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
July-September 2017
Volume 12 | Issue 3
Page Nos. 133-218

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EDITORIAL  

Improving the management of people with bronchiectasis in Saudi: A new beginning p. 133
RJ Thomas, Anne B Chang
DOI:10.4103/atm.ATM_183_17  
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GUIDELINES Top

The Saudi Thoracic Society guidelines for diagnosis and management of noncystic fibrosis bronchiectasis p. 135
Hamdan Al-Jahdali, Abdullah Alshimemeri, Abdullah Mobeireek, Amr S Albanna, Nehad N Al Shirawi, Siraj Wali, Khaled Alkattan, Abdulrahman A Alrajhi, Khalid Mobaireek, Hassan S Alorainy, Mohamed S Al-Hajjaj, Anne B Chang, Stefano Aliberti
DOI:10.4103/atm.ATM_171_17  
This is the first guideline developed by the Saudi Thoracic Society for the diagnosis and management of noncystic fibrosis bronchiectasis. Local experts including pulmonologists, infectious disease specialists, thoracic surgeons, respiratory therapists, and others from adult and pediatric departments provided the best practice evidence recommendations based on the available international and local literature. The main objective of this guideline is to utilize the current published evidence to develop recommendations about management of bronchiectasis suitable to our local health-care system and available resources. We aim to provide clinicians with tools to standardize the diagnosis and management of bronchiectasis. This guideline targets primary care physicians, family medicine practitioners, practicing internists and respiratory physicians, and all other health-care providers involved in the care of the patients with bronchiectasis.
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REVIEW ARTICLE Top

Gaining access to the periphery of the lung: Bronchoscopic and transthoracic approaches p. 162
Abdelfattah Ahmed Touman, Vlasios V Vitsas, Nickolaos G Koulouris, Grigoris K Stratakos
DOI:10.4103/atm.ATM_416_16  
Globally, lung cancer remains the leading cause of cancer-related death. Annual low-dose computed tomography has been recommended as a screening test for early detection of lung cancers. Implementing this screening strategy is expected to challenge pulmonologist to confirm the nature of the increasing number of detected pulmonary nodules. Clinicians are obliged to use the less invasive and most efficient and safe means to set diagnoses. Hence, the field of diagnostic modalities, especially the advanced diagnostic bronchoscopy is witnessing rapid evolution to fulfill these unmet needs. This review highlights the available diagnostic modalities, describes their advantages and discusses the limitations of each technique. It also suggests an integrated diagnostic algorithm based on the best available evidence. A search of the PubMed database was conducted using relevant terms described at methodology; only articles in English were reviewed by November 2016.
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ORIGINAL ARTICLES Top

