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
April-June 2017
Volume 12 | Issue 2
Page Nos. 61-132

Online since Tuesday, April 4, 2017

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A review of imaging modalities in pulmonary hypertension p. 61
Mona Ascha, Rahul D Renapurkar, Adriano R Tonelli
Pulmonary hypertension (PH) is defined as resting mean pulmonary artery pressure ≥25 mmHg measured by right heart catheterization. PH is a progressive, life-threatening disease with a variety of etiologies. Swift and accurate diagnosis of PH and appropriate classification in etiologic group will allow for earlier treatment and improved outcomes. A number of imaging tools are utilized in the evaluation of PH, such as chest X-ray, computed tomography (CT), ventilation/perfusion (V/Q) scan, and cardiac magnetic resonance imaging. Newer imaging tools such as dual-energy CT and single-photon emission computed tomography/computed tomography V/Q scanning have also emerged; however, their place in the diagnostic evaluation of PH remains to be determined. In general, each imaging technique provides incremental information, with varying degrees of sensitivity and specificity, which helps suspect the presence and identify the etiology of PH. The present study aims to provide a comprehensive review of the utility, advantages, and shortcomings of the imaging modalities that may be used to evaluate patients with PH.
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Allergic bronchopulmonary aspergillosis in patients with cystic fibrosis p. 74
Ibrahim Ahmed Janahi, Abdul Rehman, Amal Rashid Al-Naimi
Allergic bronchopulmonary aspergillosis (ABPA) is a pulmonary disorder that often occurs in patients with asthma or cystic fibrosis (CF) and is characterized by a hypersensitivity response to the allergens of the fungus Aspergillus fumigatus. In patients with CF, growth of A. fumigatus hyphae within the bronchial lumen triggers an immunoglobulin E (IgE)-mediated hypersensitivity response that results in airway inflammation, bronchospasm, and bronchiectasis. In most published studies, the prevalence of ABPA is about 8.9% in patients with CF. Since the clinical features of this condition overlap significantly with that of CF, ABPA is challenging to diagnose and remains underdiagnosed in many patients. Diagnosis of ABPA in CF patients should be sought in those with evidence of clinical and radiologic deterioration that is not attributable to another etiology, a markedly elevated total serum IgE level (while off steroid therapy) and evidence of A. fumigatus sensitization. Management of ABPA involves the use of systemic steroids to reduce inflammation and modulate the immune response. In patients who do not respond to steroids or cannot tolerate them, antifungal agents should be used to reduce the burden of A. fumigatus allergens. Recent studies suggest that omalizumab may be an effective option to reduce the frequency of ABPA exacerbations in patients with CF. Further randomized controlled trials are needed to better establish the efficacy of omalizumab in managing patients with CF and ABPA.
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Clinical and quality of life outcomes following anatomical lung resection for lung cancer in high-risk patients p. 83
Henrietta Wilson, David Gammon, Tom Routledge, Karen Harrison-Phipps
Background: Surgery remains the gold standard for patients with resectable nonsmall cell lung cancer. Current guidance identifies patients with poor pulmonary reserve to fall within a high-risk cohort. The aim of this study was to determine the clinical and quality of life outcomes of anatomical lung resection in patients deemed high risk based on pulmonary function measurements. Methods: A retrospective review of patients undergoing anatomical lung resection for nonsmall cell lung cancer between January 2013 and January 2015 was performed. All patients with limited pulmonary reserve defined as predicted postoperative forced expiratory volume in 1 s or transfer factor of the lung for carbon monoxide of <40% were included in the study. Postoperative complications, admission to the Intensive Care Unit, length of stay, and 30-day in-hospital mortality were recorded. The European Organization for Research and Treatment of Cancer quality of life questionnaire lung cancer 13 questionnaire was used to assess quality of life outcomes. Results: Fifty-three patients met the inclusion criteria. There was no in-hospital mortality, and 30-day mortality was 1.8%. No complications were seen in 64% (n = 34), minor complications occurred in 26% (n = 14), while 9% had a major complication (n = 5). Quality of life outcomes were above the reference results for patients with early stage lung cancer. Conclusion: Anatomical lung resection can be performed safely in selected high-risk patients based on pulmonary function without significant increase in morbidity or mortality and with acceptable quality of life outcomes. Given that complications following lung resection are multifactorial, fitness for surgery should be thoroughly assessed in all patients with resectable disease within a multidisciplinary setting. High operative risk by pulmonary function tests alone should not preclude surgical resection.
