acceptable range. A quality plan is in place to improve the staff practices with these bundles within a strict timeframe to improve survival rates in patients with severe sepsis and septic shock.

Effect of aerobic exercise on symptoms of primary insomnia

Ayman B. Krayem, Shaza M. Kadah 1 , Rana M. Alerwi 1 , Enas E. Mohammad 1 , Siraj O. Wali 2

Departments of Medicine, 1 Physical Therapy, and 2 Medicine, King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia

Background : Physical exercise therapy has the potential to improve sleep quality in patients with primary insomnia. Objective: To evaluate the effect of moderate aerobic exercise program in managing patients with primary insomnia. Subjects and Methods: Twenty patients (19 females and 1 male, age range 35-45 years) with chronic primary insomnia (symptom duration 1-4 years) were selected and equally divided into two groups: study and control. Both the groups were comparable in their baseline characteristics. Sleep duration and daytime symptoms were assessed at baseline by Sleep Diary and Epworth Sleepiness Scale, respectively. Both the groups received cognitive behavioral therapy and drug therapy as needed. Additionally, patients in the study group were enrolled in a supervised structured moderate aerobic exercise program (30 minutes, three times a week, for 4 weeks). Results: There was significant difference between study and control groups regarding the mean values of weekly sleep hours before (mean = 20.60±6.24 and 14.05±4.51, respectively; P=0.15) and after treatment (mean=50.85±6.32 and 13.90±4.31, respectively; P=0.000). Mean sleep hours at the end of treatment significantly increased compared to that before treatment in the study group (P=0.000), while in the control group, there was no significant difference (P=0.75). An increase in mean total hours of sleep per week was observed by the second week of treatment in the study group and was significantly increased at the end of the fourth week of exercise treatment. The mean values of sleep hours of second and fourth weeks were 39.90±6.38 and 50.85±6.32, respectively (P=0.02). Baseline mean Epworth Sleepiness Scale between both the groups was comparable (mean=2.8±0.79 and 2.8±0.92, respectively; P=0.94) but significantly increased in the study group by the fourth week compared to control (12.4±3.09 and 3.4±0.97, respectively; P=0.000). Conclusion: Supervised structured moderate aerobic exercise program is effective in treating insomnia as indicated by significant improvement in sleep duration in patients with primary insomnia. The increased Epworth Sleepiness Scale may represent recovery sleep following long-term sleep deprivation. Emphasis on aerobic exercise treatment option is indicated since many insomniacs resort to drug therapy as the main treatment modality.

Idiopathic laryngeo-tracheal stenosis

Zeead M. ALGhamdi, Abeer A. ALGhwairi, Marwan A. L. Mathani, Mohammed Regal

Thoracic Division, Department of Surgery, University of Dammam, KSA

Idiopathic laryngeo-tracheal stenosis (ILTS) is uncommon. It was first described in 1972 by Brandenburg, who monitored three cases of indefinite etiology over a 10-year period. Herein, we report the case of a 33-year-old lady who presented with progressive dyspnea and was mismanaged as bronchial asthma for the last 2 years. Her bronchoscopy revealed narrowed subglottic segment 5 mm below the vocal cords. Definitive laryngeo-tracheal resection and reconstruction was done with a satisfactory result.

The case discussed here was that of a 33-year-old non-smoker, who was a healthy lady. The patient had neither any history of previous surgery nor airway intubation for any other reason. The patient was referred to our hospital with progressive dyspnea that had worsened in the last 6 months with hoarseness in her voice. Her initial magnetic resonance image (MRI) [Figure 1] showed a long segment of stenotic subglottic area extending into upper trachea. Fiberoptic bronchoscopy could not be done as the patient could not tolerate it. Patient was admitted and rigid bronchoscopy was done under general anesthesia. Scope size 3.5 Fr was introduced with difficulty. It confirmed an area of extensive subglottic area stenosis, around 5 mm below the vocal cords and extending for 1-1.5 cm into the upper trachea. Patient was planed for elective laryngotracheal resection and reconstruction. Pearson's technique was used. Resection of the upper two tracheal rings was done. Excision of the anterior and lateral walls of the cricoid cartilage was done with preservation of the posterior plate. This was found insufficient with severe narrowing of the lumen. So, we performed subperichondrial excision of the cricoid to augment the lumen [Figure 2], followed by thyro-tracheal anastomosis and tracheostomy. Laryngeal edema subsided, and 4 days later, the tracheostomy tube was removed and the patient had normal mobile vocal cords but with hoarseness related to the edema that was improving with time. Patient was re-admitted twice with mild stridor. Repeated bronchoscopy using size 6.5 showed formation of granulation tissue over the suture line. Curettage was done in addition to removal of the remnant sutures. Pneumatic dilatation was done. Patient's condition improved except for mild hoarseness of the voice [Figure 3].

