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
January-March 2019
Volume 14 | Issue 1
Page Nos. 1-100

Online since Thursday, January 10, 2019

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EDITORIAL  

Welcome new guidelines: Now the hard work starts! p. 1
Andrew Bush
DOI:10.4103/atm.ATM_338_18  
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GUIDELINES Top

The Saudi Initiative for Asthma - 2019 Update: Guidelines for the diagnosis and management of asthma in adults and children Highly accessed article p. 3
Mohamed S Al-Moamary, Sami A Alhaider, Abdullah A Alangari, Mohammed O Al Ghobain, Mohammed O Zeitouni, Majdy M Idrees, Abdullah F Alanazi, Adel S Al-Harbi, Abdullah A Yousef, Hassan S Alorainy, Mohamed S Al-Hajjaj
DOI:10.4103/atm.ATM_327_18  
This is the fourth version of the updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up to date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is now more aligned for different age groups. The guidelines have focused more on personalized approaches reflecting better understanding of disease heterogeneity with integration of recommendations related to biologic agents, evidence-based updates on treatment, and role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and current situation at national and regional levels. There is also an emphasis on patient–doctor partnership in the management that also includes a self-management plan.
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ORIGINAL ARTICLES Top

The effect of nonbenzodiazepines sedative hypnotics on apnea–hypopnea index: A meta-analysis p. 49
Gaurav Nigam, Macario Camacho, Muhammad Riaz
DOI:10.4103/atm.ATM_198_18  
INTRODUCTION: Nonbenzodiazepine (non-BZD) sedative hypnotics (NBSH) refer to non-BZD sedatives that act as BZD receptor agonists such as zolpidem, zaleplon, and eszopiclone. Today, there is a high prevalence of insomnia with or without concurrent obstructive sleep apnea (OSA). Our goal was to study how NBSH use impacts the baseline apnea–hypopnea index (AHI) in patients with or without OSA. METHODS: PubMed/MEDLINE, Scopus, Web of Science and Cochrane Library databases were searched. RESULTS: Seventeen studies comprising a cumulative total of 2099 patients were identified in the last 30 years (between 1988 and 2017) that evaluated the effect of NBSH on respiratory parameters during sleep. The AHI mean (M) ± standard deviation (SD) in NBSH group was 13.17 ± 16.27 versus 15.94 ± 19.31 (mean difference [MD]-95% confidence interval [CI], 2.77 [1.463–4.076]). Six studies (100 patients) compared zolpidem with either placebo or no medication and demonstrated an AHI MD of −0.61 events/h (95% CI − 1.94, 0.71), overall effect Z = 0.9, P = 0.36. Four studies (362 patients) compared eszopiclone with placebo and demonstrated an AHI MD of −5.73 events/h0 (95% CI − 8.90, −0.2.57). Two large studies (979 patients) compared both zolpidem and eszopiclone to no medication and found AHI MD of −1.66 events/h (95% CI − 5.87, 0.2.55). CONCLUSIONS: The majority of patients using NBSH did not develop any worsening of existing AHI, when using NBSH, regardless of their baseline AHI values (mild, moderate, severe, or no OSA). On average, the AHI improved minimally with NBSH and eszopiclone showed the largest difference in AHI with an MD of −5.73 events/h.
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Electronic cigarette among health science students in Saudi Arabia p. 56
Sultan Qanash, Shereen Alemam, Estabraq Mahdi, Jood Softah, Abdelfattah Ahmed Touman, Adil Alsulami
DOI:10.4103/atm.ATM_76_18  
BACKGROUND: Electronic cigarette (E-cigarette) is an electronic nicotine delivery device that has been advocated as a safe alternative for cigarette smokers. Since the introduction of E-cigarette internationally and in the Kingdom of Saudi Arabia (KSA), it gained popularity, particularly among the youth and young adults. Moreover, many nonsmoker (nicotine-naïve) youth started to use E-cigarette as a new social habit. Recent researches have casted shadows on the E-cigarette safety profile. OBJECTIVE: The aim of this study is to assess the prevalence of E-cigarette use among students of health science colleges in Jeddah-KSA. It also assesses E-cigarette effectiveness as a smoking cessation method and its possible addictiveness. METHODS: The study is an epidemiological, cross-sectional study, which was conducted between November 2017 and December 2017 in three different universities in Jeddah. A self-administered online questionnaire related to E-cigarette and the conventional cigarette was used. RESULTS: A total of 1007 completed an electronic survey which was distributed to 3000 health sciences colleges' students. Of the participants 14.1% were cigarette smoker, 46% of them smoke regularly. Students who smoke half a pack per day and above were 22% of the smokers. More college students use the E-cigarette (27.7%). Moreover, one-fifth of the E-cigarettes users were