Annals of Thoracic Medicine Official publication of the Saudi Thoracic Society, affiliated to King Saud University
 
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   Table of Contents - Current issue
Coverpage
April-June 2020
Volume 15 | Issue 2
Page Nos. 47-102

Online since Friday, April 3, 2020

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EDITORIAL  

Role of long-term azithromycin therapy for severe bronchial asthma p. 47
Mohamed S Al-Hajjaj, Mohamed S Al Moamary
DOI:10.4103/atm.ATM_38_20  
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COMMENTARY Top

Clinical trials for coronavirus disease 2019: What is being evaluated and what is not Highly accessed article p. 49
Yaseen M Arabi, Ayed Asseri, Steve Webb, John Marshall, Mohamed S Al Moamary
DOI:10.4103/atm.ATM_99_20  
Since the report of the first case of coronavirus disease 2019 (COVID-19) in China in late December 2019, there have been 204 610 cases worldwide as of 18 March, 2020. As part of the response to this outbreak, there has been an impressive amount of research undertaken to better characterize the disease and to evaluate therapeutic options. By March 12, 2020, there are more than 382 studies registered in the clinical trials databases addressing COVID-19 including more than 80 randomized controlled trials.
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Spectrum of histopathological findings in coronavirus disease-19, Middle East respiratory syndrome and severe acute respiratory syndrome p. 52
Khaled O Alsaad, Yaseen M Arabi, Ali H Hajeer
DOI:10.4103/atm.ATM_105_20  
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REVIEW ARTICLE Top

An overview of exacerbations of chronic obstructive pulmonary disease: Can tests of small airways' function guide diagnosis and management? p. 54
Nowaf Y Alobaidi, James A Stockley, Robert A Stockley, Elizabeth Sapey
DOI:10.4103/atm.ATM_323_19  
Chronic obstructive pulmonary disease (COPD) is common and debilitating. Most patients with COPD experience intermittent, acute deterioration in symptoms which require additional therapy, termed exacerbations. Exacerbations are prevalent in COPD and are associated with poor clinical outcomes including death, a faster decline in lung health, and a reduced quality of life. Current guidelines highlight the need to treat exacerbations promptly and then mitigate future risk. However, exacerbations are self-reported, difficult to diagnose and are treated with pharmacological therapies which have largely been unchanged over 30 years. Recent research has highlighted how exacerbations vary in their underlying cause, with specific bacteria, viruses, and cell types implicated. This variation offers the opportunity for new targeted therapies, but to develop these new therapies requires sensitive tools to reliably identify the cause, the start, and end of an exacerbation and assess the response to treatment. Currently, COPD is diagnosed and monitored using spirometric measures, principally the forced expiratory volume in 1 s and forced vital capacity, but these tests alone cannot reliably diagnose an exacerbation. Measures of small airways' function appear to be an early marker of COPD, and some studies have suggested that these tests might also provide physiological biomarkers for exacerbations. In this review, we will discuss how exacerbations of COPD are currently defined, stratified, monitored, and treated and review the current literature to determine if tests of small airways' function might improve diagnostic accuracy or the assessment of response to treatment.
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ORIGINAL ARTICLES Top