ILTS is a rare disease of unknown origin. The pathology is related to stenosis caused by non-specific inflammation that produces ring-like scar tissue. Idiopathic tracheal stenosis has characteristic features that are different from other stenosis where there is a lack of predisposing factors and the almost exclusive affect female patients with ages between 20 and 60.

To diagnose ILTS, it is important to rule out the predisposing factors most often claimed to lead to stenosis, such as prolonged tracheal intubation, external laryngotracheal trauma, upper airway infections, Wegner's granulomatosis, amyloidosis, histoplasmosis, collagen vascular disease, chemical or inhalational burns, tuberculosis, radiation, benign or malignant neoplasms and congenital causes. It has been suggested that gastroesophegeal reflux disease, autoimmunity and, given that it appears almost exclusively in women, the possibility of a hormonal component should be investigated. The cardinal symptoms are inspiratory dyspnea (98%) and occasionally stridor; it is rarely accompanied by dysphonia or cou gh. In order to establish a correct diagnosis, the following steps should be taken into consideration: a detailed history, meticulous external and endoscopic examination, proper radiological studies to rule out the possible mentioned causes. The ideal treatment continues to be controversial. The endoscopic approach with CO 2 laser incision and dilatations is widely used by some authors with a good result. Others prefer the open surgery way with resection of the cricotracheal portions and single-stage reconstruction with good outcomes reported in the largest series published. ILTS has a high ability to recur quickly after all modalities of surgical treatment, with high rate of recurrence following the endoscopic laser surgery. Using mitomycin C postoperatively reduces re-stenosis following surgery.

ILTS is uncommon, presents usually with inspiratory dyspnea and stridor. To diagnose ILTS, it is important to rule out the predisposing factors most often claimed to lead to stenosis, such as prolonged tracheal intubation and external laryngotracheal trauma. The endoscopic approach with CO 2 laser incision and dilatations, open surgery with resection of the cricotracheal portions and single-stage reconstruction are the treatments used, although the ideal treatment continues to be controversial. ILTS has a high ability to recur quickly after all modalities of surgical treatment, with high rate of recurrence following the endoscopic laser surgery.

Implication of paralyzed diaphragm after congenital cardiac surgeries

Mohamed Fouad Ismail, Alaa Basiouni Said Mahmoud, Ahmed Jamjoom

Division of Cardiothoracic Surgery, Department of Cardiovascular, King Faisal Specialist Hospital and Research Center, PO Box 40047, Jeddah - 21499, Kingdom of Saudi Arabia

Background : Diaphragm plication has been used since 1954 for the treatment of hemidiaphragm paresis. It is now the standard treatment of diaphragm paresis (DP) for children aged less than 1 year. Methods: We performed a retrospective review for all patients who required diaphragm plication after congenital cardiac surgery from Jan 2002 to Jan 2009. Results: Sixteen patients (9 males and 7 females) with a median age of 2.75 months (range 15 days to 36 months) had diaphragmatic plication after a congenital cardiac procedure from January 2002 to January 2009. Ultrasound examination was used to diagnose DP in 14 patients (87%) and/or fluoroscopy in 12 patients (75%). Modified British Thoracic Society was the most common procedure associated with DP (43.7%). Left-sided DP needing plication was reported in 11 patients (68.7%) and right-sided DP needing plication was reported in 5 patients (31.3%). The median time between the primary surgery and diaphragm plication was 13 days (range 3-27 days). The median ventilation period before plication was 6 days (range 2-55 days); 6 of these patients (37%) had failed extubation and were re-intubated again. Nasal continuous positive airway pressure (CPAP) was applied for five of our patients (31%) after extubation and before plication. All patients were successfully extubated following plication and the median time of mechanical ventilation after plication was 4 days (range 1-14 days); 12 patients (75%) were extubated within 4 days post plication. Our patients were discharged with a median hospital stay of 36 days (range 11-80 days) and an ICU stay of 31 days (range 8-65). Conclusion: Diaphragmatic plication is an effective procedure in the management of postoperative diaphragmatic paralysis. We recommended early intervention for plication once diagnosis was confirmed.