using it on the regular daily basis. The study found that 42.7% of E-cigarettes users have used it as a tool to quit smoking. Interestingly, more than half (56.7%) of the students who used it to stop smoking has succeeded. However, only 46% of E-cigarettes users who tried to quit vaping have succeeded. Young aged, students believed that smoking is more addictive than vaping or recommended E-cigarette for smoking cessation found to have a higher chance of quitting smoking in the univariate regression analysis. While, in the multivariate analysis, students who believed that conventional smoking is more addictive than E-cigarettes; students started vaping to quit smoking, or used E-cigarettes with fruit flavor found to have significantly higher chance of quitting. CONCLUSION: The E-cigarettes vaping is more prevalent than conventional cigarette smoking among health sciences students in Jeddah-KSA. E-cigarettes are used as a tool to help smoking cessation in less than half of the user. E-cigarettes help some smokers to quit smoking. However, it seems as addictive to the users as conventional cigarette smoking.
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Betatrophin association with serum triglyceride levels in obstructive sleep apnea patients p. 63
Bunyamin Sertogullarindan, Ahmet Ufuk Komuroglu, Rifki Ucler, Hulya Gunbatar, Aysel Sunnetcioglu, Erdem Cokluk
DOI:10.4103/atm.ATM_52_18  
BACKGROUND: Obstructive sleep apnea (OSA) is a common sleep problem, in which patients are at increased risk for metabolic and cardiovascular problems, including metabolic syndrome, diabetes mellitus (DM), and dyslipidemia. Betatrophin is a novel protein that regulates fatty acid and triglyceride (TG) metabolism and is related to obesity and metabolic abnormalities, including metabolic syndrome, DM, and dyslipidemia. Although OSA and betatrophin share common abnormalities, their relationship has not been investigated. AIM: The aim of this study is to investigate the relationships among betatrophin, OSA, and the serum lipid profile. METHODS: Ninety consecutive patients with suspected OSA underwent polysomnography (PSG) to confirm OSA. Plasma betatrophin, leptin, adiponectin, and the full lipid profile were analyzed. The patients were categorized as OSA or control based on the apnea-hypopnea index (AHI). RESULTS: About 61% of patients had OSA, and 39% had normal PSG. The levels of betatrophin, leptin, and adiponectin were higher in patients with OSA (256.59 ± 29.35, 374.20 ± 37.93, and 17.86 ± 2.63 μg/mL, respectively) compared to the controls (141.86 ± 26.20, 205.53 ± 14.75, and 7.52 ± 1.02 μg/mL, respectively). Betatrophin levels were correlated with the AHI, leptin (r = 0.413, P = 0.002, r = 0.782, P = 0.000). TG levels were significantly higher, and high-density lipoprotein cholesterol (HDL-C) levels were lower, in OSA patients compared to controls (244 ± 20.33 vs. 138 ± 14.89, and 37.21 ± 1.26 vs. 43.78 ± 1.62, respectively). The TG level was correlated with betatrophin (r = 0.353, P = 0.013). Multiple regression analysis showed that the AHI, leptin, and arousals were independent predictors of betatrophin level (B = 1.70 P = 0.046 95%, B = 0.56 P < 0.005, and B = 1, 2, P = 0.003, respectively). CONCLUSIONS: Our results suggest a complex relationship between OSA, betatrophin, TG, and HDL, as well as other adipokines. Our results require further investigation to assess this complex association and re-evaluate previous related studies.
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The effect of air conditioner sound on sleep latency, duration, and efficiency in young adults p. 69
Malak N Alkahtani, Nourah A Alshathri, Najla A Aldraiweesh, Lina M Aljurf, Luluh Aldaej, Awad H Olaish, Samar Z Nashwan, Aljohara S Almeneessier, Ahmed S BaHammam
DOI:10.4103/atm.ATM_195_18  
BACKGROUND: Many individuals complain of disturbed sleep during the wintertime when their air conditioner (AC) is off. Therefore, we conducted this study to objectively assess the impact of AC sound on sleep latency, sleep duration, and sleep efficiency. METHODS: An experimental study was conducted on 48 healthy young adults, in their homes, to assess the effect of a standardized AC white noise, on sleep latency, duration, and efficiency, while simultaneously monitoring light intensity and room temperature. The study was conducted during the winter months. Sleep quality was objectively assessed using sleep actigraphy. Participants were monitored for two nights, during which two different, randomized sets of conditions were used: During one of the nights, the adults were exposed to 43 dB AC white noise; during the other night, adults were not exposed to the AC white noise. RESULTS: Actigraphy results showed that the mean sleep duration during the AC sound nights (ASNs) was 466.8 ± 60.8 min, compared to 478.8 ± 55.4 min during the non-AC sound nights (NASNs) (P = 0.6). Sleep-onset latency was 10.8 ± 15.2 min and 15.1 ± 18.2 min during the ASNs and the NASNs, respectively (P = 0.8). Moreover, there was no difference in sleep efficiency, 81% ± 7.8% vs. 78.8% ± 15.4% in the ASNs and NASNs, respectively (P = 0.9). CONCLUSION: AC sound had no significant positive effect on sleep duration, latency, and efficiency.
