Influenza viruses are responsible for the influenza outbreaks that lead to significant burden and cause significant morbidity and mortality worldwide. Based on the core proteins, influenza viruses are classified into three types, A, B, and C, of which only A and B cause significant human disease and so the vaccine is directed against these two subtypes only. The effectiveness of the vaccine depends on boosting the immune system against the serotypes included within it. As influenza viruses undergo periodic changes in their antigen, the vaccine is modified annually to ensure susceptibility. In contrast to other countries, Saudi Arabia faces a unique and challenging situation due to Hajj and Umrah seasons, when millions of people gather at the holy places in Mecca and Madinah, during which influenza outbreaks are commonly found. Such challenges making the adoption of strict vaccination strategy in Saudi Arabia is of great importance. All efforts were made to develop this guideline in an easy-to-read form, making it very handy and easy to use by health care workers. The guideline was designed to provide recommendations for problems frequently encountered in real life, with special consideration for special situations such as Hajj and Umrah seasons and pregnancy.

With increased exposure of patients to routine imaging, incidental benign intrathoracic masses are frequently recognized. Most have classical imaging features, which are pathognomonic for their benignity. The aim of this pictorial review is to educate the reader of radiological features of several types of intrathoracic masses. The masses are categorized based on their location/origin and are grouped into parenchymal, pleural, mediastinal, or bronchial. Thoracic wall masses that invade the thorax such as neurofibromas and lipomas are included as they may mimic intrathoracic masses. All examples are illustrated and include pulmonary hamartoma, pleural fibroma, sarcoidosis, bronchial carcinoid, and bronchoceles together with a variety of mediastinal cysts on plain radiographs, computed tomography (CT) and magnetic resonance imaging (MRI). Sometimes a multimodality approach would be needed to confirm the diagnosis in atypical cases. The study would include the incorporation of radionuclide studies and relevant discussion in a multidisciplinary setting.

Objectives: To describe the change in the management, and outcome of children with acute severe asthma (ASA) admitted to Pediatric Intensive Care Unit (PICU) at tertiary institute, as compared to previously published report in 2003. Methods : This is a retrospective observational study. All consecutive pediatric ASA patients who were admitted to PICU during the study period were included. The data were extracted from PICU database and medical records. The Cohort in this study (2013 Cohort) was compared with the Cohort of ASA, which was published in 2003 from the same institution (2003 Cohort). Results: In comparison to previous 2003 Cohort, current Cohort (2013) revealed higher mean age (5.5 vs. 3.6 years; P ≤ 0.001), higher rate of PICU admission (20.3% vs. 3.6%; P ≤ 0.007), less patients who received maintenance inhaled steroids (43.3% vs. 62.4%; P ≤ 0.03), less patients with pH <7.3 (17.9% vs. 42.9%; P ≤ 0.001). There were more patients in 2013 Cohort who received: Inhaled Ipratropium bromide (97% vs. 68%; P ≤ 0.001), intravenous magnesium sulfate (68.2% vs. none), intravenous salbutamol (13.6% vs. 3.6%; P ≤ 0.015), and noninvasive ventilation (NIV) (35.8% vs. none) while no patients were treated with theophylline (none vs. 62.5%). The median length of stay (LOS) was 2 days while mean LOS was half a day longer in the 2013 Cohort. None of our patients required intubation, and there was no mortality. Conclusion: We observed slight shift toward older age, considerably increased the rate of PICU admission, increased utilization of Ipratropium bromide, magnesium sulfate, and NIV as important modalities of treatment.