Correlating computed tomography pulmonary angiography signs of right ventricular strain in pulmonary embolisms to clinical outcomes p. 64
Jay Karri, Tiffany Truong, Joseph Hasapes, Daniel Ocazionez Trujillo, Steven Chua, Kaustubh Shiralkar, Gabriel Aisenberg
DOI:10.4103/atm.ATM_264_19  
INTRODUCTION: Right ventricular strain (RVS) in pulmonary embolism (PE) can be used to stratify risk and direct intervention. The clinical significance of computed tomography pulmonary angiogram (CTPA)-derived radiologic signs of RVS, however, remains incompletely characterized. We retrospectively analyzed a cohort of persons with acute PE to determine which, if any, findings of RVS on CTPA correlate with clinical outcomes. METHODS: All patients with PE diagnosed on CTPA from March 2013 through February 2015 at Lyndon B. Johnson Hospital were identified. Their records were retrospectively reviewed to identify length of stay, intensive care unit (ICU) placement, hemodynamic failure, use of thrombolytics, vasopressor requirement, mechanical ventilation, and attributable mortality. Three radiologists, blinded to clinical outcomes, separately reviewed the cohort's CTPAs to identify signs of RVS – pulmonary trunk size, internal size of the right and left ventricles, paradoxical interventricular septal bowing, inferior vena cava (IVC) contrast reflux, and hepatic vein contrast reflux. RESULTS: In our cohort of 102 persons, 12 demonstrated hemodynamic failure, 13 required ICU placement, 3 received thrombolysis, and 5 had death attributable to PE. The greatest interobserver agreement among radiologists existed for the presence of increased pulmonary trunk size (0.76 kappa by %agreement) and hepatic vein contrast reflux (0.92 kappa by %agreement). A multiple regression analysis found that when 100% radiologist agreement existed, presence of paradoxical intravenous septal bowing predicted thrombolytic usage (P = 0.02), and the presence of IVC reflux predicted attributable mortality (P = 0.03). CONCLUSION: Only IVC contrast reflux was associated with increased mortality, and no other sign of RVS on CTPA correlated with clinical outcomes. This suggests that most signs of RVS on CTPA do not reliably predict PE severity. Therefore, RVS seen by CTPA should be used cautiously in weighing the decision to initiate thrombolytics.
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The correlation between oxygen saturation indices and the standard obstructive sleep apnea severity p. 70
Siraj Omar Wali, Bahaa Abaalkhail, Ibrahim AlQassas, Faris Alhejaili, David W Spence, Seithikurippu R Pandi-Perumal
DOI:10.4103/atm.ATM_215_19  
OBJECTIVE: Currently accepted guidelines categorize obstructive sleep apnea (OSA) severity according to the Apnea–Hypopnea Index (AHI). However, it is unclear how to best define OSA severity. The present study sought to evaluate the concurrent validity of the widely accepted AHI by correlating it with various oxygen saturation (SpO2) and polysomnographic parameters. METHODS: The study utilized the data of a previous survey concerning the prevalence of OSA among a middle-aged Saudi population (n = 2682). Among the 346 individuals who underwent polysomnography, 178 had total sleep times of at least 240 min with rapid eye movement (REM) sleep and were included in the study. The standard classification of OSA severity was compared with different SpO2and polysomnographic parameters. RESULTS: The study found that there were correlations between the standard OSA severity based on AHI severity classification and different SpO2and polysomnographic parameters, including the desaturation index (DI), the sum of all desaturations, desaturation below 90%, the average duration of respiratory events, and indices of total arousals and respiratory arousals. All of these parameters correlated directly with OSA severity classification (P < 0.001 for each). However, REM sleep duration and SpO2nadir were inversely correlated with OSA severity (P < 0.003 and < 0.001, respectively). In addition, only the DI, SpO2nadir, and respiratory arousal index were predictors of OSA severity, as determined through a multiple logistic regression analysis. CONCLUSION: Our findings support the clinical reliability of the currently used standard classification of OSA severity based on the AHI.
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Clinical and pathological differences between polymorphonuclear-rich and lymphocyte-rich tuberculous pleural effusion p. 76
Tingting Zhao, Bing Chen, Yurong Xu, Yiqing Qu
DOI:10.4103/atm.ATM_15_20  
OBJECTIVE: Analysis of the occurrence factors and disease characteristics of tuberculous (TB) pleural effusion (TPE) dominated by neutrophils. METHODS: We retrospectively analyzed the clinical data of 304 patients with two types of TB pleurisy. The clinical, laboratory, and pathological features of TB pleurisy separately dominated by lymphocytes and neutrophils were analyzed. RESULTS: Neutrophil-predominant effusion was observed in 33 (10.9%) patients. The patients with TPE with polymorphonuclear leukocytes (PMNLs) had higher fever rates and higher decortication rates than those with lymphocyte-predominant TPE. Otherwise, they had lower chest distress rates and lower positive rates of pulmonary TB and lower biopsy tissue culture-positive rates than patients with lymphocyte-predominant TPE. PMNL TPE patients had higher lactic acid dehydrogenase (LDH) (1297 vs. 410 U/l,P < 0.001) and adenosine deaminase (ADA) levels (54.1 vs. 42.9 U/l, P = 0.043) and lower pleural fluid glucose (1.92 vs. 4.70 mmol/L,P < 0.001) and protein (47.4 vs. 48.4 g/L, P = 0.024) levels than that of lymphocyte-predominant TPE. Otherwise, they had lower blood ALB levels and higher C-reactive protein levels than lymphocyte-predominant TPE. Finally, PMNL TPE patients had lower rates of granuloma formation (27.2% vs. 75.2%,P < 0.001) and pleural nodules than patients with lymphocyte-predominant TPE and more frequent findings of pus, caseous exudate, and necrosis. CONCLUSION: The TB pleurisy patients dominated by neutrophils show strong inflammatory reactions and higher ADA levels in pleural effusion. These findings can significantly improve the positive rate of Mycobacterium tuberculosis in neutrophil-predominant TPE under thoracoscopy.
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A comparison between warfarin and apixaban: A patient's perspective p. 84
Abdullah U Althemery, Abdullah A Alfaifi, Abdulrahman Alturaiki, Maha A. L. Ammari, Khizra Sultana, Leanne Lai
DOI:10.4103/atm.ATM_352_19  
BACKGROUND: Novel oral anticoagulants (NOACs) were developed as alternatives to warfarin. However, the patients' preference regarding warfarin or the NOACs has not been established. Quality-of-life (QOL) surveys are a well-established method for determining the patients' preference for a treatment route. AIMS: This study compared the patients' perspectives on treatment with warfarin versus apixaban using the QOL measures. SETTINGS AND DESIGN: This cross-sectional study was conducted in 2019 for patients treated with either warfarin or apixaban at King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia. METHODS: We used a series of descriptive statistics to examine the differences in sociodemographic characteristics among patients. A propensity score-matching approach was employed to reduce the effect of confounding variables that often influence treatment selection. Greedy matching approach was used to analyze the QOL. RESULTS: A total of 388 patients were identified, of which 124 were matched between the two groups (62 patients in each group). Most of the patients were female, married, below the sufficiency level, educated, and nonsmokers. The patients using warfarin had a significantly better health state (M = 69.64, standard deviation [SD] = 16.52) than those using apixaban (M = 66.33, SD = 23.17), P = 0.011. CONCLUSIONS: Future studies should explore why patients using apixaban showed lower QOL scores and improve health-care providers' awareness of these issues.
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Thymoma diagnosis and categorization in the current scenario: Morphological analysis based on interobserver variability p. 90
Meetu Agrawal, Megha S Uppin, Shantveer G Uppin, Sundaram Challa, Sumeet Agrawal, AK Dharmrakshak
DOI:10.4103/atm.ATM_350_19  
BACKGROUND: Thymomas are not so common tumors that are encountered in day-to-day pathology reporting. The WHO system was proposed in 2015. Although, through its detailed reporting, the WHO elaborates all subtypes and morphological clinches to diagnosis, it was important to ascertain its reproducibility in our day-to-day reporting. AIMS: The aims of the study were (1) to study the interobserver agreement, concordance rates, and variability in the classification of a large number of thymomas received in our department as per the WHO 2015, (2) to correlate the WHO subtype with Masaoka–Koga stage, and (3) to study the variations in demography of thymomas in Indian patients as compared to those reported in the literature. SETTING AND DESIGN: This retrospective study was done at a tertiary care teaching hospital with huge surgical oncology patient load, also pertaining to the cardiothoracic surgeries. It is predominantly an interobserver agreement design to study the reproducibility of the WHO 2015 classification on thymic epithelial tumors. METHODS: Four pathologists have independently reviewed histopathology slides of 65 cases of thymomas and classified them into predefined categories. Kappa statistics was applied to the observations. RESULTS: There was a substantial interobserver agreement in overall classification of thymomas with a Cohen's kappa score of 0.66. A better score was achieved for the classification of Group B thymomas. The WHO subtypes correlate well with the Masaoka–Koga staging system, and this finding is statistically significant. This article also presents the clinical details of a large number of thymoma cases. CONCLUSION: The new WHO classification has good reproducibility among pathologists in thymoma reporting.
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CASE REPORTS Top