Management of complicated parapneumonic effusions and empyema using different treatment modalities

Magdi Ibrahim

Department of Thoracic Surgery, King Fahad Hospital, Almadinah Almunawarah, Kingdom of Saudi Arabia

Objectives : We seek to evaluate the efficacy of the three different treatment modalities [intrapleural instillation of streptokinase (SK), video-assisted thoracoscopy (VATS) and surgery] in the management of complicated parapneumonic effusions and empyema. Methods: We conducted a retrospective study between January 2008 and June 2010 in our thoracic surgery department in King Fahad Hospital. They were 69 patients (52 males, 17 females) aged 18-50 years. Patients were subdivided into three groups: group A-20 patients underwent intrapleural administration of SK; group B-25 patients underwent VATS; and group C-24 patients underwent open surgery (thoracotomy). Preoperative, intraoperative and postoperative variables, mortality and procedure success were compared in all the groups. Results: In all the groups, preoperative variables were well matched for age and sex. No allergic or hemorrhagic complication occurred. Operative time was statistically highly significant; it was shorter in group B. There was no intraoperative complication in group B or C. Postoperative hospital stay was statistically significant; it was shorter in group B. There was no significant difference between all the groups as regards to their post-procedural number of days on chest drainage, but clinically it was shorter in group B. Procedure success was 50% in group A, 92% in group B and 100% in group C. There was no perioperative mortality in all the groups. Conclusions: VATS is a safe and effective treatment modality for complicated parapneumonic effusion and pleural empyema. Earlier intervention with VATS can produce better clinical results.

Obesity and asthma in women

Amany Zeidan, Mervat M. El-Eshmawy 1 , Azza A. El-Baiomy 2 Mohammad E. Abou Shehata

Department of Thoracic Medicine, 1 Internal Medicine, and 2 Departments of Clinical Pathology, Faculty of Medicine, Mansoura University, Egypt

Background : Both obesity and asthma are common clinical problems, often coexisting in the same patient, and both are characterized by the presence of inflammation. Objective: This study aims to investigate the relationship between obesity, asthma and atopy. Methods: It was a case-control study that included 80 women (with written consent) divided into four groups, with 20 subjects in each: obese patients with asthma, normal-weight patients with asthma, obese patients without asthma, and normal-weight patients without asthma. All cases were subjected to spirometry, test of reversibility after inhaled short-acting b2 agonist, skin prick test. Body mass index (BMI) was calculated as weight in kg/square of the height in meters, and levels of serum markers of inflammation, high sensitivity C-reactive protein (hS-CRP) and IL-1beta (ί), were determined. Results: There was significant negative correlation between BMI and FEV1. In the obese subjects, hS-CRP level was significantly higher compared with the normal-weight subjects. The hS-CRP was also significantly higher in obese subjects with asthma compared with normal-weight asthmatic patients. IL-1 ί level was significantly higher in patients with asthma compared with subjects without asthma. Also, IL-1 ί was significantly higher in obese subjects with asthma when compared with normal-weight asthmatic patients. There was no significant difference in atopy between obese and normal-weight patients with asthma. Conclusions: Obesity is likely to have a stronger association with asthma. The higher level of hS-CRP and IL-1 ί resulting from the systemic inflammatory effects of obesity itself may be one of the mechanisms explaining this association.

Organizing pneumonia due to tacrolimus in a renal transplant patient

Elif Kupeli, Ruhsel Corut, Dalokay Kilic 1 , Cigdem Vural 2 ,Fusun Oner Eyuboglu

Department of Pulmonary, 1 Thoracic Surgery and 2 Pathology, Baskent University School of Medicine

A 49-year-old male with cough and reticulonodular infiltration involving the right lung [Figure 1] was admitted for further evaluation. Past medical history revealed diabetes mellitus, parathyroidectomy, thyroidectomy and renal transplantation.

On auscultation, bibasilar crackles were heard. On laboratory analysis, total blood count, C-reactive protein, and blood chemistry were all within normal limits. Pulmonary function test revealed a restrictive pattern with reduced diffusion capacity. Thorax computed tomogram (CT) revealed reticular densities in the right lung [Figure 2] and [Figure 3].