INTRODUCTION: Dental laboratory technicians (DLTs) get exposed to fibrinogen dusts that are very risky dusts in terms of health. In this study, respiration complaints, pneumoconiosis frequencies and working conditions of the dental technicians in Denizli were investigated. METHODS: All of the registered DLTs working in Denizli were included in the study. A 30-item questionnaire was used to gather data about the participants and their working environments. Then, pulmonary function tests (PFTs) were carried out and standard chest X-rays were taken in order to detect how much the respiratory systems of the workers were affected. Standard chest X-rays were evaluated according to International Labour Organizations classification. Depending on the screening results, technicians who were found to have had pathologies and suspected cases were examined. "High-resolution computerized tomography (HRCT)" was taken from those who were found to have pathology in their chest X-rays and they were evaluated according to the classification of Hering et al. RESULTS: There are a total of 166 DLTs working in Denizli Province participated in the study. One hundred and forty-three (86.1%) of the participants were male, and 23 of them were female. The mean age of the participants is 33.5 ± 8.1. Average working time of the workers is 16 years. Total exposure time was calculated 36,177 h. Approximately, 56% of workers were smokers. When the working conditions were considered, it was found that 98.8% of laboratories had a ventilation system. Technicians' use of personal protective equipment is low. Participants' often or continuous use of masks, gloves, goggles, and vacuum device was found 69%, 36%, 47%, and 63% respectively while working. About 21.2% of the technicians have respiratory symptoms while 15.2% of them have eye complaints. At the analysis of PFT results, 27.7% restrictive type pulmonary disorder was determined. At the analysis of chest X-rays; 1/0 profusion sub-category was 25.5%, and the large opacity rate was 16.9%. Ten pneumoconiosis cases (6%) were diagnosed after the analysis of the HRCT results. The ratio of pneumoconiosis was found much higher among male technicians, particularly those who have been working for a long time in the profession and those working at the town hospitals and Department of metal leveling. DISCUSSION: Technicians' use of personal protective tools is not enough and ratio of smoking is rather high. Pneumoconiosis cases clearly show this exposure. It is necessary to adopt comprehensive work health and safety precautions considering the determined risk factors.

Rationale: Empirical antimicrobial therapy (EAT) for Acinetobacter infections may not be appropriate as it tends to be multidrug-resistant. This study evaluated the relationship between appropriate EAT and the outcomes of Intensive Care Unit (ICU) patients with Acinetobacter bacteremia. Methods: This is a retrospective study of patients admitted to a medical-surgical ICU (2005-2010) and developed Acinetobacter bacteremia during the stay. Patients were categorized according to EAT appropriateness, defined as administration of at least one antimicrobial agent to which the Acinetobacter was susceptible before susceptibility results were known. The relation between EAT appropriateness and outcomes was evaluated. Results: Sixty patients developed Acinetobacter bacteremia in the 6-year period (age = 50 ± 19 years; 62% males; Acute Physiology and Chronic Health Evaluation II score = 28 ± 9; 98.3% with central lines; 67% in shock and 59% mechanically ventilated) on average on day 23 of ICU and day 38 of hospital stay. All isolates were resistant to at least three of the tested antimicrobials. Appropriate EAT was administered to 60% of patients, mostly as intravenous colistin. Appropriate EAT was associated with lower ICU mortality risk (odds ratio: 0.15; 95% confidence interval: 0.03-0.96) on multivariate analysis. Conclusions: In this 6-year cohort, Acinetobacter bacteremia was related to multidrug-resistant strains. Appropriate EAT was associated with decreased ICU mortality risk.

Aim: The prevalence of obstructive sleep apnea (OSA) in end-stage renal disease (ESRD) patients was reported to be 10-fold that in the general population. OSA can worsen the clinical symptoms and cardiovascular complications of ESRD. We aimed to investigate the prevalence of symptoms and risk of OSA among Saudi patients with ESRD. Settings And Design: This multi-center, cross-sectional study was conducted in Jeddah, Saudi Arabia, between June 2012 and September 2013. Methods: The prevalence of OSA was assessed using the Berlin questionnaire. The presence of daytime sleepiness was evaluated using the Epworth sleepiness scale. Data were also collected on the medical history, clinical, and laboratory findings of participants. Results: In all, 355 patients (61% male) were enrolled (mean age: 45.5 ± 15.4 years). The overall prevalence of high-risk of OSA was 44.2% (males, 47.3%; females, 44.8%; P = 0.65). The prevalence of excessive daytime sleepiness (EDS) was 74%. Controlling for age, gender and body mass index, multivariate analysis revealed that hypertension and hepatitis C infection were the only comorbidities significantly associated with OSA (odds ratio [OR]: 3.827 and 0.559; confidence interval [CI]: 2.120-6.906 and 0.324-0.964; P < 0.0001 and 0.036, respectively). OSA was also strongly associated with EDS (OR: 3.054; CI: 1.676-5.565; P < 0.0001). Conclusions: In Saudi Arabia, the risk of OSA is more common in ESRD patients than in the general population. OSA is strongly associated with EDS. Interestingly, a significant negative correlation between OSA and hepatitis C infection was noted, which warrants further investigation.