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Immunization status in chronic obstructive pulmonary disease: A multicenter study from Turkey p. 75
Tevfik Ozlu, Yilmaz Bulbul, Derya Aydin, Dursun Tatar, Tulin Kuyucu, Fatma Erboy, Handan Inonu Koseoglu, Ceyda Anar, Aysel Sunnetcioglu, Pinar Yildiz Gulhan, Unal Sahin, Aydanur Ekici, Serap Duru, Sevinc Sarinc Ulasli, Ercan Kurtipek, Sibel Gunay, RIMPACT Study Investigators
DOI:10.4103/atm.ATM_145_18  
OBJECTIVE: The purpose of this study is to detect the prevalence and the factors associated with influenza and pneumococcal vaccination and outcomes of vaccination during 2013–2014 season in patients with chronic obstructive pulmonary disease (COPD) in Turkey. METHODS: This was a multicenter retrospective cohort study performed in 53 different centers in Turkey. RESULTS: During the study period, 4968 patients were included. COPD was staged as GOLD 1-2-3-4 in 9.0%, 42.8%, 35.0%, and 13.2% of the patients, respectively. Influenza vaccination rate in the previous year was 37.9%; and pneumococcus vaccination rate, at least once during in a life time, was 13.3%. Patients with older age, higher level of education, more severe COPD, and comorbidities, ex-smokers, and patients residing in urban areas had higher rates of influenza vaccination. Multivariate logistic regression analysis showed that advanced age, higher education levels, presence of comorbidities, higher COPD stages, and exacerbation rates were associated with both influenza and pneumococcal vaccination. The number of annual physician/outpatient visits and hospitalizations due to COPD exacerbation was 2.73 ± 2.85 and 0.92 ± 1.58 per year, respectively. Patients with older age, lower education levels, more severe COPD, comorbid diseases, and lower body mass index and patients who are male and are residing in rural areas and vaccinated for influenza had significantly higher rates of COPD exacerbation. CONCLUSIONS: The rates of influenza and pneumococcal vaccination in COPD patients were quite low, and the number of annual physician/outpatient visits and hospitalizations due to COPD exacerbation was high in Turkey. Advanced age, higher education levels, comorbidities, and higher COPD stages were associated with both influenza and pneumococcal vaccination.
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Pulmonary arterial hypertension in Saudi patients with systemic sclerosis: Clinical and hemodynamic characteristics and mortality p. 83
Hadil AK Al Otair, Majdy M Idrees, Sarfraz A Saleemi, Ahmed M Eltoukhy, Ali A Alhijji, Waleed A Al Habeeb, Mohammed A Omair
DOI:10.4103/atm.ATM_33_18  
BACKGROUND: Pulmonary arterial hypertension (PAH) is a major cause of morbidity and mortality in patients with systemic sclerosis (SSc). The objective of this study is to describe the clinical characteristics, mortality, and predictors of SSc-PAH in Saudi patients. METHODS: Retrospective chart review study of SSc patients who were followed for at least 1 year in three tertiary care centers in Saudi Arabia was conducted. Clinical information, echocardiographic findings, and right heart catheterization (RHC) results were collected. Descriptive statistics were used for demographic and disease characteristics. RESULTS: Fifty-seven patients with SSc were reviewed. PAH was confirmed by RHC in 40 patients (87.5%, females). Their mean age was 45.43 ± 13.48 years. The mean pulmonary artery pressure was 42.9 ± 12.7 mmHg, the pulmonary vascular resistance index was 19.4 ± 7.7 woods unit, and cardiac index was 2.43 ± 0.68 min/m2. The median time from symptoms to first assessment was 42.8 ± 115.62 months. Most patients (77.5%) presented with functional Class III or IV and more than half (22.55%) were on dual combination therapy. Ten patients (25%) SSc PAH died over a follow up period of 37 ± 7 months. Compared to SSc patients without PAH, SSc-PAH patients had shorter 6-min walk distance (6MWD) (296.1 ± 116.5 vs. 399.59 ± 40.60 m, P < 0.0001), higher pro-brain natriuretic peptide (1755.8 ± 2123.4 vs. 69.8 ± 44.3 pg/ml P = 0.004), and more frequent Raynaud's phenomenon (RP) (90% vs. 35%, P < 0.0001). Logistic regression showed RP (odds ratio [OR] =48.58, 95% confidence interval [CI]; 3.73–633.10) and 6MWD (OR 1.02: 95% CI; 1.01–1.03) were associated with the development of PAH. CONCLUSION: Our cohort of Saudi SSc-PAH patients has a younger disease onset and a lower mortality than what is described worldwide despite late presentation and requirement of combination therapy. The presence of RP and lower were associated with the development of SSc-PAH.
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CASE REPORTS Top