The patient underwent flexible bronchoscopy which revealed an edematous, fragile mucosa in the right bronchial system. Gram (+) cocci and gram (−) bacilli were found in the bronchial washings; the culture and tuberculous polymerase chain reaction (PCR) were negative. Empiric antibiotic, antifungal and antiviral therapy was started in this immuncompromised patient who showed no signs of infection. Cytomegalovirus load in the blood and the galactomannan levels were negative. As the patient was clinically stable and the acute phase reactants were normal, the antibiotics, antiviral, antifungal therapy were discontinued. Repeat CT thorax revealed an increase in the right lung infiltration. Video-assisted thoracoscopy and a lung biopsy were performed. Histologically, the findings were consistent with the organizing pneumonia with areas of polipoid intraluminal plugs of loose connective tissue that occlude bronchioles, alveolar ducts, and surrounding alveoli [Figure 4] and [Figure 5].

Non-infectious etiologies were suspected including tacrolimus toxicity. Patient was kept on the systemic steroid and there was a dramatic clinical and radiological response [Figure 6].

Drug-induced lung disease (DILD) is the most common cause of iatrogenic damage of lungs. More than 350 drugs have been identified leading to DILD. OP has been reported from drugs such as amiodarone, bleomycin, nitrofurantoin, penicillamine or statins. OP due to tacrolimus is rare. DILD should be included in the differential diagnosis of lung infiltrates in patients in whom workup for infectious etiology remains negative.

Pattern of TB cases followed up in TB Center in Abha, Saudi Arabia, between 1999 and 2008

Badr Rashed Al-Ghamdi

College of Medicine, King Khaled University, Abha, KSA

Background : TB continues to be a problem worldwide. There have been recent changes in TB epidemiology in different parts of the world, including Saudi Arabia. This is a recent study that shows the analysis of TB cases seen in a central hospital in the main city of the southern region of Saudi Arabia (KSA). Methods: A retrospective analysis of all TB cases that were diagnosed, treated and followed up in TB Center in Aseer Central Hospital (ACH), Abha, between 1990 and 2008, was carried out. Definitions, diagnostic criteria and treatment regimen were as per Saudi TB National Control Program (adopted from WHO). SPSS software program was used for the analysis. Results: 514 cases with TB were found in the specified period (300 pulmonary, 214 extrapulmonary). Pulmonary cases were 82% and extrapulmonary cases were 18% in the year 2000, but higher extrapulmonary cases were noted after 2002 and the distribution changed in 2008 as 57% pulmonary to 43% extrapulmonary cases. No significant sex difference was found. Annual defaulter rate was about 12% (range 0-13%). Average cure rate was 75% (annual range 51-90%). The best indicator of cure was weight gain. Mortality rate was about 18% which was mainly at the two extremes of age groups (60 years). The highest mortality rate was seen in patients with TB-CNS (31%). Conclusion: The recent trend of more TB extrapulmonary cases was first seen in the year 2002 and continued thereafter. Cure rate is comparable to that of other centers worldwide. TB continues to be a cause of mortality especially in the extremes of age groups. The highest mortality rate was seen among patients with TB-CNS.

Prevalence and characteristics of restless legs syndrome in a sample of Saudi population

Ayman Krayem, Doa'a Al-Sharif 1 , Ghaidaa Al-Jehani 1 , Bader Alghamdi, Ahmad Abulaban, Siraj Wali 2

Department of Medicine, King Abdulaziz Medical City,

King Saud bin Abdulaziz University for Health Sciences, 1 Department of Physical Therapy, King Abdulaziz University Hospital, 2 Department of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia

Background : Restless legs syndrome (RLS) is a common but generally under-diagnosed disorder. Its prevalence and characteristics in Saudi population are not well defined. Method: A structured questionnaire was distributed among 412 randomly selected individuals from Jeddah area. RLS was diagnosed based on subjective agreement with four criteria proposed by the International Restless Legs Study group. Other personal, social and clinical data were also collected. Results: The mean age of all participants was 31.80 years (±SD 12.04) and there were 216 (52.4%) females. Seventy-two (17.5 %) of the participants had RLS with no significant age or gender difference between the affected and non-affected individuals. Diabetes and anemia were more common among RLS individuals (OR 2.65, CI 1.08-6.51) and (OR 2.04, CI 1.18-3.51), respectively. The mean body mass index (BMI) of RLS individuals was 27.45 kg/m2 (±SD 7.6) compared to the mean BMI of 25.84 (±SD 9.7) in normal subjects (P=0.18, not significant). However, when mean weight was compared, RLS group had significantly higher mean weight (mean difference 4.41, P=0.04). Among the patients with RLS, only 11 (15.5%) used physical therapy as a treatment modality (P=0.04) and 10 (90.9%) reported significant subjective improvement (P=0.031). The majority (68.1%) of RLS individuals never sought medical attention for this problem (P<0.0001). Conclusion: RLS seems to be very prevalent in Saudi population (17.5%). RLS symptoms may be more common in obese individuals, and anemia and diabetes are associated with the disease prevalence. Physical therapy was shown to improve RLS symptoms; however, most RLS patients may not be aware of its potential positive impact. Poor disease awareness is common and significantly delays RLS treatment.