Background: The 6-min walking test (6MWT) is one of the most commonly used tests to assess exercise capacity during chronic obstructive pulmonary disease (COPD). However, it is a relatively time-consuming test. Many authors assessed the usefulness of simpler methods, as the sit-to-stand test (STST), to estimate exercise capacity. Purpose: To demonstrate the feasibility of STST, in comparison to 6MWT, for the evaluation of functional status in Tunisian COPD patients and evaluate its correlation to the severity of the disease. Methods: We studied patients with COPD (Global Initiative for Chronic Obstructive Lung Disease A-D). All patients had plethysmography and manual quadriceps femoris muscle strength evaluation. Each patient completed a 6MWT and a STST. During the tests, dyspnea severity (Borg scale), heart rate, pulsed oxygen saturation, and blood pressure were measured. Results: In 49 patients with stable COPD (mean age 67.06 ± 8.4 years, mean forced expiratory volume in the first second 46.25% ± 19.64%), 6MWT and STST were correlated with each other (r = 0.47, P = 0.001). During 6MWT and STST, the rise in heart rate, systolic blood pressure, and severity of dyspnea were statistically significant compared to baseline (P < 0.05). However, cardiorespiratory stress was lower after STST than after 6MWT (P < 0.05). A statistically significant positive correlation was noted between the 6MWT distance and forced vital capacity (r = 0.357, P < 0.05). The 6MWT was negatively correlated with dyspnea severity at baseline (r = −0.289, P < 0.05) and with BODE index (r = −0.672, P < 0.01). STST was correlated only with age (r = 0.377, P < 0.01). No correlation was found between both tests and quadriceps femoris strength. Conclusion: As like as 6MWT, STST can determine functional status during COPD. In addition, it is less time consuming and produces less hemodynamical stress compared to 6MWT. STST can be used as an alternative for 6MWT in patients with COPD.

Objectives: With the increased volume of referrals of patients with obstructive sleep apnea (OSA) for sleep studies, there is a great need for alternatives of the standard two-night polysomnography (PSG) like split-night PSG. Therefore, we conducted this study to determine the success rate of continuous positive airway pressure (CPAP) titration during split-night PSG, and to determine the predictors of titration success and the impact on subsequent CPAP compliance in Saudi patients with OSA. Materials And Methods: This is a prospective cohort study that included consecutive patients who were diagnosed with OSA and underwent a split-night PSG (n = 454). A subgroup of patients who used CPAP therapy, agreed to come for follow-up after 4 and 10 months (n = 130). This subgroup was compared with a matched group of OSA patients who underwent a two-night sleep study protocol (n = 80). Results: The study group had a mean age of 48.7 ± 13.3 years, body mass index (BMI) of 37.5 ± 10.1 kg/m ² and apnea hypopnea index of 58.4 ± 35.0 events/h. Successful CPAP titration was achieved in 350 (77%) patients. In a full adjusted model, "BMI >35 kg/m ²" and "known cardiac disease" remained significant predictors of a lower success rate of CPAP titration. After 10 months, 88% of the patients in the split-night protocol met the set criteria for good compliance versus 85% in the two-night protocol. Conclusion: Split-night protocol is an effective protocol for diagnosing OSA and titrating CPAP. CPAP compliance rate showed no difference between the split-night and the two-night protocols.