Investigation of false-positive Mycobacterium tuberculosis culture tests using whole genome sequencing p. 90
Jinsoo Min, Kyungjong Kim, Hongjo Choi, Eun Seok Kang, Yoon Mi Shin, Jin Young An, Kang Hyeon Choe, Ki Man Lee
DOI:10.4103/atm.ATM_184_18  
Although accurate identification of Mycobacterium tuberculosis is the gold standard for tuberculosis (TB) diagnosis, there have been several reports of false-positive results. After identifying a sudden increase in extensively drug-resistant TB, false-positive mycobacterial culture tests were suspected, and we contacted the supranational reference center for molecular typing. In silico genotyping tests showed that isolates from all five patients had an identical genotype pattern, and all harbored the same Beijing strain based on sequence-based phylogenic analysis and drug-resistant single nucleotide polymorphisms (SNPs) analysis. We also used whole genome sequencing (WGS) to compare the SNPs of all isolates with a reference genome, and all were identical. We adapted WGS to efficiently detect false-positive MTB culture tests.
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Idiopathic pleuroparenchymal fibroelastosis: The first case to be managed with a successful lung transplant at King Faisal Specialist Hospital and Research Center, Riyadh p. 94
Nour Abdullah Aljefri, Fayha Farraj Abothenain, Ahmed Mohamed Hussein, Waleed Saleh, Khaled Alkattan, Shamayel Faheem Mohammed, Mohammed Alhajji
DOI:10.4103/atm.ATM_106_18  
Idiopathic Pleuro-Parenchymal Fibroelsatosis (PPFE) is a rare, progressive and recently recognized subtype of idiopathic interstitial lung disease with no recorded successful treatment other than lung transplant. We report a case of idiopathic pleuroparenchymal fibroelastosis from the Middle East, managed successfully by bilateral lung transplant performed on a 26 year old Saudi male.
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LETTERS TO THE EDITOR Top

Bone marrow micrometastasis in nonsmall cell lung cancer: A new prognostic marker? p. 99
Nikolaos Barbetakis, Dimitrios Paliouras, Nikolaos Diamantopoulos
DOI:10.4103/atm.ATM_225_18  
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Pulmonary schistosomiasis in a young male: A case report and review of the literature p. 99
Mahmood Dhahir Al-Mendalawi
DOI:10.4103/atm.ATM_229_18  
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