Status of respiratory therapists in Saudi Arabia: A national survey

Ghazi Alotaibi, Bashair Alfozan

Department of Respiratory Care, College of Applied Medical Sciences, University of Dammam, Dammam, Kingdom of Saudi Arabia

Background : Respiratory therapists (RTs) are integrative members of health care team. They assess, monitor and treat patients with cardiopulmonary disorders. Studies have shown that provision of respiratory care by dedicated and specialized professionals improves the outcome and reduces the cost of care. Respiratory care has been practiced as a specialty in Saudi Arabia since late 1970s when some military-affiliated hospitals introduced respiratory care services and sponsored scholarships to train Saudi nationals in the field of Respiratory Care. Since that time, several training programs and scholarships have been implemented to graduate qualified RTs in order to meet the increasing demand for respiratory care services. In addition, other health care sectors have started to employ respiratory care services in their hospitals by recruiting Saudi and expatriate RTs. Hospitals seeking recognition from international accreditation agencies have also started to employ respiratory care services via RTs in order to conform to accreditation requirements. Official reports indicate that there is a great need for allied health care professionals, and only 54% of current workforce is Saudi nationals. The current status of RTs in Saudi Arabia in terms of number, supply, and demand has not been investigated so far. Study Objective: This descriptive survey study was performed to provide a general profile of RTs in Saudi Arabia in terms of demographics, educational levels, credentialing, scope of coverage, and distribution per provinces and health sectors. Methods: A special questionnaire was designed to collect staffing, education, and demographic data. A list of government, military, and private hospitals was obtained from MOH and SFDA. Data were gathered from each hospital in the Kingdom of Saudi Arabia, provided the hospital employs respiratory care services via RTs. Data gathering was performed via self-administered questionnaire or telephone survey of respiratory care department managers. Data were entered and analyzed using descriptive statistical methods with MS-Excel 2007. Number of current workforce, demographic distribution, level of education, and current need for RTs are reported in this study. Results: Out of 411 hospitals surveyed, only 88 (21.4%) hospitals employ RTs. 27 (41%) of them are located in the eastern province. RTs work in hospitals that comprise 63% of total bed capacity in KSA. Out of the 88 hospitals that employ RTs, only 38 (43%) have RT departments. This study showed that there are 1477 active RTs in KSA; 371 (25%) of them are Saudi nationals. About 60% of the total RT workforce is devoted to critical care. Gender distribution is fairly shared out (53% females, 47% males). In terms of education, 70% of RTs hold Baccalaureate degree, 20% hold Diploma, with about 5.4% of RTs practicing the profession without formal education. Only 15% of total RTs hold NBRC credentials. Geographical distribution of the workforce indicates that 50% of RTs are in the central province of the country. Respiratory care coverage of the intensive care units as benchmarked with recommended standards is only 39% overall, 53% in the central province, and as low as 13.6% in the southern part of the country. Actual RTs to ICU beds ratio was 1:9 in the central province, 1:37 in the southern province, 1:20 in MOH hospitals, and 1:9 in semi-governmental hospitals. Conclusions and Recommendations: There is a severe shortage of RTs in KSA. We estimated a current need of 2428 RTs. There is an increased need for more educational RT programs in different regions of the Kingdom. Special academic programs must be designed for RTs who entered the field with inadequate training. Good communication with Ministry of Health and Ministry of Civil Services must be established to discuss the needs for RTs at a national level. Skills and concepts of critical care should be emphasized in RT curriculum. There is a pressing need for a national credentialing system to ensure minimum standard of practice.