Background: Current protocols for detection of circulating fibrocytes (CFs) in peripheral blood described in various pulmonary and nonpulmonary disorders involve complex and time consuming, non standardized techniques. Objective: Testing a method to rapidly detect and quantify CFs using whole blood lysis flow cytometry-based assay in patients with idiopathic pulmonary fibrosis (IPF) and healthy controls. Methods: One milliliter of venous blood sample in ethylenediaminetetraacetic acid (EDTA) from 33 IPF patients and 35 healthy control subjects was collected. Using whole blood lysis method peripheral blood leukocytes were labeled with monoclonal antibodies for cell surface (CD34 and CD45) and intracellular markers (collagen-1) for flow cytometric analysis. CFs were defined as CD45 ⁺ cells coexpressing collagen-I and CD34 molecules. Results: In 29 (87.8%) IPF patients and 10 (28.5%) control subjects, a well-defined highly granular CD45 ⁺ cell population was detected in dot plots generated by side scatter properties of CD45 ⁺ cells. These CD45 ⁺ cells were identified as CFs on the basis of coexpression of collagen-I and CD34; none of the other cell types in the peripheral blood were labeled with these monoclonal antibodies. In IPF patients the percentage of CFs was significantly higher compared to healthy controls (median (range): 1.37% (0.52-5.65) and 1.04% (0.1-1.84), respectively; P = 0.03). Conclusions: Whole blood lysis method combined with fluorescence-activated cell sorting (FACS) allows detecting a well-defined homogeneous population of CFs. This method is simple, reproducible, and provides an accurate and rapid estimation of CFs.

Background And Aim: Screening for tuberculosis (TB) is a key strategy for controlling infection. This study aimed to detect latent TB among dialysis patients. Methods: This is a prospective study conducted in King Saud University, Riyadh involving hemodialysis (HD) and peritoneal dialysis (PD) patients aged ≥18 years. Patients were screened for latent TB infection (LTBI) using both TBskin test (TST) and QuantiFERONTB Gold In-Tube test (QFT-GIT). All participants were followed-up clinically and radiologically every 3 months for 2 years. Results: A total of 243 (181 HD and 62 PD) patients were included and 112(46.1%) were males. 45.3% showed positive QFT in HD patients with sensitivity of 91.7%, specificity of 71.4%, positive predictive value (PPV) of 19.5%, and negative predictive value (NPV) of 91.1%. TST results in HD showed that positive TST was 17.4%, sensitivity was 63.2%, specificity was 95.5%, PPV was 51.5%, and NPV was 91.1%. Five (8.1%) showed positive QFT in PD patients with sensitivity of 7.7%, specificity of 91.8%, PPV of 6.6%, and NPV of 92.3%. TST results in PD showed that positive TST was 9.8%, sensitivity was 35.7%, specificity was 97.9%, PPV was 55.8%, and NPV was 93.3%. Previous TB infection was significantly correlated with QFT only in HD patients, but significantly associated with TST in both HD and PD patients. Also in HD, QFT was significantly associated with TST (P = 0.043). Conclusions: Due to high variability of QFT-GIT sensitivity, we recommend its use for its NPV and to use either TST or QFT in screening latent TB.

Epitheliod hemangioendothelioma (EHE) is a rare tumor of vascular origin. The pleural variant has only been reported around 20 times in English literature. It commonly occurs in older men and carries a poor prognosis with average survival lasting from a few weeks to months. Pleural EHE (PEHE) can be a diagnostic challenge due to its rarity as well as similarities to other pleural and vascular tumors. There is currently no standard treatment for EHE. Due to the rarity of this disease, reaching a final diagnosis is challenging. It's clinical, radiological, and pathological resemblance to malignant mesothelioma can cause a delay in diagnosis. Special stains such as CD31, CD34, and factor VIII related antigen can help differentiate between the two. Ordering appropriate stains in a timely manner can help avoid misdiagnosing PEHE.

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) pneumonia is associated with very high mortality. Though surgical evacuation of necrotic tissue is desirable in patients unresponsive to antimicrobial therapy, most patients are acutely ill precluding surgical intervention. We utilized a combination of extracorporeal membrane oxygenation (ECMO) with frequent toilet bronchoscopies to salvage an unaffected right lung from spillage of necrotic pus from left lung cavitary CA-MRSA pneumonia in a 22-year-old patient. Our patient while on ECMO and after decannulation was positioned with the right lung up at all times with 1-2 toilet bronchoscopies every day for almost 30 days. This time was utilized for ventilator weaning and optimizing the nutritional status prior to extrapleural left pneumonectomy. Prevention of soilage of the unaffected right lung and mitigating volutrauma with ECMO support combined with the subsequent surgical evacuation of necrotic left lung tissue led to a favorable outcome in this case. This strategy could be of value in similar presentations of unilateral suppurative pneumonia, where the progressive disease occurs despite optimal medical therapy.