Predictive factors for a successful diagnostic bronchoscopy of ground-glass nodules p. 171
Toshiyuki Nakai, Yuji Matsumoto, Fumi Suzuk, Takaaki Tsuchida, Takehiro Izumo
DOI:10.4103/atm.ATM_428_16  
Introduction: Since the National Lung Screening Trial demonstrated the utility of low-dose computed tomography screening for lung cancer, the detection rate of ground-glass nodules (GGNs) has increased. Endobronchial ultrasound with a guide sheath (EBUS-GS) is widely performed to diagnose peripheral pulmonary lesions, but there are not enough reports on the predictive ability of EBUS-GS in diagnosing GGNs. The aim of this study is to investigate the predictive factors for a successful diagnostic bronchoscopy for GGNs. Methods: Consecutive patients who underwent diagnostic bronchoscopy for GGNs from September 2012 to January 2016 were enrolled in this study. From these, cases who underwent EBUS-GS were selected. They were reviewed and analyzed to examine the association between the diagnostic yield and the following clinical factors: lesion size, lobar position, location, consolidation-to-tumor ratio, visibility on X-ray, use of virtual bronchoscopy, bronchus sign, guide sheath size, and number of biopsies. Results: We enrolled 254 cases, of which 167 were diagnosed using EBUS-GS (65.7% diagnostic yield). Univariate analysis indicated that a positive bronchus sign was a significant factor for higher diagnostic yield (72.9% vs. 34.0%; P < 0.001). The use of virtual bronchoscopy also tended toward a higher yield, but the result was not significant (69.0% vs. 54.4%; P = 0.058). However, multivariate analysis indicated that both were significantly associated with higher diagnostic yield (P < 0.001, odds ratio [OR]: 5.35; P < 0.001, OR: 1.97, respectively). Conclusions: Our results suggest that a positive bronchus sign and the use of virtual bronchoscopy are positive predictive factors for successful diagnostic bronchoscopy of GGNs.
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What should be the appropriate minimal duration for patient examination and evaluation in pulmonary outpatient clinics? p. 177
Benan Musellim, Sermin Borekci, Gulfidan Uzan, Zafer Hasan Ali Sak, Secil Kepil Ozdemir, Goksel Altinisik, Sinem Agca Altunbey, Nazan Sen, Oguz Kilinc, Arzu Yorgancioglu, The Duration for Patient Examination Working Group of Turkish Thoracic Society
DOI:10.4103/atm.ATM_396_16  
Introduction: Patient examinations performed in a limited time period may lead to impairment in patient and physician relationship, defective and erroneous diagnosis, inappropriate prescriptions, less common use of preventive medicine practices, poor patient satisfaction, and increased violent acts against health-care staff. Objective: This study aimed to determine the appropriate minimal duration of patient examination in the pulmonary practice. Methods: A total of 49 researchers from ten different study groups of the Turkish Thoracic Society participated in the study. The researchers were asked to examine patients in an almost ideal manner, without time constraint under available conditions. Results: A total of 1680 patient examinations were reviewed. The mean duration of patient examination in ideal conditions was determined to be 20.4 ± 9.6 min. Among all steps of patient examination, the longest time was spent for “taking medical history.” The total time spent for patient examination was statistically significantly longer in the university hospitals than in the governmental hospitals and training and research hospitals (P < 0.001). Among different patient categories, the patients with a chronic disorder presenting for the first time and were referred from primary or secondary to tertiary care for further evaluation have required the longest time for patient examination. Conclusion: According to our study, the appropriate minimal duration for patient examination is 20 min. It has been observed that in university hospitals and in patients with chronic pulmonary diseases, this duration has been increased to above 25 min. The durations in clinical practice should be planned accordingly.
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The influence of intermittent fasting on the circadian pattern of melatonin while controlling for caloric intake, energy expenditure, light exposure, and sleep schedules: A preliminary report Highly accessed article p. 183
Aljohara S Almeneessier, Ahmed S Bahammam, Munir M Sharif, Salman A Bahammam, Samar Z Nashwan, Seithikurippu R Pandi Perumal, Daniel P Cardinali, Mohammad Alzoghaibi
DOI:10.4103/atm.ATM_15_17  
Aims: We hypothesized that if we control for food composition, caloric intake, light exposure, sleep schedule, and exercise, intermittent fasting would not influence the circadian pattern of melatonin. Therefore, we designed this study to assess the effect of intermittent fasting on the circadian pattern of melatonin. Methods: Eight healthy volunteers with a mean age of 26.6 ± 4.9 years and body mass index of 23.7 ± 3.5 kg/m2 reported to the Sleep Disorders Center (the laboratory) on four occasions: (1) adaptation, (2) 4 weeks before Ramadan while performing Islamic intermittent fasting for 1 week (fasting outside Ramadan [FOR]), (3) 1 week before Ramadan (nonfasting baseline [BL]), and (4) during the 2nd week of Ramadan while fasting (Ramadan). The plasma levels of melatonin were measured using enzyme-linked immunoassays at 22:00, 02:00, 04:00, 06:00, and 11:00 h. The light exposure, meal composition, energy expenditure, and sleep schedules remained the same while the participants stayed at the laboratory. Results: The melatonin levels followed the same circadian pattern during the three monitoring periods (BL, FOR, and Ramadan). The peak melatonin level was at 02:00 h and the trough level was at 11:00 h in all studied periods. Lower melatonin levels at 22:00 h were found during fasting compared to BL. Cosinor analysis revealed no significant changes in the acrophase of melatonin levels. Conclusions: In this preliminary report, under controlled conditions of light exposure, meal composition, energy expenditure, and sleep-wake schedules, intermittent fasting has no significant influence on the circadian pattern of melatonin.