Mediastinal cyst infection followed by bacteremia due to Streptococcus anginosus after endobronchial ultrasound-guided transbronchial needle aspiration p. 95
Takehiko Hashimoto, Masaru Ando, Erina Watanabe, Jun-ichi Kadota
DOI:10.4103/atm.ATM_42_20  
We herein report a case of recurrent mediastinal cyst infection followed by bacteremia after endobronchial ultrasound-guide transbronchial needle aspiration (EBUS-TBNA). A 65-year-old Japanese male with sarcoidosis presented with 4 L progressive lymph node adenopathy and was diagnosed with mediastinal cyst by EBUS-TBNA. After bronchoscopy, he suffered from a high fever. Chest computed tomography showed enlargement of the 4 L lymph node with low attenuation areas, the elevation of mediastinal fat concentration. Blood cultures were positive for Streptococcus anginosus. Antimicrobial agents were administered for a total of 12 weeks, at which point the size of the lymph node was reduced. However, at 5 months after the discontinuation of antimicrobial agents, the mediastinal cyst infection recurred. It is important to conduct careful follow-up because mediastinal cyst infection following ebus-tbna may relapse with conservative treatment without invasive surgery.
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Intrapulmonary location of benign solitary fibrous tumor p. 98
Zeead M Alghamdi, Sharifah A Othman, Mohammed J Al-Yousef, Bader Z AlFadel
DOI:10.4103/atm.ATM_14_20  
Intrapulmonary solitary fibrous tumors (SFTs) are sporadic mesenchymal neoplasms that typically arise from visceral or parietal pleura. While accounting for <5% of all pleural tumors, SFTs are known to occur in nearly all bodily organs, including nasopharynx, bladder, prostate, soft tissue of neck, buttocks, extremities, and abdominal wall. Such tumors have been previously designated localized fibrous mesothelioma or pleural fibroma. SFTs have no genetic basis and are unrelated to environmental factors such as tobacco smoking or asbestos exposure. Herein, we describe a 24-year-old woman whose clinical presentation mimicked atypical carcinoid tumor. A diagnosis of intrapulmonary SFT was achieved by surgical resection.
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LETTER TO THE EDITOR Top

Hemoptysis in COVID-19: Observation p. 102
Sora Yasri, Viroj Wiwanitkit
DOI:10.4103/atm.ATM_67_20  
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