TB/HIV among patients attending referred clinics in Shaab Hospital, Khartoum

Omer Elgaili Yousif, Ahmed Saad Ibrahim 1

Faculty of Medicine, Alneelain University, 1 Shaab Teaching Hospital, PO Box 3993, Khartoum, Sudan

Background : One-third of the world's population is latently infected with Mycobacterium tuberculosis. HIV is the greatest risk factor for the progression of latent or recent TB infection to active TB disease. Globally, about 13 million people living with HIV are also infected with TB; they are at increased risk of developing active TB. Conversely, TB is among the most important causes of morbidity and mortality in people living with HIV. Rationale: Sudan is the leading country in EMRO regarding the numbers of estimated HIV cases, which account for 512,000 cases, and the dual infection accounts for 8% of the regional burden. Collaborative planning and integrated implementation of program activities can promote more effective resource utilization and integrated management of human resources, drugs and equipment. Methods: Patients of pulmonary tuberculosis registered with the Department of Chest Diseases, Shaab Hospital, were included in this study. Diagnosis of tuberculosis was based on findings suggestive of tuberculosis on physical and radiological examination and sputum testing for acid-fast bacilli (AFB). The patients were inquired about blood transfusion, drug addiction, frequent injections, smoking, homosexuality, tattooing, acupuncture, dental procedures, and multiple sexual partners. Results: A total of 500 patients were included in this study. Among these patients, 60% were from rural areas and 40% were from urban areas. Socioeconomic status showed that 80% patients belonged to low-income group and 20% belonged to middle-income group. Sexual distribution was as follows: 74% were males and 26% were females. Sera from all patients were tested for HIV with HIV-ELISA kit, Lab systems. 70 cases (14%) were found to be positive. Conclusion: HIV infection is a common and lethal problem of various countries, particularly the western ones. However, now this problem is considered to be sparking at a very high rate all over the world. Due to this high prevalence of HIV, the problem of opportunistic infections has increased many times. Various studies have been conducted on HIV and tuberculosis co-infection and reports vary from country to country. A study from Shaab revealed 14% positivity of HIV among the patients. These patients were young, unemployed, and single. In another study on 509 tuberculous patients at University Hospital in Ethiopia, 57.1% were found to be HIV-1 positive in culture-verified PTB cases. The diversity in results could be due to the fact that the above-mentioned studies have been conducted in the countries which have high prevalence of HIV.

Tunisian surgical experience in pulmonary tuberculosis: Analysis of 150 cases

S. Ezzine Baccari, B. Smati, A. Marghli, H. Touinsi, S. Sassi, T. Kilani

Division of Thoracic and General Surgery, Tunis, Tunisia

Objectives : The prevalence of pulmonary tuberculosis (TB) remains high in several parts of the world like in Tunisia. With the availability of effective chemotherapy for pulmonary TB, indications for surgical intervention have become limited. However, it is still required for some complications and sequelae. The aim of this study was to determine the current role of surgery as well as morbidity and late outcomes after surgical intervention in an emerging country. Methods: This study presents a single-institution retrospective audit. Records of cases that had undergone various surgical procedures for pulmonary TB were evaluated. A total of 150 procedures were carried out for various indications after excluding those admitted for tuberculous empyema or aspergilloma. Indications for surgery were persistent sputum-positive status in 16 patients, bronchiectasis or destroyed lung in 66 patients and for diagnostic reasons in 68 patients. Results: Mean age was 42.09 (10-73) years, and the male:female ratio was 2:19 (103/47). Operative procedures included 83 lobectomies, 27 pneumonectomies, 9 bilobectomies, 27 wedge resections, and 4 segmentectomies. Intraoperatively, we encountered dense adhesions in 54% of cases which required extra-pleural dissection. In two cases, we extended resection because of the lack of the elasticity of the remaining lung. The complications we encountered were 2 post-pneumonectomy fistulas with empyema at 11 and 29 days respectively after surgical intervention, 3 cases of postoperative bleeding, prolonged air leaks (more than 7 days) in 22 cases, lack of lung expansion in 16 cases, and atelectasis in 8 cases. All cases of multidrug-resistant pulmonary tuberculosis were negative in sputum cultures, 3 months following the surgical procedure, and there was 1 relapse in 12 months. Postoperative mortality was 5.3% (8/150): 5 patients with right pneumonectomy and 3 after right superior lobectomy. 130 patients are still under follow-up. Conclusion: Our study confirms the good results obtained by lung resection for tuberculosis, which have been reported by all the authors in the rec ent times. Proper selection of the patients and early decision for surgical intervention can achieve a high success rate and the salvage of lung parenchyma in this difficult group of patients. It adds further support to the idea that surgery may be a valuable tool for eradicating residual active foci in cases where socioeconomic conditions render the medical management difficult or hazardous.


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