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Distribution patterns of the metastases of the lung carcinoma in relation to histological type of the primary tumor: An autopsy study p. 191
Ivana Savic Milovanovic, Mihailo Stjepanovic, Dragan Mitrovic
DOI:10.4103/atm.ATM_276_16  
Introduction: Lung cancer is among leading causes of death worldwide. Different histological types of the lung carcinoma show significant differences in behavior. Objectives: The aim of this study is to determine the distribution patterns of metastases of different lung cancer histological types in autopsied individuals. Methods: Protocols from all autopsies performed at the Institute of Pathology from 2008 till 2014 were reviewed retrospectively, and information on individuals' age, sex, histological type of primary lung cancer, presence and location of metastases, and causes of death were recorded. Results: More than 90% of the individuals with lung cancer metastases were older than 50 years (mean age: 64.5 ± 10.3), with two-fold male predominance. The most frequent histological type in both sexes was adenocarcinoma (48%). Although, in general, hematogenous metastases were mostly found in the liver and adrenal glands, various histological types of lung cancer show specific dissemination patterns. Metastases in adrenal glands derived mostly from adenocarcinoma and large-cell carcinoma. Metastases in the intestines most frequently originated from large-cell carcinoma (P = 0.01). Metastatic complications and bronchopneumonia were the most frequent causes of death. Conclusions: While, overall, the most frequent hematogenous metastases occur in the liver and adrenal glands, various histological types of lung cancer show specific dissemination patterns. Knowing distribution of metastases is essential for making algorithms of treatment, as well as for improving clinical assessment of the patients with unclear clinical findings and suspicion on occult primary lung cancer.
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Assessment of anti-factor Xa activity of enoxaparin for venous thromboembolism prophylaxis in morbidly obese surgical patients p. 199
Nouf Al Otaib, Zohour Bootah, Maha A Al Ammari, Tariq M Aldebasi, Abdulmalik M Alkatheri, Shmeylan A Al Harbi, Salah M AbuRuz, Abdulkareem M AlBekairy
DOI:10.4103/atm.ATM_31_17  
Background: Venous thromboembolism (VTE) can be encountered by 60% of hospitalized patients. Anticoagulants have been recommended to reduce the risk of VTE in patients with risk factors. However, no specific dosing recommendations for obese patients are provided in the current practice guidelines. The purpose of this study was to determine the efficacy and safety of weight-based dosing of enoxaparin for VTE prophylaxis among morbidly obese patients undergoing surgery. Methods: Adult patients were enrolled if they have a body mass index (BMI) of ≥35 kg/m2 and were scheduled for surgery. These patients were prescribed enoxaparin (0.5 mg/kg subcutaneously [SC] once daily). Peak anti-factor Xa levels were measured 4 h after the third dose of enoxaparin. The primary outcome measure was to determine whether a weight-based dosing of enoxaparin of 0.5 mg/kg produce the anticipated peak anti-Xa levels (0.2–0.6 IU/m) among obese patients undergoing surgery. Secondary outcomes include the incidence of VTE, the incidence of minor or major bleeding, and the incidence of heparin-induced thrombocytopenia (HIT). Results: Fifty patients were enrolled in the study. The mean age was 53 ± 16 years, 74% of the patients were female. The mean BMI was 40.5 ± 5, and the average enoxaparin dose was 50 ± 9.8 SC daily. Nearly 88% of the patients reached the target anti-factor Xa (0.427 ± 0.17). None of the patients developed HIT or VTE. There was no incidence of major or minor bleeding. Conclusions: Weight-based enoxaparin dose led to the anticipated peak anti-Xa levels (0.2–0.6 IU/mL) in most of the morbidly obese study patients undergoing surgery without any evidence of major side effects. The weight-based dosing of enoxaparin was also effective in preventing VTE in all patients. Although these results are promising, further comparative trials are needed in the setting of morbidly obese surgical patients.
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Pulmonary consequences of hypothyroidism p. 204
Samiaa Hamdy Sadek, Walaa Anwar Khalifa, Ahmad Metwally Azoz
DOI:10.4103/atm.ATM_364_16  
Background: Although hypothyroidism has an insidious onset and relatively asymptomatic, exertional dyspnea and fatigue can be the presenting complaints. Objectives: The aim is to assess functional lung impairment in hypothyroid patients both at rest and during exercise. Methods: A case-control study was carried out on 42 patients with newly diagnosed hypothyroidism and 12 control subjects. Hypothyroidism was diagnosed based on high value of thyroid stimulating hormone (TSH) ≥6 μIU/ml, and low value of free thyroxin (FT4) ≤0.8 ng/dl, both groups had chest X-ray, spirometry, diffusing capacity of the lungs for carbon monoxide (DLCO), arterial blood gases (ABGs) and symptom-limited exercise testing using treadmill. Results: Both groups were comparable as regard age, sex, and body mass index. Although ABG and spirometry were within normal in both groups, forced vital capacity %, and forced expiratory flow (FEF25–75) % were significantly reduced in the hypothyroid group (P = 0.014, 0.000, respectively), DLCO significantly reduced in hypothyroidism (P = 0.005). As regard exercise testing parameters, maximum oxygen consumption %, minute ventilation, tidal volume, and oxygen pulse were significantly reduced in hypothyroidism (0.005, 0.000, 0.000, and 0.02 respectively). TSH significantly negatively correlated with forced expiratory volume in 1 s %, FEF25–75%, and DLCO while they significantly positively correlated with FT4. Conclusion: Even with the presence of normal chest X-ray, arterial blood gases, and spirometry in patients with hypothyroidism DLCO and exercise testing parameters can be significantly reduced.
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CASE REPORTS Top