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Prevalence and risk factors of obstructive sleep apnea syndrome in a Saudi Arabian population p. 88
Siraj Omar Wali, Bahaa Abalkhail, Ayman Krayem
Background: Obstructive sleep apnea (OSA) is a common disorder worldwide; however, epidemiological studies on its prevalence lack in Saudi Arabia. This study aimed to determine the prevalence and risk factors of OSA in Saudi Arabia. Methods: The study was performed from 2013 to 2015 in two stages. The screening stage was first; a random sample of Saudi employees (n = 2682) 30–60 years of age completed a survey that included the Wisconsin questionnaire. According to these data, the subjects were categorized as habitual, moderate, or nonsnorers (NSs). The confirmatory second stage was a case–control study conducted on 346 individuals selected from each group using polysomnography (PSG). Results: In the first stage, the prevalence of habitual snoring was 23.5%, moderate snoring was16.6%, while 59.9% of the sample was NSs. Among the 346 individuals who underwent PSG, a total of 235 (67.9%) subjects had OSA with an apnea-hypopnea index (AHI) of ≥5; 76 (22.0%) had OSA syndrome (OSAS), defined by an AHI of ≥5 plus daytime sleepiness; and 227 (65.6%) had clinically diagnosed OSA syndrome (COSAS), as defined by the American Academy of Sleep Medicine. A conservative estimate of at least 8.8% (12.8% in men and 5.1% in women) was calculated for the overall prevalence of OSA. Similarly, the overall estimated prevalence of OSAS and COSAS was 2.8% (4.0% in men and 1.8% in women) and 8.5% (12.4% in men and 4.8% in women), respectively. A multivariate analysis revealed age, gender, obesity, and hypertension as independent risk factors of OSA. Conclusions: Our study demonstrated that the rate and risk factors of OSA in the Saudi population are similar to those observed in Western studies.
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Systematic analysis of measurement variability in lung cancer with multidetector computed tomography p. 95
Binghu Jiang, Dan Zhou, Yujie Sun, Jichen Wang
Objective: To systematically analyze the nature of measurement variability in lung cancer with multidetector computed tomography (CT) scans. Methods: Multidetector CT scans of 67 lung cancer patients were analyzed. Unidimensional (Response Evaluation Criteria in Solid Tumor criteria), bidimensional (World Health Organization criteria), and volumetric measurements were performed independently by ten radiologists and were repeated after at least 5 months. Repeatability and reproducibility measurement variations were estimated by analyzing reliability, agreement, variation coefficient, and misclassification statistically. The relationship of measurement variability with various sources was also analyzed. Results: Analyses of 69 lung tumors with an average size of 1.1–12.1 cm (mean 4.3 cm) indicated that volumetric technique had the minimum measurement variability compared to the unidimensional or bidimensional technique. Tumor characteristics (object effect) could be the primary factor to influence measurement variability while the effect of raters (subjective effect) was faint. Segmentation and size in tumor characteristics were associated with measurement variability, and some mathematical function was established between the volumetric variability and tumor size. Conclusion: Volumetric technique has the minimum variability in measuring lung cancer, and measurement variability is associated with tumor size by nonlinear mathematical function.
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A study of chronic obstructive pulmonary disease-specific causes of osteoporosis with emphasis on the emphysema phenotype p. 101
Mona Ali Fouda, Esam Hamad Alhamad, Mohammed Saleh Al-Hajjaj, Shaffi Ahmed Shaik, Ahmad Amer Alboukai, Feisal Abdulla Al-Kassimi
Background: Osteoporosis, the most common extra-pulmonary complication of chronic obstructive pulmonary disease (COPD), may be related to general causes or COPD-specific causes such as low forced expiratory volume in 1 s (FEV1) and hypoxia. A few studies reported that emphysema is an independent risk factor for osteoporosis. However, other workers considered the association to be confounded by low FEV1 and low body mass index (BMI) which cluster with emphysema. Aims: To study the association between osteoporosis and emphysema in a model that includes these potentially confounding factors. Methods: We studied prospectively 52 COPD patients with both high resolution computed tomography and carbon monoxide diffusion coefficient as diagnostic markers of emphysema. Dual-energy X-ray absorptiometry was used to measure the bone mass density (BMD) of lumbar vertebrae and neck of the femur. Vertebral fractures were evaluated using the Genant semiquantitative score. Multiple linear regression analysis was used to identify the following independent variables: age, BMI, FEV1% predicted, PaO2, emphysema score, C-reactive protein (CRP), and dyspnea score as related to BMD. P ≤ 0.05 was considered statistically significant. Results: There was no significant difference in the serum Vitamin D levels, vertebral fracture score, or BMD between the emphysematous and nonemphysematous patients. Multivariate analysis showed that (in a model including age, BMI, FEV1, PaO2, emphysema score, CRP, and dyspnea score) only reduced BMI, FEV1, and PaO2were independent risk factors for low BMD. Conclusions: The emphysematous phenotype is not a risk factor for osteoporosis independently of BMI, FEV1, and PaO2.
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Vitamin D deficiency and interleukin-17 relationship in severe obstructive sleep apnea–hypopnea syndrome p. 107
Sonia Toujani, Wajih Kaabachi, Meriem Mjid, Kamel Hamzaoui, Jouda Cherif, Majed Beji
Purpose: We aimed to assess Vitamin D (VD) abnormalities in patients with severe obstructive sleep apnea–hypopnea syndrome (OSAHS), to study its association with clinical and polygraphic data, and to correlate VD levels with interleukin-17 (IL-17). Methods: Ninety-two patients with severe OSAHS were consecutively enrolled between September 2014 and February 2016 and compared to age-, sex-, and body mass index (BMI)-matched controls. Anthropometric parameters and medical history were collected. The serum levels of VD and IL-17 were determined by radioimmunoassay and enzyme-linked immunosorbent assay, respectively. Results: Ninety-two severe OSAHS patients and thirty controls were enrolled in the study. All OSAHS patients had VD deficiency. The mean level of VD was at 7.9 ng/ml among OSAHS group versus 16.8 ng/ml among control group. IL-17A levels were elevated (20.3 pg/ml) in OSAHS group compared to healthy group (10.05 pg/ml). VD levels were negatively correlated with nocturia severity (r = −0.26; P = 0.01) and positively correlated with mean O2saturation (r = 0.59; P = 0.02) and lowest O2saturation (r = 0.3; P = 0.03). IL-17 levels were positively correlated with nocturia severity (r = 0.24; P = 0.03) and negatively correlated with mean O2saturation (r = −0.42; P = 0.03). A significant negative association was observed between IL-7 and VD levels (r = −0.64, P = 0.2 10−4). The magnitude of this correlation was higher for important nocturia, lower MSaO2, or higher BMI. Conclusions: VD deficiency in patients with severe OSAHS is common with a negative association between IL-17 and VD serum levels. Hypoxia could play an important role in this association. Further studies are needed to clarify this relationship.
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Endobronchial ultrasound plus fluoroscopy-guided biopsy compared to fluoroscopy-guided transbronchial biopsy for obtaining samples of peripheral pulmonary lesions: A systematic review and meta-analysis p. 114
Jian Ye, Ruifeng Zhang, Shenglin Ma, Limin Wang, Weizhong Jin
Background: We report a meta-analysis of recent studies comparing the diagnostic yields of endobronchial ultrasonography plus fluoroscopically-guided transbronchial biopsy (EBUS + TBB) with that of conventional fluoroscopically-guided TBB for peripheral pulmonary lesions (PPLs). Methods: We searched Medline, the Cochrane Library, PubMed, and Google Scholar through 31 March 2013 using the keywords: lung neoplasm, pulmonary lesions, diagnosis, endobronchial ultrasound, fluoroscopy, and fluoroscopic. Results: Four studies were included in the study with a total of 461 patients, 222 in the EBUS + TBB group and 239 in the TBB only group. The meta-analysis revealed that the group with EBUS + TBB was more favored in terms of positive diagnostic yield than the group diagnosed with only conventional TBB (odds ratio [OR] = 2.211, 95% confidence interval [CI] = 1.422–3.438, P< 0.001). Subgroup analysis based on lesion size found that smaller PPLs had higher accuracy (OR = 4.502, 95% CI = 2.002–10.126, P< 0.001) than PPLs of large size (OR = 1.849, 95% CI = 1.033–3.311, P= 0.039). Conclusion: Obtaining TBB samples for histopathological diagnosis is enhanced by the addition of EBUS to conventional fluoroscopic guidance; this is, especially important for patients with small peripheral lung lesions who benefit greatly from early diagnosis.