Severe fibrosing mediastinitis with atypical presentation: Effective control with novel therapeutic approach p. 209
Abdulaziz Uthman Joury, Ahmad Amer Al Boukai, Tarek Seifaw Kashour
DOI:10.4103/atm.ATM_47_17  
Fibrosing mediastinitis (FM), also known as sclerosing mediastinitis, is an uncommon but serious disease involving the mediastinal structures. A high index of suspicion is essential to establish the diagnosis of FM and starting the appropriate therapy for patients. Here, we report a case of a young female who presented with chest symptoms and subsequently underwent different laboratory and radiologic investigations and an excisional biopsy. The findings of these investigations were consistent with the diagnosis of idiopathic FM. Her disease was associated with complete occlusion of three pulmonary veins and the left main pulmonary artery. The patient was treated with initial high-dose steroids followed by maintenance steroid and methotrexate therapy with very good long-term disease control. Clinical response, high-sensitivity C-reactive protein, and erythrocyte sedimentation rate were used to monitor disease activity and response to therapy.
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The most frequent ABCA3 nonsense mutation -p.Tyr1515* (Y1515X) causing lethal neonatal respiratory failure in a term neonate p. 213
AlNashmi AlAnazi, Ralph Epaud, Humariya Heena, Alix de becdelievre, Abeer Mohammad Miqdad, Pascale Fanen
DOI:10.4103/atm.ATM_386_16  
Defects in the surfactant biosynthesis are associated with respiratory distress syndrome, commonly occurring in premature infants due to lung immaturity. However, interstitial lung diseases have also been observed in full-term infants with mutations in the SFTPC, SFTPB, NKX2-1, or ABCA3 genes, involved in the surfactant metabolism. Herein, we report a newborn baby with neonatal respiratory distress and diffuse lung disease caused by ABCA3 mutation. The baby died at 5 weeks of age after developing pulmonary hypertension. Genomic DNA was analyzed for four genes involved in surfactant metabolism out of which the c. 4545C>G (p.Tyr1515*) homozygous mutation in exon 29 of ABCA3 was identified which is one of the most frequent mutation causing lethal neonatal respiratory failure in a term neonate. This case study emphasizes the importance of raising awareness about this diagnosis in the clinical settings for fruitful outcomes in health-care delivery.
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LETTERS TO THE EDITOR Top

Role of pleural transthoracic ultrasound guidance p. 216
Maria Giulia Tinti, Elisabettamaria Frongillo, Marco Sperandeo
DOI:10.4103/atm.ATM_77_17  
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Prevalence of antibodies against the Middle East Respiratory Syndrome coronavirus, influenza A and B viruses among blood donors, Saudi Arabia p. 217
Manar Alrashid, Alanoud Abu Taleb, Ali Hajeer, Yaseen Arabi
DOI:10.4103/atm.ATM_143_17  
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