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Pulmonary actinomycosis mimicking lung cancer on positron emission tomography p. 121
Hayoung Choi, Hyun Lee, Suk Hyeon Jeong, Sang-Won Um, O Jung Kown, Hojoong Kim
Pulmonary actinomycosis frequently mimics lung malignancy on radiologic imaging studies. Positron emission tomography-computed tomography (PET-CT) is a useful diagnostic modality for differentiating lung malignancy from benign diseases. However, few studies evaluated PET-CT findings of pulmonary actinomycosis. Therefore, it is unclear whether PET-CT is helpful to distinguish lung malignancy from benign lung disease when pulmonary actinomycosis is clinically suspected. We investigated PET-CT findings in 11 patients with pathologically confirmed pulmonary actinomycosis. The median maximal standardized uptake value (SUV) on PET-CT of pulmonary actinomycosis was increased to 5.5 (interquartile range, 4.2–8.8), which was higher than the threshold value of 2.5 indicating malignancy. Pulmonary actinomycosis without central necrosis demonstrated higher maximal SUV of 7.5 (4.9–12.2) compared to 4.8 (3.2–5.6) of ones with central necrosis. PET-CT might be not helpful in differentiating lung malignancy from benign lesions when pulmonary actinomycosis is clinically suspected.
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Simultaneous presentation of two noninflammatory lung diseases in an HIV-infected patient p. 125
Rafael Martínez-Girón, Santiago Martínez-Torre
The simultaneous presentation of two noninflammatory pulmonary diseases, pulmonary alveolar proteinosis and Kaposi's sarcoma (Ks), in an HIV-infected patient, is described. A 29-year-old black race patient was admitted to the hospital because of general malaise, weight loss, dyspnea, chest pain, and cough with hemoptoic expectoration. Chest X-rays revealed a patchy bilateral alveolar pattern with a tendency toward the formation of condensations. The serological test revealed HIV positivity (CD4 counts of 393 cells/mm3). Because there was no response to the treatment course, a thoracic CT was performed, showing interlobular thickening with intralobular septal lines and ground glass opacities ("crazy-paving” pattern). An open lung biopsy was performed. Histopathological diagnosis of pulmonary alveolar proteinosis and pulmonary Ks was made.
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Asthma-like attacks terminated by slow pathway ablation p. 127
Selcuk Ozturk, Hasan Turhan, Ertan Yetkin
Asthma is a chronic airway disease in which the pathological mechanisms are reversible airway obstruction, bronchial hyper reactivity, and constriction of the lower airways. Supraventricular tachycardia (SVT) is a common arrhythmia which originates above the bundle of His and causing heart rates exceeding 150 beats/min. SVT patients present with palpitation, chest pain, chest discomfort, dyspnea, hyperventilation, and lightheadedness, occasionally. Besides, extraordinary presentations of SVT are available in literature. In this report, we describe a case of a patient presenting with treatment-resistant asthma-like attacks lasting for 20 years whom was suspected SVT as an underlying etiology and treated by slow pathway radiofrequency ablation.
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Alterations of pulmonary function in patients with inflammatory bowel diseases p. 129
Mahmood Dhahir Al-Mendalawi
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Erratum: Saudi guidelines on the diagnosis and treatment of pulmonary hypertension: Pulmonary hypertension due to left heart disease p. 130

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Erratum: Saudi guidelines on the diagnosis and treatment of pulmonary hypertension: 2014 updates p. 131

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Erratum: Introducing the comprehensive unit based safety program for mechanically ventilated patients in Saudi Arabian intensive care units p. 132

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